Chapter 4 - Health Record Content and Documentation Flashcards
documentation mantra
the saying: “If it wasn’t documented, it wasn’t done (or didn’t happen)”; a saying used to warn healthcare professionals about the importance of documentation
data quality
the reliability and effectiveness of data for its intended uses in operations, decision-making, and planning; lack of data quality can impact the quality of care a patient receives, impair the ability of the medical coder to assign the correct codes, and put the hospital in danger of lawsuits or legal penalties
documentation standards
those principles, codes, beliefs, guidelines, and regulations that guide health record documentation
template
a pattern used in EHRs to capture data in a structured manner and specify the information to be collected
fraud
(as defined by the CMS) the intentional deception or misrepresentation that an individual knows, or should know, to be false or does not believe to be true, knowing the deception could result in some unauthorized benefit to himself or some other person(s)
abuse
(as defined by the CMS) any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are priced fairly
licensure organization
the legal authority or formal permission from the authorities to carry out certain activities that require such permission (e.g. the state and federal government)
Medicare Conditions of Participation (CoP)
a set of standards that a healthcare organization must meet to receive Medicare funding
Medicare Conditions for Coverage (CfC)
another set of standards that a healthcare organization must meet to receive Medicare funding
deemed status
a status granted to an organization by the CMS; it means that that organization not only meets but exceeds expectations for a particular area of expertise
allopathic medicine
an archaic term used to define science-based, conventional, modern medicine
osteopathic medicine
a “whole person” approach to medicine—treating the entire person rather than just the symptoms; distinct from allopathic medicine
statute
a piece of legislation written and approved by a state or federal legislature and then signed into law by the state’s governor, or the President of the United States
authentication
the process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature
auto-authentication
can have two meanings: (a) a procedure that allows dictated reports to be considered automatically signed unless the HIM department is notified of needed revisions within a certain time limit, or (b) a process by which the failure of an author to review and affirmatively approve or disapprove an entry within a specified time period results in authentication
clinical data
the information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services; it is also the basis for the reimbursement of the treatment and service rendered to the patient
medical history
the portion of clinical data that addresses the patient’s current complaints and symptoms and describes his or her past medical, personal, and family history
physical examination
the physician’s assessment of the patient’s current health status after evaluating the patient’s physical condition
AMA
acronym for “against medical advice”; a patient who leaves the hospital against the advice of his healthcare professional
physician orders
the instructions the physician gives to other healthcare professionals who perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient
standing orders
the orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure
clinical observations
the comments of physicians, nurses, and other caregivers that create a chronological report of the patient’s condition and response to treatment during his or her hospital stay; this is usually included in the progress note
progress note
an ongoing record of a patient’s illness and treatment, used to justify and coordinate further treatment
integrated health record
a format used for health records in which information is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse chronological order
care plan
a summary of the patient’s problems from the nurse or other professional’s perspective; it includes a detailed plan for interventions
decedent
a person who has died
pathologist
a scientist who studies the causes and effects of diseases, especially one who examines laboratory samples of body tissue for diagnostic or forensic purposes
recovery room report
a type of health record documentation used by nurses to document the patient’s reaction to anesthesia and other conditions after surgery; also called recovery room record
anesthesia report
a report that documents any preoperative medication and the response to it, the dosage of the anesthesia administered and the route of administration, the duration of administration, the patient’s vital signs while under anesthesia, and any blood products administered to the patient during the procedure, along with other relevant preoperative information.
operative report
a report that describes in detail the surgical procedures performed on the patient
pathology report
a report dictated by a pathologist after examination of tissue received for evaluation
consultation report
a report that documents the clinical opinion of a physician other than the primary or attending physician. The consultation is usually requested by the primary or attending physician, but occasionally may be the request of the patient or the patient’s family. The consultation report is based on the consulting physician’s examination of the patient and a review of the patient’s health record.
discharge summary
a concise account of the patient’s illness, course of treatment, response to treatment, and condition at the time of patient discharge (official release) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or to his or her caregiver at the time of discharge
transfer record
(used when a patient is being transferred from the acute setting to another healthcare organization) also called a referral form; a brief review of the patient’s acute stay along with current status, discharge and transfer orders, and any additional instructions will be noted
administrative data
coded information contained in secondary records (such as billing records) describing patient identification and insurance. Patient registration information would be considered administrative data as would patient account information.
ambulatory surgery centers (ASC)
ambulatory care facilities that perform surgery
ancillary services
tests and procedures sometimes ordered by a physician; these services assist the physician with diagnosing and treating the patient
physician office record
a health record created by a physician; traditionally, it refers to a record of a single physician treating a long-term patient
Patient Driven Payment Model (PDPM)
a Medicare model implemented in October 2019 to improve payment accuracy by addressing each patient’s circumstances independently and classifying patients into payment groups based on specific, data-driven patient characteristics.
Minimum Data Set (MDS)
part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes
Interim Payment Assessment
an assessment, required by the PDPM, that must be performed when there is a significant change in the patient’s situation
pay-for-performance
programs have performance measures that healthcare providers must meet or exceed to receive financial payment
Medicare Access and CHIP Reauthorization Act (MACRA)
a 2015 pay-for-performance law that changed how the federal government pays physicians
core measures
government-backed national standards of care and treatment processes for common conditions
core measure compliance
a measure that shows how often a hospital provides each recommended treatment for certain medical conditions
source-oriented health record
a health record where things are grouped together by point of origin (e.g. all of the nursing records are together, the physician notes are together, respiratory, physical therapy, lab, medications, all kept together)
universal chart order
a system where the discharged patient record is organized in the same order as when the patient was on the nursing floor; eliminates the time-consuming assembly task performed by the health information department
subjective, objective, assessment, plan (SOAP)
a method used to construct physician progress notes. Physicians use the acronym SOAP to remember what elements of documentation must be included in a progress note. The subjective component is patient’s complaint and a review of the medical history. The objective component is vital measurements and laboratory results. The assessment is the doctor’s diagnosis. The plan is the doctor’s treatment plan.
problem-oriented health record
a style of health record created in the 1970s by Lawrence Reed; it defines and documents clinical problems individually; it consists of a problem list, the history and physical examination and initial lab findings (the database), the initial plan (tests, procedures), and progress notes
document imaging
the process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end user
clinical documentation integrity coordinator
a person who works with physicians to ensure the documentation is completed and contains enough information to assign diagnosis and procedure codes. (e.g. the documentation should identify whether the right or left radius was fractured)
copy and paste functionality
a function that allows a healthcare provider to select health record documentation from one source or section of the EHR and replicate it in another source or section of the EHR; this is dangerous as it can lead to medical errors
