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HIT Record Management > Chapter 7 > Flashcards

Chapter 7 Flashcards

0
Q

What are the types of microfilm?

A

1) roll microfilm
2) jacket microfilm
3) microfiche

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1
Q

What is microfilming and what should be considered when copying?

A

Microfilm is the process of producing many photograph copies

Should consider:

  • The type and amount of information
  • updating it
  • accessing it
  • budget
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2
Q

General considerations for purchase of supplies?

A
  • Quality of product
  • design function
  • costs
  • reliability of manufacture
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3
Q

purchase considerations

A
  • Size
  • tabs
  • folder weight
  • reinforcement on top and tabs
  • Color
  • pre-printing info such as logos
  • pockets
  • fasteners
  • expandability, thickness
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4
Q

Retention considerations

A
  • State statutes and regulations
  • facility needs
  • Storage space
  • Deactivation -active:3-5years
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5
Q

Options of retention for medical records

A
  • destruction of records
  • off-site storage
  • micrographics or optical imaging
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6
Q

Methods of destroying paper records

A

Burning, shredding, pulping, pulverizing

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7
Q

Methods for destroying microfilm

A

Recycle, pulverizing

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8
Q

Destroying electronic data

A

Magnetic Degaussing

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9
Q

Certificate of destruction

A
  • date destructive
  • method
  • description of disposed records
  • signed by two witnesses
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10
Q

Commercial storage considerations

A
  • delivery
  • maintain confidentiality of records
  • Insurance if fire theft flood
  • billing terms
  • guarantee record return
  • Record tracking
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11
Q

Types of health record analysis

A

1-quantitative
2-qualitative
3-statistical

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12
Q

Quantitative analysis

A

A list of deficiencies for the health record:

  • patient identification: on every page
  • all authorization present
  • all forms and reports are correct and present
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13
Q

Delinquent record

A

When an incomplete record is not returned within a number of days (usually 15 to 30 days)

Fill out a deficiency slip that indicates what reports are missing

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14
Q

Elements of good documentation

A
  • legibility
  • readability
  • timeliness
  • error correction
  • no gaps
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15
Q

Compensable event

A

And event during the hospitalization which might become a lawsuit

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16
Q

Responsibilities of HIM committee

A
  • timeliness and accuracy of record
  • Health records clinically pertinent
  • Useful and quality assessment and legal document
  • determining format of medical records
  • developing policies and procedures
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17
Q

Outguides

A

Plastic folders in the file area to replace a record that’s been removed

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18
Q

Requisition slip

A

A paper in the larger pocket of the outguide in which gives information about the record removed and where it is
Contains:
Patients name, record number, person requesting the record, date the record was signed

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19
Q

Computerized record tracking system

A

Stores current and past locations of record

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20
Q

Activity ratio

A

of requests / #of records on file

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21
Q

Accuracy ratio

A

Records located / # records requested

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22
Q

Issue in record control

A
  • Transportation of records
  • limit room access
  • file room security
  • loose reports
23
Q

Form inventory

A

Collection of all and previous revisions of forms

24
Q

Forms justification sheet

A 
Rationale should include: 
-purpose of new form
-always responsible 
-how form will solve problems
-how info is currently documented
-external requirements for forms:JC, CMS
-
25
Q

Purposes of forms

A
  • collect data
  • instruct user
  • report information
  • standardize don’t
  • assign responsibility
  • meet users needs
26
Q

Basic designs for forms

A
  • Meets all users needs: patient, healthcare provider..
  • purpose of form: instruct, identify, report
  • Technology used: barcode, touchscreen, pens
  • Standard abbreviations and terminologies
  • include instructions
  • keep it simple: not overcrowded
27
Q

Issues with hybrid record

A
  • defining legal health record
  • identifying components for request
  • dual work process
  • cost of paper and electronic record
28
Q

EDMS

A

Electronic document management system

29
Q

Workflow for hybrid record

A
  • Record assembly: repairing torn pages, removing staples to prepare for scanning
  • Record retention: 6 months after scanning
  • Record retrieval: available through EDMS
  • Reconciliation: resolve discrepancies
  • Record processing:
    1) check quality of image scanned
    2) scanned within timeframe
    3) Paper records are verified it belongs to patient records before scanning
30
Q

6 functions of EDMS

A

1) automated forms processing
2) electronic signature
3) document capture
4) Document indexing
5) document retrieval
6) document management

31
Q

Optical imaging system

A

Scanning documents into a system:

32
Q

Names of electronic health record

A

1) CPR: computer-based patient record
2) EMR: electronic medical record
3) EHR: electronic health record

33
Q

Components of EHR

A
  • EDMS
  • HIE
  • Patient care charting
  • CPOE-computerized provider order entry
  • Data mining
34
Q

Organization of medical staff

A
  • Active: most active physician
  • associate: new physicians
  • consulting: physicians who consult on a patient
  • faculty: physician who educate students
  • Housestaff: resident
  • courtesy: physicians who admit patients infrequently
  • honorary: retired physicians who are honored

Attending physician: responsible for the care of patient during admission

Admitting physician: orders patients admission and begins care

35
Q

Clinical organization

A
  • medicine
  • surgery
  • gynecology
36
Q

Governed medical staff

A

By-laws: structure of body

Rules and regulations: specific actions required of physicians

37
Q

Medical staff committee

A
  • credential committee: makes recommendation
  • Quality improvement: evaluation of patient care
  • morality and morbidity: reviews dead cases
  • infection control: review hospital acquired infections
  • medical record committee: timeliness of medical records and documentation
  • pharmacy: review Usage of medications
38
Q

Per diem rate basis reimbursement

A

Rate covered charges for room, board and services

39
Q

Case mix index

A

A measure of costliness of treating hospital patients: 1.05 means patients are 5% more costly than average to treat

-most common: diagnosis related groups DRG

40
Q

Legislative acts that fight fraud and abuse

A
  • FCA: Federal false claims act
  • HIPAA
  • BBA: balanced budget act

OIG: office of Inspector General- responsible for detecting, preventing, investigating Medicare fraud and abuse

41
Q

Delinquency rate compliance with joint commission:

A

-compliance:
delinquency rate not more than 50% of average monthly discharge rate AMD and no single quarterly measurement is greater than 50% AMD

-partial compliance:
Delinquency rate not more than 50% of AMD but one or more quality measurement is greater than 50%

-insufficient compliance:
Delinquency rate is greater than 50% but less then twice 200% of AMD rate

-recommendation for conditional accreditation

Is exceeds 30 days of incomplete

42
Q

MPI

A

Master patient Index:

Identifies all patients admitted or treated at health care facility

43
Q

Record identification

A
  • alphabetical

- Numerical

44
Q

Numbering methods

A
  • serial
  • unit
  • serial-unit
  • SS#
  • Family numbering
45
Q

MPI filing system

A
  • alphabetic

- phonetic (soundex)

46
Q

Numeric filing systems

A
  • straight numeric
  • terminal digit
  • middle digit
47
Q

Filing equipment

A
  • file cabinets
  • open shelf file
  • movable open shelf (lateral mobile, doublebank) :
    1) compressible units
    2) motorized units (carousels)
48
Q

Calculating shelves

A 
1000×.5 = 500
500×.25 = 125
36×8 = 288
500+125 = 625
625÷288 = 2 .17 units ~~3 units
49
Q

HIM Function

A
  • ensure quality, security, availability of health information
  • monitor quality of patient information
  • Store and retrieval of patient information
  • Transcriptionist
  • release of information
50
Q

EMPI

A

Enterprise Master patient Index:

References all patients and two or more facilities

51
Q

Duplicate , overlay, overlap

A

Duplicate: a patient having duplicate medical record number

Overlay: patient assigned another patient’s medical number

Overlap: more than one medical records exist for the same patient within an enterprise

52
Q

MPI clean up process

A

1) deterministic algorithm: exact match of data elements
2) probabilistic algorithm: mathematical formulas that analyze MPI data
3) rules-based algorithm: assigns weights and uses them to compare record

53
Q

Duty of care

A

Time of creation to time of destruction

54
Q

Addendums

A

A type of correction.

Signed report that provides additional information after a previous entry

55
Q

Access control

A
  • authentication: verify identity (ID and password, access card)
  • authorization: right given to use a resource
  • nonrepudiation: unable to deny action

HIT Record Management (4 decks)

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