Chapter 7 Flashcards
What are the types of microfilm?
1) roll microfilm
2) jacket microfilm
3) microfiche
What is microfilming and what should be considered when copying?
Microfilm is the process of producing many photograph copies
Should consider:
- The type and amount of information
- updating it
- accessing it
- budget
General considerations for purchase of supplies?
- Quality of product
- design function
- costs
- reliability of manufacture
purchase considerations
- Size
- tabs
- folder weight
- reinforcement on top and tabs
- Color
- pre-printing info such as logos
- pockets
- fasteners
- expandability, thickness
Retention considerations
- State statutes and regulations
- facility needs
- Storage space
- Deactivation -active:3-5years
Options of retention for medical records
- destruction of records
- off-site storage
- micrographics or optical imaging
Methods of destroying paper records
Burning, shredding, pulping, pulverizing
Methods for destroying microfilm
Recycle, pulverizing
Destroying electronic data
Magnetic Degaussing
Certificate of destruction
- date destructive
- method
- description of disposed records
- signed by two witnesses
Commercial storage considerations
- delivery
- maintain confidentiality of records
- Insurance if fire theft flood
- billing terms
- guarantee record return
- Record tracking
Types of health record analysis
1-quantitative
2-qualitative
3-statistical
Quantitative analysis
A list of deficiencies for the health record:
- patient identification: on every page
- all authorization present
- all forms and reports are correct and present
Delinquent record
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
Elements of good documentation
- legibility
- readability
- timeliness
- error correction
- no gaps
Compensable event
And event during the hospitalization which might become a lawsuit
Responsibilities of HIM committee
- 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
Outguides
Plastic folders in the file area to replace a record that’s been removed
Requisition slip
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
Computerized record tracking system
Stores current and past locations of record
Activity ratio
of requests / #of records on file
Accuracy ratio
Records located / # records requested
Issue in record control
- Transportation of records
- limit room access
- file room security
- loose reports
Form inventory
Collection of all and previous revisions of forms
Forms justification sheet
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 -
Purposes of forms
- collect data
- instruct user
- report information
- standardize don’t
- assign responsibility
- meet users needs
Basic designs for forms
- 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
Issues with hybrid record
- defining legal health record
- identifying components for request
- dual work process
- cost of paper and electronic record
EDMS
Electronic document management system
Workflow for hybrid record
- 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
6 functions of EDMS
1) automated forms processing
2) electronic signature
3) document capture
4) Document indexing
5) document retrieval
6) document management
Optical imaging system
Scanning documents into a system:
Names of electronic health record
1) CPR: computer-based patient record
2) EMR: electronic medical record
3) EHR: electronic health record
Components of EHR
- EDMS
- HIE
- Patient care charting
- CPOE-computerized provider order entry
- Data mining
Organization of medical staff
- 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
Clinical organization
- medicine
- surgery
- gynecology
Governed medical staff
By-laws: structure of body
Rules and regulations: specific actions required of physicians
Medical staff committee
- 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
Per diem rate basis reimbursement
Rate covered charges for room, board and services
Case mix index
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
Legislative acts that fight fraud and abuse
- FCA: Federal false claims act
- HIPAA
- BBA: balanced budget act
OIG: office of Inspector General- responsible for detecting, preventing, investigating Medicare fraud and abuse
Delinquency rate compliance with joint commission:
-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
MPI
Master patient Index:
Identifies all patients admitted or treated at health care facility
Record identification
- alphabetical
- Numerical
Numbering methods
- serial
- unit
- serial-unit
- SS#
- Family numbering
MPI filing system
- alphabetic
- phonetic (soundex)
Numeric filing systems
- straight numeric
- terminal digit
- middle digit
Filing equipment
- file cabinets
- open shelf file
- movable open shelf (lateral mobile, doublebank) :
1) compressible units
2) motorized units (carousels)
Calculating shelves
1000×.5 = 500 500×.25 = 125 36×8 = 288 500+125 = 625 625÷288 = 2 .17 units ~~3 units
HIM Function
- ensure quality, security, availability of health information
- monitor quality of patient information
- Store and retrieval of patient information
- Transcriptionist
- release of information
EMPI
Enterprise Master patient Index:
References all patients and two or more facilities
Duplicate , overlay, overlap
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
MPI clean up process
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
Duty of care
Time of creation to time of destruction
Addendums
A type of correction.
Signed report that provides additional information after a previous entry
Access control
- authentication: verify identity (ID and password, access card)
- authorization: right given to use a resource
- nonrepudiation: unable to deny action
