Healthcare Documentation Flashcards
HIM professional
health information management
Consistency
uniformity of content / vocab standards. No slang, ambiguous language, only standard abbreviations
Qualitative analysis
review of med record ensures standards are met and determine accuracy of record documentation
Quantitative analysis
review of med record to determine completeness
Audit: concurrent review
Review of the medical record carried out while the patient is actively receiving care. HIM professionals and document authors review the records as they are created and compiled. The benefit of this type of review is that documentation issues can be identified at the time of patient care and rectified (if necessary) in a timely manner.
Audit: occurrence screening
Review technique of medical records of current and discharged patients with the goal of identifying events which could potentially lead to compensation by the healthcare provider. Risk management audit. The reviewer looks for accidents, omissions, or medical errors which resulted or could potentially result in a personal injury or loss of property. Occurrences include instances when the wrong surgery was performed or an informed consent for a procedure was not obtained.
Audit: retrospective review
Review of the medical record after the patient has been discharged, but is still very useful for identifying and addressing weaknesses in documentation processes, areas where staff need additional training, and, where appropriate, addressing deficiencies in individual records.
