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EHRC > HIS: Patient, personal, or population records > Flashcards

HIS: Patient, personal, or population records Flashcards

0
Q

An HIS contains many individuals __________ of ___________ and healthcare services.

A

records of health

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1
Q

An HIS may be made of ___________,_________, and/or ____________ records.

A

patient, personal, and or population records

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2
Q

A digital patient record used within a single care setting or environment.

A

Electronic medical record

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3
Q

What does EMR stand for?

A

Electronic medical record

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4
Q

A digital patient record that can be used across more than one healthcare organization is what?

A

Electronic health record

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5
Q

What does EHR stand for?

A

Electronic Health Record

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6
Q

Name the terms for the health and healthcare terms themselves are:

A

electronic health record, electronic medical record, and lifelong patient record

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7
Q

A great deal of discussion among health professionals and health systems experts has been given the goal of creating s lifelong or longitudinal, electronic medical record for each citizen. What part of the HIS is this statement referring to?

A

Patient records/lifelong patient records

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8
Q

Explain the purpose of the lifelong patient record.

A

With appropriate authorization individuals or their future care givers could gain access to relevant health-related information such as immunizations, present and past major surgeries. Such records have been known by a number of name, including “ continuity of care record” and traveler’s EHR.”

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9
Q

Much discussion and debate has circulated about the best way to assure access to and timeliness of lifelong records, Possiblilites include:

A
  1. Putting the information on portable memory devices
  2. Allowing access over secure Web portals
  3. Encrypting the information for e-mailing among patients and caregivers
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10
Q

Entire health records will be held in one place for a lifetime. True or False

A

False. It is clear that the entire record will not be held in one place for all time.

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11
Q

Some kind of distributed approach will be used and this will require some kind of_______________

A

Master patient index.

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12
Q

What does the master patient index allow?

A

It allows computers to know where such information on a specific patient is held and that approvals are required to allow access to such information.

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13
Q

The patient record traditionally is two-way True or False

A

False. The traditional patient record is one-way. The healthcare provider inputs information and data and the patient does not see the record.

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14
Q

In the new patient record, the patient has access. True or False

A

True

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15
Q

May contain the information a person wisher to maintain for private use without the information being accessible to any HIS

A

Electronic or digital personal health record (PHR)

16
Q

Explain Integrated electronic health records

A
  • links patients with their own EHRs so they see most if not all the records that their doctors and nurses see
  • patients are integrated into their data management as well as their own care
  • possible because of the internet and secure Web portals
17
Q

Estimate how many Americans not get their care through secure Web portal?

A

By some estimates, ten millions of Americans

18
Q

There are four purposes of population records, name them.

A
  1. administrative and/or business operations such as reimburstments for services rendered
  2. Clinical groups for outcomes management
  3. Public health/bio-surveillance
  4. Research
19
Q

Why would patients having absolute control over their records cause conflict?

A

This will interfere with bio-surveillance which is serves the needs of public health experts, who need to track communicable disease. as well as with biomedical researchers.

20
Q

Name some adminstrative modules of HIS

A
  1. Master patient index
    - -a database within an HIS containing unique patient identification codes for all the patients in a healthcare system
  2. Admission, discharge, and transfer (ADT)
    - -sometime called hotel
    - -allows staff to admit patients, transfer them from facility to facility or room to room, etc., and discharge the patients
  3. Scheduling and Registration
  4. Insurance and Billing Information
    - Medical Records Coding
    - DRG Assignment
21
Q

Name the departmental systems within a HIS

A

Laboratory information systems (LIS)
-division include chemistry, hematology, etc.
-processes orders for clinical lab services and test
-connects with lab machines so pt specimens are automatically transferred to the LIS and HIS where they are made available for clinicians
Radiology information systems (RIS)
-includes patient scheduling, result reporting, and image tracking
-stores, organizes, and distributes patient radiological data
Picture archiving and communication systems (PACS)
-stores x-rays, CAT scan, ultrasound, and other types of medical images on a computer screen
Pharmacy
-receives and processes medication orders
-features pharmacy billing, inventory management, generation of medication labels, fills lists, patient profiles, and support for clinical pharm. activities
tight intergration with POE and clinical decision support systems

22
Q

Name some of the clinical modules of an HIS

A
  1. Provider or physician order entry (POE)
  2. Clinician documentation
  3. Bar-code medication administration (BCMA)
  4. Decision support
23
Q

MPI and EMPI

A

Master Patient Index (MPI)
-Used in a single system to uniquely identify a patient
-Assigns a Medical Record Number
—Practice Fusion
EMPI
-Used when there are multiple systems each with its own MPI
—Uses Query and Response
—Local registration systems uses EMPI to determine if patient already exists in the system

24
Q

Name the ________MPI and EMPI

A
  1. Function - is embedded in registration and scheduling workflow
  2. Capability - help to uniquely identify a patient and prevent duplicate records
  3. Duplicate records represent a patient safety risk because:
    - -results not available on the patient record
    - -erroneous results on the patient record
  4. Training for schedulers and registrars is critical
25
Q

In a MPI and EMPI is there ownership of a duplicate record?

A

There must be ownership of duplicate record policy in all systems that store patient records.

26
Q

Who will identify and correct duplicates?

A

In a hospital environment the Medical department

27
Q

What does the Medical Records department do with ownership of duplicate record policy?

A

The Medical Records department:

  • uses reports to identify duplicates
  • develops written policies for corrections
  • assigns responsibility for correction
28
Q

The organization may use what type Scheduling

A
  • Enterprise scheduling
  • Department scheduling
  • –often seen in Radiology
29
Q

The capability of scheduling includes managing schedule of

A
  • Physicians and/or staff
  • Equipment
  • Rooms
  • –Operating rooms
30
Q

Organizations may support_________-________by the patient

A

self-scheduling

31
Q

Registration is performed by someone who is trained in

A
  • customer service
  • use of computer system
  • MPI/EMPI concepts
  • basic healthcare insurance concepts
32
Q

What happens when a registrar checks-in a patient

A
  • creates account and EMR encounter
  • creates new patient in MPI and or EMPI if the patient does not already exist
  • collects basic billing and in insurance
  • front-office function in hospitals, clinics, ancillary service areas, physician offices
33
Q

An ADT module includes the ability to

A
  • admit the patient to an inpatient setting
  • discharge the patient
  • transfer the patient to another clinical unit
  • has census capability
  • has notification and interface capability
34
Q

Name the financial and admin modules?

A
  1. Insurance and Billing
    - –creates bills for patients and 3rd party payers
    - –captures and tracks patient insurance policy information and other benefit information
  2. Payroll
    - –May or may not interface with HIS
    - –often a component of HR system module
    - –often has interfaces with time and attendance systems that automate the “clock punching” process
  3. Material management
    - –supports procurement of capital equipment and operational supplies and inventory functions
    - –automates purchasing ordering shipping storage processes
    - –assists with managing inventory
  4. Accounts Payable
    - –collection management
  5. Gender ledger
  6. Budgeting
  7. HR
35
Q

Some billing modules include

A
  1. charge master- provides information about charges to the other HIS modules
  2. automation of charges for prescriptions, in and out patient, co-payments, and tracking of billing caps
  3. event tracking- for insurance company reviews or disputes of bills
  4. group plan coverage information
  5. electronic data exchange (EDI)- capability to send transactions ot clearinghouses, which send them on to payers

EHRC (10 decks)

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