HRM EXAM Flashcards
Prehistoric Medicine consists of?
Belief that illness was the result of supernatural forces, disease was caused by invasion of evil spirits.
Tribal priests drove angry gods and evil spirits from diseased bodies with the use of various plants, potions, and procedures such as trephining, which was cutting through the skull with a stone instrument to release evil spirits.
In Ancient Medicine, Greek Philosophers believed what?
Greek philosophers believed that earth, water, air, and fire were the four elements that governed their universe.
Hippocrates is considered what?
often called the “Father of Medicine”, was the first medical practitioner who considered medicine to be a science and an art, separate from religion
The Hippocratic Oath is?
still used today, expresses Hippocrates’ expression of early medical ethics and high ideals
What did Galen do?
Galen excised tumors and treated fractures
What did Antyllos do?
Antyllos treated cataracts and bronchial fistulae
Early Preventative Medicine started by…
minimizing contamination and isolation procedures being identified.
In the medieval years (864-930 AD), what diseases were identified?
measles, smallpox, tetanus, meningitis
First hospitals were created in?
the first hospitals were created in the middle East.
During the Renaissance years (1300-1600 AD), what changed?
Autopsies became more common in an attempt to understand the human body.
Anatomy became better understood as illustrators depicted internal organs, bones, muscles, blood vessels, nerves
In 1895, Wilhelm Roentgen discovered…..
X-rays to view inside the body
In 1898, Pierre and Marie Curie discovered….
radium which would become a weapon used to treat cancer
When was chemotherapy introduced?
1910
What did Penicillin become?
the first antibiotic
When were AIDS & HIV identified?
1981
Who isolated insulin at UofT in 1921?
Sir Francis Banting and Charles Best, under the direction of John James Rickard Macleod, isolated insulin.
Who invented was the Experimental external cardiac pacemaker-defibrillator?
Dr. John A. Hopps, 1951-1955.
Pre-confederation (<1867) Canadian Healthcare was provided by…..
Prior to confederation, the religious community and families provided health care to each other in the best way they could.
The first medical schools were established in the 1820’s, where was the first in Canada?
The Montreal Medical Institute was one of the first medial schools established in Lower Canada.
This is now the faculty of medicine at McGill University.
When was the The College of Physicians and Surgeons of Upper Canada established and permanently incorporated?
The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated.
Who pioneered the right for women to practice medicine?
The pioneers, Emily Howard Stowe and Jennie Kidd Trout were responsible for this.
Emily helped lead the creation of the Ontario Medical College for Woman which was affiliated with the University of Toronto.
What happened Post-confederation within healthcare?
The Victorian Order of Nurses were established in 1897 to provide needed care to the populace.
When was The Canadian Red Cross Society developed and assisted with the health of individuals, families, and communities?
May 19 1909.
When was old age pensions introduced in Canada?
in 1927
When was unemployment insurance created in Canada?
unemployment insurance in 1940
When was the family allowance created in Canada?
the family allowance was created in 1944.
Saskatchewan’s Premier Tommy Douglas, introduced what?
introducing government funded medical insurance in the 1940’s.
Premier Tommy Douglas initiatives in health care, moved throughout the other provinces in Canada.
In 1956 the Federal government passed the Hospital Insurance and Diagnostic services Act and the Medical Care Act in 1966. What do these two make when put together?
Together these acts formed the creation of Canada’s publicly-funded universal health insurance known as Medicare.
In 1984, The Canada Health Act was passed, what did it do?
prohibited user fees and extra billing by doctors.
What are the 3 main levels of Continuum of Care?
- Primary
- Secondary
- Tertiary
What is primary care?
Primary Care: First point of contact care Includes preventive care and acute care medicine
Examples:
* Annual physical exam
* Health Education
* Immunizations
* Vision and hearing assessments
* Annual dental assessments
* Medical consultations
* Acute trauma
* Advanced Life Support (ACLS)
What is secondary care?
Secondary Care: Services provided by medical professionals whose primary care was provided by a primary care provider
Examples:
* Sub-specialty consultation
* Acute complex trauma
* Advanced Trauma Life Support (ATLS)
* On-call consults
What is tertiary care?
Tertiary Care: These services are provided by hospitals with advanced and/or specialized treatment abilities Services provided by uniquely qualified health professionals
Examples:
* Burn center treatments
* Neurosurgery
* Cardiothoracic surgery
* Neonatology
* Organ transplants
* High-risk pregnancies
What does the governing board do?
- The governing board is basically the watch-dog of the hospital.
- They ensure that the hospital is following its strategic plan, remains financially solvent, and operates under the Hospital Act and other regulations.
- The bottom line responsibility of the governing board is to ensure the patient is well cared for.
What does administration do?
Hospital administration is the coordinators between staff and the Governing board.
Who are the medical staff?
This includes the physicians, other specialists that work in the facility.
That includes:
* Doctors of Osteopathy
* Medical Doctors
* Doctors of Podiatric medicine
* Doctors of dental surgery
What are house officers?
includes physicians who work in the medical facility, also known as house staff.
What are the categories of Medical Staff?
Active – practitioners who admit patients in a facility, perform both outpatient and inpatient procedures, and work full time in the facility
Associate – resident in training
Consulting – includes specialists
Courtesy – physicians currently working in other facilities; can also be consulting physicians.
Honorary – staff who have worked for many years, and consult post retirement, although not in a medical capacity.
Allergy and Immunology is?
Treatments of allergies and the immune system
Anesthesiology
Pain management, surgery and beyond
Colon and Rectal Surgery
Treatment and management of diseases of the intestines; diseases of the intestines
Dermatology
Care for skin disorders
Family practice
Total health management
General surgery
Regular surgeries
Gynecology
Care of female reproductive and urinary conditions
Internal Medicine
Treatment of adult medicine
Medical Genetics
Care of patients with Genetically linked diseases
Neurology
Care and treatment of disorders of the nervous system
Obstetrics
Management of pregnancy
Ophthalmology
Care of eye disorders
Orthopedics
Care of musculoskeletal disorders
Otorhinolaryngology
Care of disorders of ear (ot), nose (rhino) and throat (Laryng)
What is Health Data?
health facts about a patient that describe a health issue
Plastic and reconstructive surgery
Repair and restructure of body surfaces
Psychiatry
Care of behavioural health issues
Radiology
Diagnostic tool
Thoracic Surgery
Surgical procedures for chest area
Urology
Treatments for disorders of the genitourinary system and adrenals
A typical flow through the life of a health record is?
- Patient is discharged from facility.
- Chart is held in the medical unit that the patient was in for several days so that final nursing notes can be documented and physicians can have an opportunity to complete their written notes.
- Chart is picked up by a “chart runner” whose job is specific to picking up discharged charts and safely bringing them to the Health Records Department.
- Once received in the health records department, a discharge list is produced, and items are checked to ensure that all discharged records are in the department. Missing records are followed up on immediately.
- All charts are logged into the department on a chart tracking system, which provides an audit trail of the charts whereabouts.
- The chart then gets assembled, and scanner readied in an electronic environment.
- Once scanner readied, it moves to the scanning area. Each page is scanned-front and back, and then moved to the verifying desk.
- The chart is verified – this means each page is looked at to ensure that all the information is for the same patient, and same admission, and the quality of the scanned item is good.
- The chart moves to the analysis desk where area are checked to ensure compliance with internal documentation requirements
- If there are no discrepancies found in analysis, the physical chart can be set for destruction. The computerized chart is considered the original chart.
- If discrepancies are found, a discrepancy sheet is printed off detailing what the attending physician must complete. The physical chart is filed by physician name in an incomplete chart room.
- Once completed the discrepancy is closed in the system, items that require re-scanning are done at this time. Once all is verified again, the chart can be set for destruction.
When is the Health Records Department Open?
The health record processing department is open 24 hours per day, and all 7 days.
Receptionist responsibilities?
- The receptionist assists people that come into the department.
- Provide medical documentation/chart copies to the emergency department, (ER), Intensive care unit (ICU) Continuing care unit (CCU) and Ambulatory care for patient care.
- Telephone duties
*order stationary and other supplies for the department.
- Sign in charts that are being returned to the department. (Except for daily discharge charts)
- Sort incoming mail and distribute as required.
What does a discharge clerk do?
- ensure that all inpatient discharge reports are received, recorded and organized by date and placed in the designated area.
- control and log all fetal monitoring strips.
- daily discharges are imported electronically and printed off as a check list.
- receives the physical chart in the department and records receipt of all discharged charts in an electronic chart tracking system
- follows up on missing charts or documents by contacting the unit that the patient was on.
- Organizes and files chronic care chart “thinning”.
What is “thinning”?
Chronic care patients are acutely ill patients that require extensive care, and their visits are lengthy.
This creates a thick chart which is not easy to control on the floor, so certain components, such as the (MAR) medication administration reports or continuing care flow sheets are forwarded to the health records department for storage until the patient is discharged.
File Clerk-Scanner Ready, does?
- Whether a chart is being processed to be filed manually or to be scanned into the system, it must be properly prepared.
- The file clerk removes all staples, removes duplicate forms (admission sheets, emergency face sheets), ECG rhythm strips and odd sized results and reports must be taped carefully on a mounting sheet.
- All sheets that do not have an Addressograph label have to be labeled with patient name, unit number, and account (admission) number. If they are double faced sheets, both from and back must be labeled.
- The clerk then will put the chart in assembly order, ensuring that all patient documentation is in date order, and all information is for this patient and encounter from time of admission to discharge.
Scanning Clerk does what?
- For facilities that scan documentation into a chart, the scanning clerk will verify that charts have been properly scanner readied.
- They scan the chart in the optical scanner, and rescan imperfect images.
- They are responsible for troubleshooting minor issues with the scanner and reporting the bigger ones.
Verifying Clerk does what?
- The verifying clerk will verify the image quality of all documents.
- They assign or confirm that the correct patient and form identification is available for each form.
- They confirm that the document image has become a part of the electronic record.
What does the analysis clerk do?
- The analysis clerk is responsible for ensuring inpatient information is complete according to legislated and hospital guidelines.
- The clerk prepares incomplete notification sheets that inform the primary physician of discrepancies in the chart.
What does a destruction clerk do?
completes a destruction log of charts that have been successfully scanned and verified, and ensures safe destruction of the paper copy.
What does an Incomplete Chart Room Clerk do?
- The incomplete file room clerk is responsible for filing all of the charts awaiting completion by physicians.
- They file all charts in terminal digit order and by physician name and assist physicians with determining issues with the chart.
- At times they are required to reanalyze a chart if the physician points out an error in directing the chart to the most responsible physician.
Finally, once a chart is completed by a physician, they discharge the chart from the incomplete file room and direct it to destruction; as well as sending any paper changes for rescanning. (Also called scan-complete)
What does the File Clerk – Clinic Retrieval do?
The primary function of the clinic retrieval clerk is to provide patient records for scheduled clinic visits.
The clerk prints off the clinic listings for the next day, then prints off the requested patient information from the chart.
Documents are organized in files, and are signed out to the clinic.
What does the File Clerk- Report Distribution do?
This position entails distribution of medical diagnostics and clinical reports to primary care physicians, specialists, legal firms, and insurance companies as required by the writer of the document.
What reports are handled by the record distribution clerk?
- consultations
- clinical reports
- discharge summaries
- history and physical reports
- oncology notes
- operative notes
- psychiatric notes
- social work notes
- preadmission notes
- diabetes education notes
- nephrology notes
- speech and audiology
- occupational health
- physiotherapy
- emergency treatment records and other specialties of the facility.
What does the Reception- Release of Information do?
- The release of information receptionist greets clients coming into to the department, assisting them with the completion of their consent to disclose medical information.
- They explain the general procedures in the department, and request input from the specialist when the questions are beyond their scope.
- They also key all requests for release in information into the ROI request screen, and print letters for additional information required.
*They may do other general clerical duties as required.
Medical Transcriptionist
transcribes dictated data creating medical reports such as consultations, clinical reports, discharge summaries, History and physicals.
Health Record Technician-Coder
A coder assigns codes from Classification Systems to abstracted medical information including: diagnostics, and interventions to disorders/diseases.
Health Data Analyst
A health data analyst compiles statistical data for hospital usage, W.H.O., and C.I.H.I.
Release of Information Specialist
A release of information specialist processes requests for medical information from hospitals, doctor’s offices, patients and their families, social service agencies, police, insurance companies, legal firms, risk management, and others.
Manager of Health Information Department
The managers of heath information departments are responsible for a range of areas, and depending on the size of the facility; can be responsible for the day to day flow of record processing, transcription, coding, analysis, and hospital statistics.
Director of Health Information Management
The director of health information management is responsible for all of the functions within the department, including Privacy with direct reports often including departmental management, and Release of Information.
They are involved in many committees both internally and externally.
Contract Service
Contract services are used in the Health Information Management for transcription, coding, and image scanning for chart processing.
CHIMA stands for?
In Canada, the governing body of health information management professionals is the Canadian Health Information Management Association (CHIMA).
CCHRA stands for?
The Canadian College of Health Record Administrators
What are complications?
Additional diagnoses that describe conditions arising after the beginning of hospital observation and treatment and that modify the course of the patient’s Illness or the medical care required; they prolong the patient’s length of stay by at least one day in 75 percent of the cases.
What is a Comorbidity?
Pre-existing condition that will, because of it’s presence with a specific principal diagnosis, cause an increase in the patient’s length of stay by at last one day in 75 percent of the cases.
Acute Care Facilities
When we refer to acute in a medical context, it means a disease or occurrence that that came on suddenly.
An example would be tonsillitis, or else, a car accident that takes you to a hospital for medical care.
Behavioral hospitals
- These facilities provide care for mental health issues, and or chemical dependency.
- The Centre for Addiction and Mental Health (CAMH) is the largest mental health facility in Ontario. It has 26 offices across Ontario which services all types of mental illness as well as addiction control.
Home Care
Home care is provided to people who require assisted living in their homes.
They may have a serious illness, physical or mental disability.
The population serviced by home care would be mainly senior, however all age ranges would be covered.
What is the CCAC and what does it do?
Community Care Access Centre is a service provided that helps to coordinate care at home, or access to assisted living in the community.
They also assist with arrangements for Long term care. The CCAC’s are funded in Ontario by Local Health Integration Networks (LHIN) of the Ministry of Health and Long -Term Care.
What this means, simply, is that they are covered under OHIP.
Hospice
Hospice care involves care for terminally ill patients that have determined that they desire to spend their last days in their own homes or at times within a facility.
The focus of care is palliative, not curative. Palliative care includes services that relieve pain and discomfort for the patient.
It also provides support to family members that are assisting in the care.
This is classified as Respite care.
Long Term Care
Long-term care involves a move into a facility which specializes in individuals who cannot live in their homes independently.
The CCAC’s are funded in Ontario by the Ministry of Health and Long -Term Care.
What this means, simply, is that they are covered under OHIP.
The Patient Record: what is it?
- It is called a health record, medical record, and medical chart.
- It is a business record
- It is a legal document
- It is a method to store Administrative data which is a compilation of demographic, socioeconomic, and financial data.
- It is primarily a history of the health of the patient.
Demographic Data
a statistical term used to refer to characteristics (information) of human population. Simply put-it is basic information about you.
1. Name 2. Address 3. Telephone number 4. Date of birth 5. Emergency contacts 6. Gender
What is socioeconomic data?
If we break down this term, socio=social, and economic= financial position.
Included in this group is:
1. Marital status
2. Race/ethnicity
3. Occupation
4. Place of employment
What is financial data?
Financial data would include insurance including OHIP plus any secondary insurance. It is a method to store Clinical Data.
Example
1. insurance
2. OHIP
3. Secondary Insurance
What is clinical Data?
Clinical data is as the term infers is Health information that includes diagnostic reports, such as:
- Radiology
- Lab reports
- Cardiopulmonary reports
What does CPSO stand for and what does it do?
The College of Physician and Surgeons of Ontario.
They have produced a policy statement with covers administration of Heath records.
The college is a regulatory body for the medical practice.
Medical records can be subject to reviews from regulatory bodies such as…
- CPSO Peer Assessment Program and Independent Health Facilities Program
- The Coroner’s office-CPSO investigations
- OHIP billing reviews
- The medical records are requested in lawsuits, hearings and inquests.
The Cumulative Patient Profile (CPP) is made up of what?
- Patient demographic information – name address phone numbers OHIP number.
- Personal and family data-next of kin, person to notify, family health history, occupation, and major events that may have affected the patient through their life.
- Medical history of patient
- Risk Factors – smoking, stress in personal or occupational matters, family genetics.
- Allergies and drug reactions
- Health maintenance – annual physical, breast screening, colonoscopy, bone density
- Names of consulting physicians
- Long term treatment-current medication, dosages and treatment. Ex Asthma treatments
- Major Investigations
- Date the CPP was last updated
SOAP is an acronym that stands for….
S-Subjective: describes the patient’s statement of how they feel-(symptoms)
O-Objective: describes the findings of diagnostics done prior to this assessment
A-Assessment: describes the opinion, or possible diagnosis of the physician
P- Plan: describes what the physician will do to care for the patient.
Most Responsible Physician (MRP) is
The physician that attended to the patient through their episode of care.
They are responsible for completion of the Admission sheet, also known as the Admission Face Sheet which provides a summary of the care.
They are also responsible for completion of the discharge summary which is another form of summary.
The Longitudinal Patient Record
contains all of the information from all episodes of care that a patient receives; including all the different family doctors, specialists, hospitals, radiology centres, labs, etc. that a patient has received through a lifetime of care.
What are important elements of the CPR?
- The record should include active and inactive problems, and should include all diagnostics, consults, clinical reports, and summaries of the history of the patient.
- The system must be secure in order to protect the confidentiality of the patient’s information.
- The data in the CPR should be maintained utilizing a standardized dictionary of terms.
Bar coding
pre coded forms with bar codes automatically index or sort the document into the required area.
Report numbers
Certain documents are pre numbered, again with the purpose to index or sort the document into the required area.
Canadian Health Infoway
The Canadian Health Infoway was created in 2001 to coordinate and facilitate the creation and development of electronic health systems across Canada
What is done when a record is edited?
- Records should be accurate and promptly completed
- Records should follow chronological formats
- Records should be filed safely and maintained
- Records should be readily available when required.
- Records should be identifiable: patient name and other identifiers such as date of birth, health card number, and occurrence number.
- The record should tell the story of the encounter and support diagnosis determined as well as diagnosis and progressive care.
- Entries must be legible and authenticated by the author.
- Records must be retained for a period designated by provincial statues and hospital policy.
- All encounters must be coded and indexed to provincial standards
- The hospital must establish standard policies and procedures for release of medical information.
The Face Sheet or Admission face sheet is
so named as it is the first page of an inpatient encounter.
It lists demographic and clinical information.
What is an intervention?
what is done to correct a patient’s medical problem.
It may be surgical, or diagnostic in nature.
The Admissions Record Contains…
- Facility name, address, hospital number
- Patient name
- Unit number
- Registration number – also called an encounter number Admission date and time
- Health card number Ambulance, Language spoken
- Date of birth, sex, age, marital status
- Age group
- Resident code
- Admission category – urgent
- Patient address and phone number
- Religion
- Emergency contact name & phone number
- Next of kin, and relationship
- Comments
- Accommodations: requested- (private, semi-private, ward)
- Assigned room number
- Transferred from
- Most responsible Physician, Family Physician, Other physician(s)
- Medical alerts
- Estimated discharge date
- Admitting diagnosis
- Allergies: drug, food, others.
What is a Consultation?
additional opinions provided by specialists, an attending physician will request a specialist see a patient who has a complex condition.
Physician’s orders are?
gives guidance to the healthcare team. Orders can be provided for treatment, laboratory tests, radiology, medications with dosage, medical devices, to call in consults, provide seclusion, or restraints.
Progress Notes
notes that are made concurrently with a physician/ patient encounter.
They may also be called multi-disciplinary progress notes, as they are used by a variety of care-givers such as nurses, registered practical nurses physiotherapists, occupational therapist, respiratory therapists, social workers dieticians, etc
Subjective Data contains….
- Presenting complaint, including the severity and duration of symptoms.
- Whether this is a new concern or an ongoing/recurring problem.
- Changes in the patient’s progress or health status since the last visit.
- Past medical history of the patient and his or her family, where relevant to the presenting problem.
- Salient negative responses.
Objective Data contains….
- Relevant vital signs
- Physical examination appropriate to the presenting complaint.
- Positive physical findings
- Significant negative physical findings as they relate to the problem.
