Module 4 Records Management Flashcards
The Master Patient Index (MPI) is also called ____
Central Person Index (CPI)
Enterprise-wide Master Person/Patient Index (EMPI)
Database of patient registration information of all the patients who are being or have been treated at the hospital in any capacity
Master Patient Index (MPI)
MPI includes ___ and ___ patients such as those who received service in day procedure areas, clinics, and the emergency room.
inpatients and ambulatory care patients
The first level of content in MPI that remains fairly consistent from visit to visit
demographic information
List the data elements one finds in demographic information.
full name, gender, date of birth, address, personal health care number, chart number (or encounter number used to identify and locate previous visits
The second level of content in MPI that usually varies from visit to visit
visit information
T or F. Visit information is specific to that encounter with the healthcare facility
T
List the data elements one finds in visit information.
specific episode number, encounter/admission date, patient type/service, admitting diagnosis, attending physician
What are the primary uses of an MPI?
locating the record, report routing, statistics (bed count), and providing a current list of inpatients
Information contained in an MPI is protected by _____ that pertains to the health record
legislation
MPI information is subject to the authority and provisions of the ____ in Alberta
Health Information Act
Smaller healthcare facilities may still be using ___ MPIs where patient information is written or typed on an index card then stored in a card catalogue
manual
The most common MPI method is a ____ often shared between many hospitals in the same treatment area
computerized system
What are the advantages to computerized MPIs?
- easy retrieval of patient information
2. allows more than one person or department to access the MPI at one time
Computerized MPI automatically assigns the ___ number
specific encounter
Computerized MPIs have ____ systems built into the system to allow statistics to be run on capacity and treatment types
reporting
T or F. Ensuring an effective back-up system is in place for the healthcare facility’s MPI is crucial, and
is often part of the role of the HIM professional.
T
The MPI is the key to the _____ of all charts
and patients in a healthcare facility, and that information must be backed up frequently and
reliably.
location
T or F. Unlike the actual patient health record, MPI information is stored PERMANENTLY as a record of all
patients who have ever been admitted or treated in a healthcare facility.
True
AHS typically uses what kind of MPI?
regional EMPIs
In MPIs, ___ is entered on the first visit; information can be verified and updated as needed on readmission
data
What are frequent errors in MPIs that must be reviewed frequently?
Duplicate chart numbers for one patient, or two patients with the same number
What are the different ways data can be collected for MPIs?
- interview
- checklist
- questionnaire
Data collection process completed by a nurse or allied health provider, but the questions are asked of the patient; allows for descriptive answers
interview
Data collection process completed by a nurse or allied health professional, but check boxes allow for standard collection of information for simple data elements
checklist
Data collection process similar to an interview, but shorter, and with a specific purpose. Completed by a nurse, physician or allied health care provider, often through a combination of observation and patient questioning
questionnaire
What does preparing a document for scanning involve?
- removing staples, clips, etc
- scanning
- quality assurance
- indexing the document to the correct patient
What needs to be taken into account when deciding how to best store health records?
frequency of record use
ease of access
stage in the progression to an EHR
What is the main advantage in switching to an EHR?
Saving space required to store paper-based health records
What is important to consider when determining the appropriate filing system for paper-based patient records?
- size of the filing system
- frequency of access for filing and retrieval
- future growth of the population served by the facility
- facility rules/guidelines for inactivating records
- availability of secondary or off-site storage
- future electronic stage intent
- record retention period
What type facilities are best suited to filing cabinets?
small, low-volume facilities with dirty environments and high-fire dangers
What type facilities are best suited to open-shelf files?
high-volume file areas with clean environments and enough space to move files around
What areas of a hospital are best suited to open-shelf files?
clinics and outpatient areas
What type facilities are best suited to motorized revolving files?
small, low-activity areas with one primary file worker
What type facilities are best suited to compressible units?
low-to-medium file activity with limited space and two or three file maintenance workers
Filing storage type that is locked and best for files needing high security
filing cabinets
Filing storage type with full access to the front, like a bookshelf
open-shelf files
Filing storage type with shelves that move around a central spine with records carried on bucket shelves; runs by a motor
motorized revolving shelves
Filing storage type with open-shelf files that move in parallel lines on a track to form an aisle opening with the files being moved with motor assistance or a hand crank
compressible units
What are the advantages of filing cabinets?
- protects records from environmental damage
- locks to enhance security of the records
- stores records with sensitive information or those involved in court proceedings safely
What are the advantages of open-shelf files?
- easy access to any part of the shelf
2. accommodates multiple workers at a time
What are the advantages of motorized revolving shelves?
- requires little aisle space
- filing work can be done at one height level
- records can be covered and locked
What are the advantages of compressible units?
- saves space of unused aisles
- easy access once an opening is created
- hand cranked units will not have the power or motor failure issue
What are the four types of filing storage?
- filing cabinets
- open-shelf files
- motorized revolving files
- compressible units
What are the disadvantages of filing cabinets?
- requires dedicated aisle space
2. opening one drawer at a time can be time consuming
What are the disadvantages of open-shelf files?
- requires dedicated aisle space
2. leaves records exposed to the environment
What are the disadvantages of motorized revolving shelves?
- if charts aren’t fully loaded and unloaded, the bucket becomes unbalanced and the motor won’t run
- Iif there is a motor or power failure, records are unavailable
- cost of installation and maintenance can be high
What are the disadvantages of compressible units?
- Same as motorized revolving aisles
- it is important to ensure no other worker in the files before closing the aisle and opening a new one, or worker will be injured
What are other two ways to store files?
microfilming & electronic storage
Archiving process involving photographing the original document and storing the image on film in a very small size
microfilming
Paper records can be stored here through the use of scanners; bar codes can be used to uniquely identify the record
electronic storage
Electronic storage can index pages with the record for the ___, the ___, and the ___ type
individual, encounter, document type
What are the advantages of microfilming?
Reduces paper handling and can be reproduced
What are the advantages of electronic storage?
Allows for storage of a substantially large amount of data
What is the disadvantage of microfilming?
Require special readers which make it relatively expensive
The health record should be located in a place that will facilitate rapid ____ and ____
retrieval and distribution
Health Information Management professionals need to be aware of the _____ issues that accompany the storage
of patient health records
space management
What are the two methods of storage for paper-based health records?
centralized and decentralized
Retains all information about a person in one location within the organization or facility
centralized storage
Centralized storage would be in the ____ department, staffed by trained clerks and HIM professionals who can provide records requested by authorized users.
health information
What are the advantages of centralized storage?
- costs are lower
- easier to maintain the necessary levels of security in regards to record control
- consistent supervision is available for file maintenance staff
What are the disadvantages of centralized storage?
- requires transportation of requested records to various locations within the organization for facility
Parts of the health record are located in different places within the organization or facility; outpatient department or clinics may file their charts in their own department
decentralized storage
What are the advantages of decentralized storage?
- the file format can be flexible to meet the needs of each storage area.
- requires less transportation of patient records
What are the disadvantages of decentralized storage?
- increases the cost of storage equipment
2. control of who is accessing records can be more difficult
T or F. EHRs don’t alleviate the storage issues associated with paper-based patient charts
False
What are some challenges of an EHR?
back up and access of health records
EHR presents fewer challenges in terms of:
- space restraints
- workflow issues
- misfiles
- record tracking
Ideally, all health records would be retained in indefinitely, but due to _____ this is not feasible
space restraints
T or F. Prior to HIA, there were only suggested guidelines in place for retention periods
T
Which act provides instructions regarding the retention of health records?
The Health Information Act (HIA)
The Health Information Act (HIA) for AB states that retention of health records should be kept 1. a minimum of __ years from the last date of discharge or 2. __ years following the date the patient reaches the age of 18 for minor patients (or __ years, whichever is longer)
10 years, 2 years, 10 years
What is an enterprise-wide MPI (EMPI)?
MPI used across different facilities
HIA states that if records are microfilmed on discharge, the original record must only be kept for __ year/s
one
HIA states that -ray films can be destroyed after __ years
5
HIA states that anything the hospital board considers necessary can be retained for _____ as determined
an additional period
According to HIA’s guidelines for destruction, destruction of records bust be ____ and ____
secure and complete
What are the best ways to destroy paper and hard copy media records?
pulping or shredding
Health information stored on hard drives and external storage must be _____ before they’re disposed of or sold
professionally wiped clean
____ guidelines specifically for documentation can minimize provider errors
data quality guidelines
CHIMA published a white paper titled ______
An Essential Guide to Clinical Documentation Improvement
T or F. Physicians/healthcare providers aren’t trained to develop proper documentation skills, which required hospitals and healthcare systems to compensate with training and educational programs and tools
T
What are some examples of poor documentation?
- inconsistent documentation among all providers
- incomplete progress notes
- missing progression of illness, degree of severity, or disease manifestation notes
- missing causal relationships
- postoperative complications not listed
- historical Dx is documented as current
How is quality of documentation evaluated?
measuring:
a. # or % of discharge summaries/operative reports missing at the time of coding
b. # or % of cases with a specific diagnosis not documented by the physician, or not documented with specificity
c. # or % of cases with lab or DI tests results not confirmed by physician
CHIMA suggests all facilities should have ____ program to minimize errors arising from poor documentation
Clinical Documentation Improvement (CDI)
What are the four key steps in a CDI program?
- Needs assessment/re-abstraction study and documentation review
- Analysis of above results w recommendations for improvement
- Physician/clinician engagement and education
- Ongoing management/evaluation
One of the worst issues in documentation involves ____ and ____ use in a health record
abbreviation and acronym use
Organization that produces a list of error-prone abbreviations, symbols, and dose designations
The Institute for Safe Medication Practices
Filed according to patient’s last name, followed by first name then middle name/initial
alphabetical filing
What are the three groups of paper file storage from biggest to smallest?
- centralized/decentralized
- filing cabinets, open shelf, motorized revolving, compressible units
- alphabetic filing, straight numeric filing, terminal digit filing
Alphabetical filing works for less than ___ records with a stable patient population and little or no computerization
5000
Names with ___ and ___ are filed as if there were no apostrophe, space, or hyphens present
prefixes and hyphenation
What is the “nothing before something” rule?
Patients without a middle name/initial come before those who do
Filed according to lowest to highest number, with new records added at the end of the number series
straight numeric filing
Breaks the chart number down into 3 groups from right to left; accommodates large volumes of records because long chart numbers are divided into sections and can be managed more easily
terminal digit filing
What are the last 3 numbers in terminal digit filing called?
primary digits
What are the middle 3 numbers in terminal digit filing called?
secondary digits
What are the first 3 numbers in terminal digit filing called?
tertiary digits
What are the advantages of terminal digit filing?
- distributes records evenly throughout the storage area
- allows assignment of file clerks to different areas
- easily purge files
- add new patients with minimal file shifting
Surgical records are unique in that they require additional ____ forms
specialized
Surgical records are grouped together in ___ and arranged in ___ order for each operative event on the same admission
in sets; chronological order
T or F. Most of the same forms used on a medical health records are also used on a surgical record
T
___ must be obtained from the patient for all non-routine diagnostic or therapeutic procedures including surgical procedures
informed consent
What must happen in order to qualify as informed consent?
Surgeon must explain the procedure(s) to the patient, any alternative procedures, risks of undergoing or not undergoing operation, any known or unlikely outcomes; must be explained in a way that the patient understands
How do patients demonstrate that they understand what has been explained to them?
By repeating the information in their own words and showing they understand the expected outcome of the surgery
Surgical form that is a concise report by the anesthetist of the details surrounding the administration of anesthesia
Anesthetic/anesthesia record
Anesthetic/anesthesia records aren’t required with what two types of anesthetics?
local anesthetic or anesthetics administered by a surgeon/obstetrician
Surgical form that contains preanesthetic evaluation, preoperative medication(s), anesthetic agent, technique of administation, effect and duration of anesthetic, continuous monitoring of vital signs during administration of the anesthesia
anesthetic/anesthesia record
Surgical form that a patient completes with a nurse to provide pertinent information to the anesthetist regarding previous anesthetics, medications, allergies and specific medical conditions that could influence the selection of anesthetic technique and/or agents
patient preanesthetic form
Surgical form that provides a detailed account of the findings and procedures carried out by the surgeon during a procedure
operative report
The surgeon should dictate the operative report ___ following the surgery
as soon as possible
In the meantime, a brief summary can be written in the ___
physician’s progress notes
If there is more than one major surgeon performing their own procedure, each surgeon should dictate their own
operative report
What is the general format of most operative records?
a top section and a body of the report
What’s included in the top section of an operative report?
patient identification, names of surgeon, their assistants, and the anesthetist, date, preop diagnosis, postop diagnosis, procedure(s) performed
What is included in the body section of an operative report?
a detailed description of the operative technique and findings, including anesthetic agent(s) used, findings, operative procedure(s) performed, closure, condition of the patient at the end of surgery, additional info as needed
Surgical form that provides a concise review of the examination of tissue sent to the pathology lab
pathology/histology/tissue report
What does the pathology report include?
- gross examination
- microscopic examination
- description of the tissue
Surgical form that includes brief history and identification of the specimen(s), tissue findings, diagnosis, both clinical and pathological
pathology/histology/tissue report
Surgical form on which circulating nurse does their recording, rather than on the regular progress/nurses’ notes
operative detail sheet/nurses’ operating room record
Surgical form that contains date/theatre number/type of anesthesia/duration of anesthesia and surgery/names of anesthetist, surgeon and assistants, scrub and circulating nurses/operations performed, specimens sent to the lab/catheters, drains, and/or packing inserted and left in at the end of surgery
operative detail sheet/nurses operating room record
Surgical form that used to record the number of sponges, needles and instruments used during the operation to ensure nothing is accidentally left in the patient
sponge, needle and instrument count sheet
If there is a discrepancy on a sponge, needle and instrument count sheet, the patient may need to be ___ before leaving the operating room to try to locate the missing item
x-rayed
