Module 5 Introduction to Data Quality Flashcards
HIM professionals are one of the main collectors of health information and therefore have the responsibility to maintain ____
high quality data
Name some data collection trends.
- increasing amounts of data are being collected and used for a variety of purposes
- conversion of paper > hybrid > EHR
- adding data collection from more settings like home care, long term care
- standardization
As we move toward a fully integrated, pan-Canadian EHR, the importance of ___ has become more evident
standardization
Standardization needs to be considered for which 4 factors?
- systems
- processes/methods
- rules
- timelines
High quality data means data that is:
- accurate
- timely
- complete
- held to a high level of integrity
ICD-10-CA/CCI were implemented in which years in Canada?
2001-2003
When were ICD-10-CA and CCI implemented in Alberta?
2002-2003
When is ICD-11 due to go to the WHO Assembly?
2017
Name a future system trend.
computer assisted coding
Who is using data collected?
CIHI, Insurance, education, research, funding, drug companies
What are the impacts of poor quality data?
insurance denied, miss out on teaching and learning opportunities, impact funds
What promotes data quality?
national coding standards, training/education sessions, use of abstraction and encoder systems
______ systems have built in edits to ensure that the data entered fits the expected format of the field, falls within the acceptable range of values, and has a logical relationship to other fields
abstraction and encoder systems
Done to determine the quality of coding in clinical and non-clinical information; helps to identify the sources of coding standardization and/or inaccuracy issues
reabstraction studies
What is the purpose of reabstraction studies?
Not to place blame, but to identify possible data quality issues
What are some causes of coding variations?
- Misinterpretation of standards
- Non-compliance with, or lack of knowledge of, the standards
- Hospital or regional practices that negatively affect the data quality
- Quality and completeness of chart documentation
- Unintentional human error
Verifies the accuracy and completeness of the record, and ensures the chart is in the correct facility-determined order
health record analysis
What are the two main types of health record analysis?
quantitative and qualitative analysis
The third type of health record analysis which should be met if the quantitative and qualitative analysis is completed accurately
legal analysis
A detailed review of the health record, usually completed after a patient has been discharged from the facility
quantitative analysis
Why is quantitative analysis done?
- to verify the presence of required data
- to ensure that reports have been authenticated and/or signed by the healthcare provider responsible for that form or entry
If a chart isn’t complete, it is termed _____
delinquent record
Delinquent records must be completed in the timeline set by the facility’s _____
bylaws
Accreditation standards often require that delinquent records be completed within ___ days of discharge
14
T or F. Failure to complete missing information may result in the physician having their admitting privileges suspended until the charts are complete.
T
Once a physician completes the missing elements, the chart is ____ to ensure completion.
reanalyzed
Most hospitals using paper-based health records will use _____ indicating any omissions placed at the front of the incomplete episode of care, indicating the responsible documenter, what and where the deficiencies are in the record, and the date and signature of the employee who performed the quantitative analysis.
pre-printed form
Electronic Health Record programs will have a ____ procedure in the software
deficiency notification
The professional analyzing the chart will open the chart to view it, and then create a ______ to note any missing signatures or documentation. Once the document is created, the physician receives a ______ when they log into the EHR
deficiencies document, deficiency message
T or F. Physicians can either electronically sign or reject the deficiency
T
A health record can meet the standards required for quantitative analysis, but this may not
mean the documentation is _____ and _____
consistent and error-free
Analysis that requires thorough knowledge of medical terminology, anatomy, and pathophysiology in order to identify inconsistences and refer them for review by the appropriate medical or clinical staff committee
for follow-up.
qualitative analysis
It is the role of the ___ to determine whether there is a true inconsistency, or if the documentation is sufficient in its current state.
committee
T or F. Performing quantitative and qualitative analysis can be very labour-intensive, and therefore costly
T
What is the current trend in quantitative/qualitative analysis?
Shifting the responsibility of ensuring documentation is complete to the healthcare providers.
Pre-printed forms address which 6 main data elements?
- omissions
- who needs to complete the chart
- what the deficiencies are
- where the deficiencies are
- date
- signature of the employee who did the QA
Incomplete charts are often filed in a separate area by either _____ or _____
provider name or chart number
T or F> Once the provider has completed the charts they will go through quantitative analysis again to confirm omissions were completed; once confirmed the charts will be re-filed in the active area
T
