Unit 4 Flashcards
Steps of record flow
- Patient registered
- Previous doc. delivered
- Doc. Is written by healthcare professional
- patient is discharged
- Health record is assembled
- Health record is analyzed for missing documentation
- Physicians and other healthcare professionals complete missing doc or signatures
- Record is permanently filed.
Centralized registration
Patients presenting for any type of care are registered through one central area
Decentralized registration
Multiple points of patient access depending on the type of care, emergency department, outpatient, diagnostics, ambulatory surgery, and so on
Master patient (person) index (mpi)
Permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is permanently maintained.
Medical record number
Unique numeric identifier for each patient seen in a health facility
Some facilities store pediatric patients records for how long
25 years
HIM manger who oversees record security does what
Most input on the final selection of a filing system used to house paper health records
Healthcare facilities can increase the efficiency of reimbursement cycles through what?
Performing high-quality, timely coding of diagnoses and treatments
Clinical data
Data found in a health record that are of a medical nature
WORM tech
Acronym for write once, read many. Records may be read numerous times, but nothing on the disc can be altered in any way.
Jukebox
Means of storing multiple optical disks using a robotic arm
Clinical data
Collected patient info, such as symptoms and diagnosis
Unit record
Master record that houses each individual encounter record
Enterprise
System of health providers and facilities that are under the same ownership
Outguide
Colored tag that aids kn the filing and organizing of paper records
Demographic data
Data that identifies the patient
Concurrent documentation takes place
While a patient is being seen or treated
Administrative data
Nonmedical data, such as patient idenfiers, insurance related data, etc
Hybrid record
Healt record maintained in paper format, electronic format, and or in the form of recordings or tracings derived from diagnostic tests
Client/server
Use of pcs in a Bert where functions are split between tasks.
Record retention plan
Written policy that documents the length of time a healthcare facility retains its health records, the form in which the records will be kept, and the location of records
Reimbursement cycle
Processes that take place from the time a patient is registered for care to the time the services are paid in full
Leagal health record
Considered the official business record and would be presented if subpoenaed
Clinical doc. Improvement (cdi)
Review of health records to ensure that the doc in the health records is at the level of specificity that allows for code assignment
