Health Information Functions, Purpose, and Users

These flashcards cover key concepts regarding health information management, including the purposes and functions of health records, data terminology, coding, algorithms, and systems used in electronic health records.

What is the primary purpose of a health record?

Patient care.

What are primary purposes of the health record?

They are related to direct patient care and management of patient care.

Define aggregate data.

Data extracted from individual health records combined to form deidentified information about groups of patients.

What is the master patient index (MPI)?

The permanent record of all patients treated at a healthcare organization.

What is an electronic health record (EHR)?

A digital record of health-related information that conforms to interoperability standards.

What is the difference between data and information?

Data are raw facts, while information is data turned into meaningful context.

What is clinical coding?

Assigning codes to represent diagnoses and procedures for billing and record-keeping.

Name a secondary purpose of the health record.

Education of healthcare professionals.

What is a deficiency slip?

A form created to identify missing documentation or signatures in a health record.

What does the term 'overlap' refer to in health records?

When a patient has more than one health record number at different locations.

What is a deterministic algorithm?

An algorithm that requires exact matches in data elements like patient name and date of birth.

What is the value of a personal health record (PHR)?

It allows individuals to collect, track, and share health information for themselves or someone they care for.

What is the difference between qualitative and quantitative analysis?

Qualitative analysis assesses the quality of documentation, while quantitative analysis reviews for missing documents or signatures.

What is meant by version control in health records?

Policies to manage access to different versions of documents in electronic health records.

What is a turnaround time in the context of health information management?

The time between receipt of a request for patient information and when that information is sent to the requester.

What is data mining in health information systems?

The process of extracting and analyzing large volumes of data to identify patterns or relationships.

What does an audit trail in an EHR provide?

A chronological record of activities that provides evidence of user actions related to health records.