Health Information Functions, Purpose, and Users

This set of flashcards covers key concepts, definitions, and important information related to Health Information Management, including the purposes of health records, roles of various users, and functionalities of health information systems.

What are the two primary purposes of the health record?

Primary purposes relate to patient care, while secondary purposes involve healthcare needs not directly related to patient care.

Define aggregate data in health information management.

Aggregate data are extracted from individual health records and combined to form de-identified information about groups of patients.

What is the role of the Master Patient Index (MPI)?

The MPI is a permanent record of all patients treated at a healthcare organization, used to link patient demographics and health records.

Explain the difference between data, information, and knowledge.

Data are raw facts; information is data that is meaningful; knowledge is the understanding gained from information that allows for informed decision-making.

What is a hybrid health record?

A hybrid health record combines both paper and electronic health records.

What functions does the HIM department perform?

The HIM department ensures the quality, security, and availability of health records, performs medical transcription, clinical coding, record storage, and more.

Define EHR.

An EHR is an electronic record of health-related information conforming to interoperability standards that can be created, managed, and consulted across healthcare organizations.

What is clinical coding in the context of health information management?

Clinical coding involves assigning codes to represent diagnoses and procedures used in patient care.

What is a deficiency slip?

A deficiency slip identifies needed documents or signatures missing in a health record.

List some individual users of the health record.

Individual users include patient care providers, coding and billing staff, patients, and healthcare managers.

What are the advantages of using a document management system (DMS)?

A DMS can scan, store, and provide electronic access to paper records, facilitating workflow and improving record management during the transition to an EHR.

What is a deterministic algorithm?

A deterministic algorithm requires exact matches in data elements to identify patients.

Explain the significance of version control in EHRs.

Version control manages multiple versions of documents to ensure users access the correct and most current document, while retaining previous versions for reference.

What is the purpose of an outguide in managing health records?

An outguide identifies the location of health records that have been removed, indicating where they should be returned.

Describe the term 'data mining' in health information systems.

Data mining is the process of extracting and analyzing data from databases to identify patterns or relationships for predicting behaviors.

What does the term 'deidentified data' mean?

Deidentified data are data stripped of all identifying elements that can reveal the identity of the patient.

What is meant by the term 'delinquent record'?

A delinquent record is one that remains incomplete for a specified number of days, usually exceeding 15 to 30 days.

What is meant by the term 'probabilistic algorithm' in health data management?

A probabilistic algorithm uses mathematical probabilities to assess the likelihood that two patients are the same based on available data.

Define the term 'clinical decision support (CDS)'.

CDS refers to systems providing health professionals with knowledge and person-specific information, intelligently filtered and presented at appropriate times, to enhance health and healthcare.

What are the risks associated with free-text data in EHRs?

Free-text data can lead to documentation issues such as inaccuracies, redundancies, and difficulties in retrieving information due to lack of structure.