ALL CHAPTERS

Health care delivery services

* Home health care
* Hospice care
* Long-term care
* Rehabilitation facilities
* Behavioral health facilities

Outpatient surgery center

Patients undergo surgical treatment and return home after recover, typically hours after the procedure.

Physician’s office or clinic

Physicians offer primary care or medical/surgical specialty care. The physicians may belong to an integrated delivery system or have private medical practices that are physician-owned entities.

Outpatient diagnostic or therapeutic services

Freestanding facility, hospital depart. or a satellite facility provides a variety of services. Services range from an Imaging Center, Infusion Center, or cancer treatment.

Neighborhood health clinics

Care is provided to economically disadvantaged, and treatment is family-centered.

Public health department

Provides preventive medicine services such as well-baby clinics.

Urgent care center

On-duty physician provides immediate care for non life-threatening condition. Many patients elect to use the center after the physician’s office is closed.

Home health care

Allows patients to remain at home and be treated by: NursesSocial workersTherapistsOther licensed healthcare professionals

Home health care settings include

Assistance with ADLsAssessment and monitoring of illnessesIV medication administrationWound care

Hospice care

Provides comprehensive medical and supportive care to terminally ill patients and their families. Hospice is based on the philosophy of palliative care, providing comfort rather than curative care. An interdisciplinary team provides care to the hospice patients.

What hospice settings include

HomeHospitalsLong-term facilitiesStand-alone hospice care facilties

Curative care

Therapeutic care

Interdisciplinary team members

PhysiciansNursesSocial workerSpiritual caregivers

Interdisciplinary team

Provide care to the hospice patients.

Long-term care facilities LTCs

“Nursing homes” and primarily provide care for older patients, mostly who cannot care for themselves.

Long-term care facility settings

* Skilled nursing facility or nursing facility
* Retirement communities
* Assisted living facilities
* Adult day-care programs

Skilled nursing facility or nursing facility

A team of healthcare professionals provides medical necessary services on a daily basis. Patients are often transferred from acute care (hospital) for continuing 24hr medical care.

Retirement communities

These communities provide a variety care based on the residents’ needs. Different levels of care range from independent living to skilled care.

Assisted living facilities

Assisted living is for adults who need help with everyday tasks. Patients may need help with ADLs, but not full-time nursing care. Some are part of retirement communities.

Adult day-care program

Offer a range of services during daytimes hours. The goal of the program is to provide respite for caregivers and avoid costly alternatives. Some center specialize in caring conditions such as Alzheimer’s disease.

Licensed practical nurse

AKA vocation nurse

Indicative

Another term for demographic data

Data that have been processed into a useful frame of reference is called

Information

Data entry

Process of recording data into an information system, either by: Hand to paperThrough a computer into an electronic record

Data is accurate when it is both:

valid and representing an expected range of values.

Data is timely when:

it’s entered or recorded with an appropriate time frame.

Concurrent data entry

Data what is preferably as the events being recorded are happening.

Data is complete when:

all of the data related to the patient’s visit has been recorded.

Preventive controls

Ensure data errors don’t happen through: Reprinted, multi-choice forms to collect dataSoftware drop down menusValidity checks that don’t allow the used to enter invalid info

Detective controls

Ensure data errors are discovered, and are critical in the paper record where there may not always be a practical way to prevent data entry errors. In the paper and electronic record, detective controls include deficiency and errors and omissions reports.

Corrective controls

Follow \____ controls and fix errors after they’ve been found. When they can’t be corrected or are too frequent, root cause analysis (RCA) is used to determine the cause of the error and create protocols, preventive controls, and employee education. Some errors may cause employee disciplinary action and/or loss of professional licensure.

Data controls

Preventive controlsDetective controlsCorrective controls

Authenticated

Signed by the author

Postcharge processing

RetentionSecurityAccess

Hybrid record

Both paper and electronic; most labor-intensive than electronic-based record.

Retention

Process of stowing the record appropriately for the required amount of time.

Security

Process of preventing accidental destruction or inappropriate use of the record.

Access

Process of ensuring that the record is available to authorized users when it is needed.

MPI (Master patient index)

Database of a **facility’s** patients and their encounter info; indexed to the patient’s health record identification number and must be retained permanently.

Assembly

Process of: ReorganizingBindingPreparing \----- the record for further processing.

Why paper records need to oftenly be reorganized after they are received in HIM?

Because there are differences in order in which the records are kept in the patient care unit.

Loose pages

Documents that are not present with the record at the time of discharge.

Universal chart order

Used when all departments have collaborated and agreed on keeping the paper record in the same order both before and after discharge.

Quantitative analysis

Process of reviewing health record to ensure that it is complete.

Analysts must know:

which forms are used in each service and be able to identify noncompliance and forms, signatures, and countersignatures.

Guiding principles in quantitative analysis

* Existence
* Completeness
* Authentication

Existence

Record must contain all elements required by licensure and accrediting bodies for particular facility; also must contain all elements required by clinical services and elements common to all patients.

Completeness

Record must be complete and not missing data elements.

Authentication

Each piece of documentation within the record is properly dated, times, and authenticated in accordance with state or accrediting agencies that apply to the facility.

Retrospective analysis post-discharge analysis

Analysis performed after the patient has been discharged, and is most commonly performed with the paper record.

Concurrent analysis

Analysis performed during the patient’s stay; used to review patient record and assign codes.

Release of information (ROI)

Function of retrieving the health record and providing it, or parts of it, to individuals who need it.

To release information, HIM professionals must understand the following:

1. Who is authorized to receive a record
2. Who is authorized to receive a copy of a record
3. How to prepare a record for review

Central staging area

Where paper records in process are kept to limit movement and reduce the risk of losing the record’s location.

Batch control forms

List the processing status of each record and track any records that is removed from the processing cycle, for instance if a patient is readmitted or if the record needs to be reviewed by another department.

Legacy systems

Paper or computer systems that are no longer used by facility.

Filing

Process of organizing health record folders on a shelf, file cabinet, or computer system. Methods include: Alphabetical filingStraight numerical filingTerminal-digit filingTerminal-digit filingMiddle-digit filing

Alphabetical filing

Used in: Small physician’s officeClinicHome health facilityNursing home Ordered by last name.

Straight numerical filing

Simply filing in numerical order, often used in large facilities when there is minimal activity with the records once they are filed.

Outguides

Physical file placeholder inserted in place of the missing record to communicate the date and time the record was removed and its routing location.

Microfilm

Reproduction of a complete original paper record as miniature pictures stored on plastic film.

Microfiche

After processing, images are assembles on roll film or slices into small strips of film and put into jacket.

Chart locator systems

Keep track of the location of all records in the health care facility. Records are “signed out” to the location where they are being sent and “signed in” when they are returned.

Scanned document imaging

Digitizes health documents, which can be viewed electronically, and eliminated need for paper storage.

Application

Software that has a special purpose, such as word processing or spreadsheet, or is for a particular industry such as practice management or electronic health record software.

Care provider

Term used to refer to a physician, physician’s assistant, dentist, psychologist, nurse practitioner, or midwife.

Clearinghouse

A service that processes data into a standardized billing format and checks for inconsistencies or other errors in the data.

Current Procedural Terminology (CPT)

Coding system used to convert narrative procedures and services into numeric form. CPT® is used to code procedures and services in a physician’s office; in a hospital setting, it is used for outpatient coding (emergency room, outpatient diagnostic testing, or ambulatory surgery, for example).

Demographic (identifying) data

Data that identify the patient. Consist of name, date of birth, sex, race, and Social Security number (may vary by facility policy).Submitting insurance claims via wire to a clearinghouse or directly to the insurance carrier.

Electronic claims submission

Submitting insurance claims via wire to a clearinghouse or directly to the insurance carrier.

Electronic health record (EHR)

Comprehensive record of all health records for a patient, which can be shared electronically within a health system and with other healthcare providers as necessary.

Electronic medical record (EMR)

The legal patient record that is created within any healthcare facility (hospital, nursing home, ambulatory surgery facility, physician’s office, etc.). The EMR is the data source for the electronic health record (EHR).

HIPAA Transactions and Code Set Rule (TCS)

Adopted in fiscal year 2003, a set of rules that standardized the electronic exchange of patient-identifiable, health-related information. This rule set is based on electronic data interchange (EDI) standards, and its purpose is to simplify the processes and decrease the costs associated with payment for healthcare services.

International Classification of Diseases, 10th revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS)

ICD-10-CM is the classification system used to convert narrative diagnoses into alpha-numeric codes in all healthcare settings. \\n \\n ICD-10-PCS is the classification system used to convert narrative procedures into alphanumeric codes in hospital settings. Effective October 1, 2015, these classification systems replaced ICD-9-CM.

Interoperability

Many different functions can take place and information can be shared between computer systems, or within applications of the same computer system, which is not possible with a manual or paper record system.

Master Patient Index (MPI)

A permanent listing of all patients who have received care in a hospital (inpatient or outpatient).

Patient List

*Master Person List*

*Master Person Index*

In **physicians’** offices often referred to as a Master Patient List or Patient List.

Point of care

Documentation, dictation, and ordering of tests and procedures that occur at the same time the patient is being seen.

Practice management (PM)

Software used in physicians’ offices to gather data on every patient and perform administrative functions from the time an appointment is made through the time the bill for each visit is paid.

Speech recognition technology

Software that recognizes the words being said by the person dictating and digitally converts the speech to text; as it is used it “learns” the dictator’s voice, and therefore improves the accuracy of the transcription.

Superbill, encounter form, or routing slip

A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed.

Report-writing

EHR capability allowing fast, reliable data submission and retrieval

Account (billing) number

A unique number assigned to every new encounter (emergency department visit, outpatient visit, ambulatory surgery visit, inpatient stay, or physician’s office visit).

Accountable Care Organization (ACO)

A reimbursement model where hospitals, physicians, and other healthcare providers form partnerships whereby all are accountable for the quality of care, efficiency of medical services (to contain costs), and patient satisfaction; a pay-for-performance model of healthcare reimbursement.

Administrative data

Identifying information, insurance-related information, authorizations, and business correspondence found in a patient’s health record.

Chief complaint

The reason for which a patient has made an appointment (usually in his or her own words, for instance, “I have a sore throat”).

Clinical Documentation Architecture (CDA)

Developed by HL7, a document markup standard that specifies the structure and semantics of clinical documents such as discharge summary, operative report, etc.

CMS-1500

The form used by physicians’ offices and other outpatient settings to submit insurance claims.

Continuity of Care Document (CCD)

A document exchange standard used to share patient summary information.

*such as in the case of a patient being referred from one healthcare provider to another*

Data dictionary

A document that specifies the format of each data field as well as a detailed explanation or definition for that field, which allows for consistency of data collection.

Default value

A value that automatically appears in a field each time it appears on a scree.

*(e.g., the current date in a date field, the local area code in a home phone number field).*

Demographic (identifying) data

Data that identify the patient. Consist of name, date of birth, sex, race, and Social Security number (may vary by facility policy).

Health Level Seven (HL7)

A set of standards that makes sharing of data between or among healthcare entities possible.

Library

In computer software, a listing or choice of entities, for instance, employers, insurance plans, ICD-10-CM codes, or CPT® codes.

Master Patient Index (MPI)/Patient List

A permanent listing of all patients who have received care in a hospital (inpatient or outpatient). In physician’s offices, often referred to as a Master Patient List or Patient List. May also be known as a Master Person List or Master Person Index.

Medical record number

A unique number assigned to each patient seen by a facility or an office.

Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA)

Act that ended the Sustainable Growth Rate formula that had been used to determine payments to providers for healthcare services billed to Medicare beneficiaries. Also known as the Doc Fix Act.What

Merit-based Incentive Payment System (MIPS)

A reimbursement system that replaces the Sustainable Growth Rate formula previously used by Medicare Part B with a value-based system. The value-based system is called the Quality Payment Program (QPP).

Quality Reporting Document Architecture (QRDA)

Based on HL7’s approved Clinical Documentation Architecture (CDA), QRDA is a data standard used for reporting quality measure data and that is EHR compatible across different health IT systems.

UB-04

The form used to submit insurance claims for hospital patients.