management of health records

all healthcare settings/facilities maintain

health records

health information management

ensures a patient care record is managed and maintained to ensure

electronic health record (EHR)

longitudinal electronic health record of pt health info generated from 1+ encounters in any care delivery setting

EHR includes

patient demographics, progress notes, problems, meds, vitals, past history, immunizations, lab data, radiology reports

EHR ___ and ___ a clinician’s workflow

automates and streamlines

EHR can generate

a complete record of clinical pt encounter

VUMC EHR software is

EPIC

responsibility and regulations of EHR begins at

patient scheduling the appointment

EHR responsibilities:

pt care staff, health information manager

EHR regulations

federal conditions of participation and state depts of health are regulatory bodies; provide guidelines to develop org policy

what organizations is EHR responsible for

Joint commission, healthcare facilities accreditation program; also have guidelines for medical record creation and documentation

master patient index (MPI)

electronic database that IDs all pts; makes it possible to store, link, maintain pt records across all ehr systems

EHR: what does history and physical provide

detailed info on why pt is being seen for current episode of care, medical history, physical exam, clinician’s impression or diagnosis, care plan

EHR: ancillary reports

imaging studies, lab work, path reports, monitoring/tracing of bodily functions

EHR: operative reports

description of details of surgical proc

clinical decision support systems (CDSS)

use tools to enhance healthcare decision making- for physician orders. include alerts, reminders, guidelines

revenue cycle management

process of pt financial and health info moving into, through, out of healthcare org, culminating w org getting reimbursement for services provided

three parts of revenue cycle

front end process, middle process, back end process

front end process: before visit

determine medical necessity

middle process: during visit

clinical coding w ICD’s and CPT’s

back end process: after visit

claims processing and payment

medical necessity

healthcare services/supplies needed to diagnose/treat illness, injury, condition, disease, that meet accepted standards of medicine

medicare, plus commercial payers, require

precertification process that ensures exam will be covered by insurance and meets medical necessity

ICD codes

used for diagnostic coding; reason for visit that is documented by physician and translated into ICD-10-CM codes

CPT codes

code proc. for outpatient encounters/ancillary services. includes radiology; reside in charge-master

example: if doing a SPECT, but doctor says they want a SPECT/CT, you must…

add CT CPT code

back end process

it’s vital for org fiscal health that a strong and coordinated revenue cycle management process is in place to ensure that all proc. and exams are appropriately reimbursed

HIPAA

health insurance portability and accountability act

hospital information system (HIS)

provides ability to manage all paperwork in one place

radiology information system

part of HIS, dedicated to radiology pts.

Program that works with PACS. EPIC’s RIS is called Radiant

Picture archiving and communication system (PACS)

medical imaging tech used in healthcare org to securely store and digitally transmit electronic images and reports