Health Information Management Technology, An Applied Approach Chapter 3

Primary purpose of health record

patient care

management of patient care

administrative purposes

secondary purpose of health record

- Education of healthcare professionals

- Legal, accreditation, and policy development

- Public health and research

three forms of health records

paper, electronic and hybrid

aggregate data

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed

individual users of the health record

those who depend on the health record in order to complete their job

institutional users of the health record

Organizations that need access to health records in order to accomplish their mission.

MPI: Master Patient Index

A listing or database of all the patients treated by a health care facility, indexed according to an indentification process.

EMPI

Enterprise Master Patient Index.

-links the patient's information at the different facilities

overlay

the patient is erroneously assigned another person's health record number

Duplicate health record

Occurs when the patient has two or more health record numbers issued; the patient's medical information becomes fragmented with some information under the first number and the remainder under the second

overlap

when a patient has more than one health record number at different locations within the enterprise

Deterministic algorithm

Requires exact matches in data elements such as the patient name, date of birth, and Social Security number.

Probabilistic algorithm

Algorithm that uses mathematical probabilities to determine the possibility that two patients are the same

Rules-based algorithm

Algorithm that assigns weights to specific data elements and uses those weights to compare one record to another

Serial numbering system

A type of health record identification and filing system in which patients are assigned a different but unique numerical identifier for every admission

Unit numbering system

A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters

Serial-unit numbering system

A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned

alphabetic filing system

A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition

patient account number

A number assigned by a healthcare facility for billing purposes that is unique to a particular episode of care; a new account number is assigned each time the patient receives care or services at the facility

numeric filing system

the health records are filed by the health record number.

Terminal-digit filing system

In this type of medical record filing system, the last digit or group of last digits is the primary unit used for filing.

Ex: 44-37-98 is filed as File section 98, shelf number 37, and folder number 44.

centralized filing system

filing system organizes patient records in once central location under the control of the facilities HIM dept.

requisition

request for health record

outguide

A device used in paper-based health record systems to track the location of records removed from the file storage area

Record reconciliation

The process of assuring that all the records of discharged patients have been received by the HIM department for processing

assembly

process of ensuring that each page in the health record is organized in a standard format

qualitative analysis

monitoring the quality of the documentation

Quantitative analysis

A review of the health record to determine its completeness, making sure all reports, forms and signatures are present

Corrections to health record

-it should be dated, timed and signed

addendum

additional information

-it should be dated, timed and signed

amendment

clarification made to healthcare doccumentation after the original document has been signed

-it should be dated, timed and signed

forms

1. Should contain a unique identifying number

2. Include original and revised dates for tracking and purging of obsolete

3. Include concise title, company name and logo

4. Should be 8.5 by 11 inches

5. 20 to 24 pounds in weight is recommended for copiers, scanners and fax machines

6. Type size no smaller than 9 points for lowercase and 10 points for uppercase letters

7. unique number assigned to each form

standards

are fixed rules that must be followed

guideline

provides general direction about the design of the form

example of institutional user of health record

third party payer

example of individual user of health record

patient