Health Information Management Lecture 3

What is an inpatient?

A patient who stays in the hospital for more than 24 hours.

What are they referring to by stating 'registration to discharge'?

The entire process of a patient's stay in the hospital, from registration to being discharged.

What is an inpatient?

A patient who stays in the hospital for more than 24 hours.

What are they referring to by stating 'registration to discharge'?

The entire process of a patient's stay in the hospital, from registration to being discharged.

What approaches must be considered when collecting data?

Various methods and techniques for gathering information.

What are the functions of a health record?

Facilitate ongoing care and treatment, support clinical decision making and communication among clinicians, document services provided to the patient, provide information for evaluation of care quality and efficacy, provide information for medical research, facilitate operational management of the facility, provide information as required by laws and regulations.

What is 'MPI'?

Master Patient Index, a database that stores patient information.

What is a longitudinal health record?

A compilation of an individual patient's medical history from birth to death.

Who are the 'front-line workers' in patient registration?

The healthcare professionals responsible for registering patients.

Why is a longitudinal health record important?

Prevents medical errors, provides information on patient's allergies, history of diseases, surgeries, and past medical problems, allows for informed treatment decisions.

What are some of the reasons for registration errors?

Incomplete or incorrect information provided by the patient or healthcare staff.

What are the impacts of registration errors?

Miscommunication, delays in treatment, potential harm to the patient.

What is the responsibility of the provider of care in quality documentation?

Ensuring that entries made in the record are of high quality according to the facility's regulations and standards.

What are the responsibilities of HIMs when errors are detected?

Identifying and rectifying errors, ensuring data accuracy and integrity.

What data can be found on a health record?

Administrative, demographic, clinical, and financial data.

What is the history of the health record?

Recognized as essential in the 1920s.

What is clinical data?

Information related to a patient's condition, treatment, and progress.

How has the health record changed over time?

From paper-based to hybrid and fully electronic.

What are some examples of clinical data?

Diagnoses, interventions, history & physical notes, physicians orders, consultation reports, nursing notes, ancillary service reports, surgical service reports.

What is the purpose of the health record?

To document and communicate patient information, track progress, and improve continuity of care.

How have HIM directors/managers' roles changed?

From managing records and staff to standardizing procedures and transitioning to computerized systems.

How are clinical observations documented in a health record?

In formats such as progress notes, history notes, consultation reports, nursing notes, surgical notes.

Who is the custodian of health records?

Healthcare facility and professionals who compile them.

What questions can be answered by reviewing a patient's record?

Department(s) offering services, type of reports, demographic data, clinical data, financial data, healthcare providers, outcome of the visit.

How are patients categorized in the hospital record?

Based on service assignment: ambulatory, inpatient, obstetrical, or newborn.