Health Records and Health Information Management (CH25)

The common function of the health information management department is to:

Provide availability, accuracy, and protection of clinical info

Health records are more commonly completely:

Electronic; but can be scanned and stored as computerized images.

Miniature form

Microfilm

Clinical decision making and financial reimbursement depend on the:

Information contained in the health record

Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of c

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Coding involves converting diagnoses and procedure into a:

numeric classification system

System for Medicare patients by which a predetermined level of reimbursement is established before services are provided

Prospective Payment System (PPS)

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

Diagnosis-Related Groups (DRGs)

Codes are reported to:

Medicare & other third-party payers, such as Insurance companies

__ __ __ __ must communicate needed data to departments

Health information management practitioners

Health records and radiology records are retained by a facility for a specific amount of time according to the:

Code of Federal Regulations, state law, and accreditation requirements

Health records are to be retained for a minimum of __ years from the date the patient was last seen

5 years

According to the MAMMOGRAPHY QUALITY STANDARDS ACT, a facility must keep a mammogram in the permanent medical record for __ years, or no less than __ years if a patient has had no other mammograms at that facility, or longer is mandated by state law.

no less than 5 years, or no less than 10 years

Standards for the maintenance and the documentation within health records have been established by accrediting agencies such as:

The Joint Commission (TJC), and the American Osteopathic Association via its Healthcare Facilities Accreditation Program (HFAP)

Documenting in the patient's record

Charting

Charting should be done by whom when a patient receives either diagnostic or therapeutic radiologic services?

Radiologists or Radiographers

The health record, per TJC, must contain sufficient information such as:

1. Identify the patient
2 Support the diagnoses
3. Justify the treatment
4. Document the course and results
5. Facilitate continuity of care

A computerized system tracks film and folders with a:

Bar code system

The term __ __ implies that the patient has been informed of the procedure or operation to be performed, the risks involved, and the possible consequences.

Informed consent

__ __ contains information relative to patient incidences or event occurrenes

Incident report

Before a radiologic procedure is performed, a __ is completed

Radiology order for service

A Radiology order for service includes:

1. Patient demographic information
2. Specific procedure being requested
3. Physician order the procedure

If Medicare does not cover the procedure,, the patient is notified and is required to sign:

an advance beneficiary notice (ABN)

The results of the procedure are documented on a:

Radiology report

A __ __ must be completed for every service for which a medical claim will be filed.

Written report

Radiology reports must be included in the patient record to describe:

the radiologic services the patient received

Where do original copies of documents go?

In the patient's record

__ documentation is not legal in any state.

Pencil

In a paper record, who is responsible for correcting an error in the documentation?

The person who makes the error

The concept of the DRG is that patients fall into statistically similar, __ __ groups.

Diagnostically related

The health information professional uses the __ __ provided by the __ to code the patient's information into the classification system.

Diagnosis terminology
Physician

The __ is used for procedural classification of inpatient procedures

International Classification of Diseases (ICD-10-CM), Procedure Classification System (ICD-10-PCS)

Using a computer programer called a __, the health information practitioner computes the patient's DRG.

Grouper

__ codes are used to code procedures for outpatient encounters and coding for ancillary services such as radiology and laboratory.

Current Procedural Terminology, 4th Edition (CPT-4)

A criticism of DRGs has been that:

the system does not take into account the severity of a patient's disease.

The __ and __ classification systems are used for inpatient reporting.

ICD-10-CM and PCS
(effective 10-1-15)

For outpatients, hospitals must report the diagnosis using the __ or __ codes and __ codes for the procedures.

ICD-10-CM
ICD-9-CM
CPT-4

The physician's offices uses the __ codes for the DIAGNOSIS, and the __ coding system for the PROCEDURES.

ICD (International Classification of Diseases)
CPT (Current Procedural Terminology)

Radiology codes in CPT include:

1. Diagnostic and Therapeutic radiology
2. Nuclear Medicine
3. Diagnostic ultrasonography
4. Radiation oncology

Code number range from:
Chest radiograph, single view, frontal, would be coded as:
MRI of the cervical spine with contrast media is coded to:

70010-79999
71010
72142

List the 4 data tables in the IRD database:

1. Anatomical
2. Sub-anatomical
3. Pathological
4. Sub pathological

__ __ is a process by which the quality of the care and services provided to patients within a health care facility are monitored and elevated.

Performance improvement

The terms __ __, __ __, and __ __ are all used to encompass activities related to performance improvement

quality assurance, quality assessment, and performance improvement

List the dimensions of performance:

1. Efficacy
2. Appropriateness
3. Availability
4. Timeliness
5. Effectiveness
6. Continuity
7. Safety
8. Efficiency
9. Respect & caring

The __ __ is an important legal document that the health care institution uses to define what was or was not done to the patient.

Patient record

What is the proper method for correcting an error that an author makes in a health record?

Draw a single line through the error, write "ERROR", record the correct info., date & sign.

Which of the following is not a function of a hospital health information management department?
1. Coding of diagnoses and operative procedures and diagnosis-related group assignment
2. Documenting relevant patient information in the medical record
3. Qu

Documenting relevant patient information in the medical record

The prospective payment system is a payment system based on?

the diagnosis-related group (DRG) or the ambulatory patient classification (APC)

Which of the following is an example of an organization that accredits hospitals and other health care institutions in the US?

The Joint Commission

The chief complaint, included in a patient's history, is a statement made by the:

Patient

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation affects radiology and other hospital departments by its focus on:

Patient record confidentiality

Which of the following is not required to be included in a patient's health record?
1. Medical history
2. Radiology reports
3. Patient's telephone number
4. Physical examination report

Patient's telephone number

Criteria used in performance improvement activities must be all of the following EXCEPT:
1. Clinically valid
2. Diagnosis or procedure oriented
3. Generally acceptable to department staffs
4. Written

Diagnosis or procedure oriented

Assessment of problems in performance improvement activities must be:

ongoing

In making a correction to an entry in the paper health record, the documenter should:

line out the error, authenticate, and insert correct information

The organization (chart orders, forms) of a hospital patient record is determined by:

the hospital's own preference