Chapter 7 & 14 HIT 109

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Chapter 7 & 14 HIT 109

  1. 1. Chapter 7<br />Data Access and Retention <br />
  2. 2. The main purpose of the health record is to provide communication between health care providers!<br />
  3. 3. Specific uses:<br />Patient care<br />Clinical coding<br />Billing<br />Statistical analysis<br />Other operational processes<br />
  4. 4. Types of record identification systems<br />Alphabetic Patient Identifiers<br />Small facilities<br />Alpha order by last name<br />Not a good security measure<br />Numeric Patient Identifiers<br />Serial Numbering<br />Different but unique number for every admission <br />Unit Numbering <br />Unique number used for all encounters<br />Serial-Unit Numbering<br />Numbers assigned serially but records brought forward and filed under the last number assigned<br />
  5. 5. Filing Equipment and Space Management<br />Open shelf<br />Motorized units<br />Compressed units<br />Space<br />Retrieval issues<br />Centralized vs. decentralized filing system<br />
  6. 6. Health Record Filing Systems<br />Most familiar<br />Work well for small spaces<br />Number broken down into two digit pairs<br />Read right to left<br />Example: 670187 would be written 67-01-87<br />87 is the primary number<br />01 is the secondary<br />67 is final<br />File first in location 87, then on shelf 01, and then on the 67th place on the shelf<br />Alphabetic and Straight Numeric<br />Terminal Digit<br />
  7. 7. Master Patient Index (MPI)<br />Permanent database including every patient ever admitted to or treated by the facility<br />Kept permanently<br />
  8. 8. Record Tracking<br />Signing out or checking out records<br />Tracking those not returned<br />Strict policies and procedures<br />Should be able to locate a chart in 15 minutes<br />
  9. 9. Record Retention <br />Policies and procedures depends upon:<br />State laws<br />Medicare regulations<br />Other federal regulations<br />Accreditation standards<br />Facility policies<br />
  10. 10. Chapter 14<br />Data Analysis & Use<br />
  11. 11. Data Sets<br />Defined by the government<br />Required to be collected<br />Used to provide comparative data across the country, state, healthcare community, etc<br />
  12. 12. Facility-Specific indexes<br />Master Patient Index (MPI)<br />Chapter 7<br />Disease Index<br />Sequenced according to ICD-9-CM code numbers<br />Operation Index<br />Numerical order by the patient’s procedure codes using ICD-9-CM or CPT codes<br />Physician Index<br />Arranged according to physician code number assigned by healthcare facility<br />
  13. 13. Secondary data sources<br />Facility-specific indexes<br />Registries (either facility or population based)<br />Other healthcare databases<br />They provide information that is not easily available by looking at individual health records<br />
  14. 14. Register vs. index<br />Focuses on a specific group of people and collects information on just that group<br />i.e. Cancer Registry, Trauma Registry, Implant Registry, etc<br />Looks at entire patient population and then groups them into specific categories<br />Register<br />Index<br />
  15. 15. Information collected in a register<br />General identifying information<br />Whatever specific information <br />Example: ER Room Register<br />Name, address, zip code, nature of the injury/illness, time person enters ER, time patient received triage, time the patient was seen by a physician, disposition of the patient, time of discharge, mode of transportation, support person with patient<br />

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