1
Q
Data governance
A
procedures and plans are available, and it encompasses security of structured and unstructured information
2
Q
Data Governance Includes
A
authority
decision making
Accountability
3
Q
OECD
A
Organization for economic cooperation and development
Goes over the relationship between Board of Directors managers and shareholders, etc.
4
Q
Data Governance Vs. Information Governance
A
- Data governance goes over the input of information.
- Information governments goes over how information is used and analyzed
5
Q
Data lifecycle management
A
Data planning, data inventory, and evaluation, capture, data transformation and processing, data access and distribution, data maintenance, data archival. And data distribution And data destruction.
6
Q
Data architecture management:
A
- Defined as specifications used to describe as existing state, defined data requirements, guide, data integration, and control data. Assets as put forth in a data strategy.
- Include establishing data standards, policies, and procedures for the collection, storage, and integration of enterprise data and design of information systems.
- Identifying and documenting data requirements that meet the needs and support the process of the organization.
- Developing and maintaining enterprise and conceptual data and process models that represent the organization’s business rules.
7
Q
Artifacts
A
.: developed through architecture, data management such as data models, use cases, data flow diagrams, and data dictionaries are as important to data management as the blueprints prepared by an architect are to a building design and maintenance.
8
Q
Metadata management
A
- structured information used to increase the effective use of data. Metadata is easier to locate, retrieve, use, and manage. Data Element name, data type, and field length are examples of Metadata That is used to describe data in databases.
- Plays an important role in achieving interoperability among different computer systems and providing search and navigation capabilities.
9
Q
Metadata management functions requiring data governance include the following:
A
managing data dictionaries.
Establishing enterprise metadata strategy.
Developing policies, goals and objectives to our metadata management and use.
Adopting metadata standards.
Establishing and implementing metadata metrics.
Monitoring procedures to ensure metadata policy implementation.
10
Q
Master data management:
A
- refers to master data that an enterprise maintains about key business entities, such as customers, employees, or patients, and to reference data that is used to classify other data or identify allowable values for data such as codes for state abbreviations or products.
- A good example of master data is the master patient index that includes master data on the key entity.: the patient., usually includes patient, medical record number, patient last, middle, and first names, birthday, gender, and address.
11
Q
Content management
A
encompasses managing growth structure data. For example, data stored in databases and unstructured data such as data contained in text documents.
12
Q
Data security management:
A
process in which organizations implement protection measures and tools for safeguarding data and information from unauthorized accidental or intentional modification, destruction, or use.
13
Q
Information, intelligence and big data:
A
business intelligence is defined as a broad category of applications and technologies for gathering, storing, analyzing, and providing access to data to help enterprises are users make Better Business decisions.
14
Q
Data quality management:
A
characterized as continuous process setting standards, building quality into the processes that create, transform, and store data, and measuring data against standards.
15
Q
Terminology and classification management:
A
consists of the processes for managing the breadth of healthcare terminologies, vocabularies, classification system, and data sets that an organization may use and also serves as terminology authority for the enterprise.
16
Q
American College of Surgeons and the Joint Commission:
A
ACS provided the impetus for standardizing health records when it developed minimum standards for hospitals early in the 20th century.
17
Q
The Joint Commission (TJC) is the
A
successor organization to the ACS in the area of standardization. In a joint effort of the ACS American College of Physicians, American Medical Association and American Hospital Association The Joint Commission was able to Accredit hospitals before they existed.
18
Q
The Joint Commission surveyors
A
routinely review the health records of current patients to obtain knowledge about the facilities, performance and process of care.
19
Q
Internal standards:
A
-bylaws, rules, and regulations are developed by the medical staff and approved by the board of trustees, or governing body in health care facilities.
20
Q
The bylaws outline
A
the content of patient health records, identify the exact personnel who can enter the information and health records, and may restate applicable Joint Commission and other requirements. They also describe the time limits for completing patient health records.
21
Q
Definition of the health record:
A
- the health record must outline and justify the patients treatment, support, diagnosis of the patient’s condition, described the patients progress in response to medication and services, and explain the outcomes of the care provided.
- Health record itself is the property of the health care facility.
22
Q
The longitudinal health care record
A
The Longitudinal health care record is a record compiled about an individual that contains health records from various encounters and from numerous healthcare delivery settings.
23
Q
Responsibility for quality documentation:
A
-ensuring data accuracy of health record content is one of the primary responsibilities of the HIM professional
24
Q
The provider of care is responsible for ensuring that entries made in the record
A
are of high quality. Please look at page 106 guideline. figure 4.1.
25
Administrative Information:
- Administrative and demographic information is generally found on the front page or face sheet of the paper health record and on the login screen of the dashboard in an EHR.
- The data that it includes, it identifies the patient and data related to payment and reimbursement and other operational needs of the health care facility.
26
Advanced directives:
- when a patient has a written advance directive, its existence must be noted in the health record
- The advance directive can be included as part of the health record, although its inclusion may not be a required.
- Patients must be informed that they have the right to have an advanced directive. Caring connections is the program of the National Hospice and palliative care organization and NHPCO.
27
History
History is the summary of the patients illness from his or her point of view.
28
Physical Examination
The physical examination is a comprehensive assessment of the patients physical condition through examination and inspection of the patients body by the practitioner. The end of the physical examination should include the impression, which is a list of the patients problems based on the information obtained.
Look at Table 4.1 on page 109:
Chief complaint
It's really a present illness or present illness
Past medical history.
Social and personal history.
Family medical history.
Review of systems.
29
The physical examination is conducted by
observing the patient, palpitating or touching the patient, tapping, the thoracic and abdominal cavities, listening to the breath and heart sounds, and taking the blood pressure.
30
Time frame for the history and physical examination:
CMS conditioners of participation requires that the history and physical examinations also referred to as H&P be completed no more than 30 days before or 24 hours after admission and the report must be placed in the record within 24 hours after admission.
If a history and physical has been completed within the 30 days prior to admission there must be an updated entry in the medical record that documents an examination for any changes in the patient’s condition since the original history and physical examination and this entry must be included in the record within the first 24 hours of admission.
The history and physical examination must be completed by the physician or another qualified individual who has medical staff privileges in accordance with state line hospital policy.
31
The joint commission requires a history and physical examination
to be recorded and made part of the patient health record prior to any operative procedure.
32
Diagnostic and therapeutic orders:
Orders for Tests must demonstrate the medical necessity and explain the reason for the order
The legibility of orders is important to ensure that they are clearly understood by the personnel we must carry them out
Physcian or other credential practitioner or verbally communicated to persons qualified and authorized to receive and record verbal orders either in person or by telephone
33
Verbal Orders
For verbal orders of person accepting the order should record the order read it back to the ordering physician sign it and give his or her title such as RN, PT, or LPN.
Verbal orders for medication are usually required to be given to you and to be excepted only by nursing or pharmacy personnel
The joint commission requires the documentation of verbal orders to include the date and names of individuals who gave, received, and implemented the orders.
34
Signatures on orders:
Orders must be dated and authenticating manual or electronically by the treating practitioner responsible for the patients care who gave the orders.
Many facilities require the ordering practitioner to indicate that the telephone orders are accurate complete and final by authenticating them in writing or electronically within 24 hours.
CMS regulations allow verbal orders to be signed by another provider responsible for the patient’s care even if the order did not originate with that provider.
35
Other types of orders: drugs, DNR, and restraint orders
Narcotics and sedatives have a automatic time limit or stop order.
Do not resuscitate orders must contain documentation that the decision to withhold resuscitative services was discuss when the decision was made and who participated in the decision this discussion is often documented in the progress notes.
Specific time limits for seclusion and restrain orders must be followed and there must be continuous oversight of the patient
36
Discharge orders:
Discharge orders for hospital patients must be documented in the health record and can only be issue via physician.
When a patient leaves against medical advice this fact should be noted in lieu of a discharge order because the patient was not actually discharged.
37
Progress notes:
chronological statements about the patient’s response to treatment during his or her stay in the facility.
38
Integrated progress note
some facilities have various practitioners record progress notes on a common form or within one electronic section
while another record formats there may be separate section for physician, nursing, and therapy progress notes
39
Consultation
Opinions of physicians with specialty training beyond general board certification.
40
Nursing services:
Nurses begin recording information in the health record when the patient is admitted to the facility
Summarize the date, time, and method of admission; the patient’s condition, symptoms, and vital signs; and other information
All nursing knows must be signed by the individual who provided the service or observed a patient condition full names and titles are required with each entry
41
Charting by exception
or focus charting is a method of documenting only unusual findings where deviations from the prescribed plan of care occurred
42
Medication administration records are maintained
by nursing staff or all patients and include medications given, time, form of administration, and dosage and strength.
43
Ancillary services:
Laboratory and radiology reports and reports from other services such as electrocardiograph and electroencephalograph must be signed by the physician responsible for the interpretations
44
The operative report must be documented
either in writing or dictated by the surgeon immediately after surgery I must include the names of the surgeon and assistance, the names of the procedures performed, a description of the procedures, findings of the procedures, any specimens removed, any estimated blood loss, and the postoperative diagnosis.
45
The operative section of the health record
includes the anesthesia record, the interoperative record, and the recovery record
46
Every patient’s record must include a complete history and physical examination prior to any surgery or invasive procedure unless there is an emergency.
any surgery or invasive procedure unless there is an emergency
47
The joint commission standards require that prior to high-risk procedures and those involving use of anesthesia or deep sedation
a provisional diagnosis is recorded by the licensed independent practitioner involved in the patient’s care.
48
There must be a preanesthesia evaluation or an updated evaluation prior to surgery and it must cover information on the anesthesia use, risk factors, allergy and drug history, potential problems, and a general assessment of the patient’s condition. In interoperative anesthesia record must be maintained of all events during surgery including complete information on the anesthesia administration, blood pressure, pause, respiration, and other monitors of the patient’s condition. Finally after surgery the appropriate anesthesia personnel must document I post operative anesthesia follow up report including any anesthetic complications.
information on the anesthesia use, risk factors, allergy and drug history, potential problems, and a general assessment of the patient’s condition
49
- In intraoperative anesthesia...
| - Finally after surgery the appropriate anesthesia personnel must document
- the record must be maintained of all events during surgery including complete information on the anesthesia administration, blood pressure, pause, respiration, and other monitors of the patient’s condition.
- Finally after surgery the appropriate anesthesia personnel must document post-operative anesthesia, follow-up report including any anesthetic complications.
50
The joint commission requires the health record contain post-operative information,
including the patient’s vital signs, level of consciousness, medications including fluids, and any dispense blood or blood products; and any unforeseen incidents or complications and the handling of those occurrences
51
The surgeon must enter a brief operative progress note in the record
immediately after surgery before the patient is transferred to the next level of care.
52
The autopsy report includes exam details provided by the medical exam or pathologist that leads to a determination of a
cause of death. it will contain a summary of a disease process or trauma along with related treatments, gross and microscopic findings, and at clinical diagnosis.
A provisional diagnosis should be documented in the chart within three days and the final report should be made part of the chart within 60 days of the examination
53
Autoposy Reporting
A provisional diagnosis should be documented in the chart within three days and the final report should be made part of the chart within 60 days of the examination
54
Organ transplantation
CMS and joint commission require hospitals to inform families of the opportunity to donate organs, tissues, or eyes. All the patients meeting the united network of organ sharing UNOS criteria must be evaluated in the documentation must be part of the health record. Documentation showing that the organ procurement organizations OPO must be notified regarding a deceased patient or a patient your dad must be included in the health record so the anatomical gift can be preserved and use.
55
For obstetrical cases, the health record includes
the antepartum record, the labor and delivery record, and the postpartum record. The ante-partum of the prenatal record is information usually collected in the physicians office before the birth event and made it available to the hospital by the 36 week of pregnancy.
56
The labor and delivery record is information collected
the time the patient is admitted to the hospital through to the delivery.
57
The postpartum record provides details about the patient
after delivery through the recovery process.
58
Discharge Summary
- Also called the clinical resume it provides details about the patient stay well in the facility and the foundation for future treatment.
- It is prepared when the patient is discharged or transferred to another facility or when the patient dies. The summary states that patient’s reason for hospitalization and gives a brief history explaining why he or she needed to be hospitalized.
59
In addition to describing the patient’s conditions at discharge, the discharge summary gives
specific instructions given to the patient or family for future care, including for information on medication, referrals to other providers, diet, activities, follow-up visit to the physician, and the patient’s final diagnoses.
60
if a patient dies in the hospital the facility often requires the physcian
who pronounced the death to write a note that gives the time of death. No matter how long they were in the facility this documentation is required.
61
A discharge summary is not typically required for patients who are in the hospital for 48 hours or less.
who are in the hospital for 48 hours or less.
62
When the patient dies 48 hours or less after admission, the short stay record is
insufficient and a complete discharge summary must be prepared.
63
the discharge summary must be completed within
30 days after discharge; however facility policy may require a quicker completion date.
64
When a patient has transferred the physician should complete the discharge summary within
24 hours.
-the joint commission allows where a transfer summary and the patient is transferred to another level of care in the facility or the patient here is transferred to another provider.
65
Emergency care may be filed
separately or incorporate into the health record when the patient is admitted to the same facility.
66
When the patient leaves the emergency department before being seen against medical advice this fact should be noted
on emergency department form.
67
Emergency department records must maintain
- a chronological record or log of all patients visiting the emergency department with the name, date, time, of arrival, and record number.
- This register also includes the names of patients who were dead on arrival.
68
Emergency medical treatment and labor act EMTALA:
states that patient cannot be transferred or refuse treatment for reasons related to ability to pay or source of payment nor can hospitals determine that space is unavailable based on ability to pay or source of payment.
69
The accreditation Association for ambulatory healthcare AAAHC Has additional requirements for the content of the
ambulatory care record that are provided for ambulatory surgery centers ASC, community health centers, health plans and medical homes, office base surgery centers, and primary care.
70
Ambulatory facilities that only perform surgery are called
Ambulatory facilities that only perform surgery are called ASCs -ambulatory surgery centers.
71
The Medicare conditions of participation requires that the inpatient within a psychiatric hospital
- receive a psychiatric evaluation.
- A discharge summary discussing whether or not a treatment goals have been met or further treatment is necessary along with plans for aftercare should also be noted
72
NAHC
national Association for home care and hospice
73
Home health services documentation requires
- Patient health records must contain a legible record of each visit describing what was done to offer the patient during the visit. Developed and documented periodic plans of care
- Attending position to document an update the plan of care. It is also necessary for the physician to certified the patients need for care, and recertification of the need must be documented periodically.
74
Hospice care services: NHPCO
Hospice care is he oriented approach to expert medical care, pain management, and emotional and spiritual support expressively tailored to the patient’s needs and wishes.
Must have certificate cation by the patients attending position in the hospice that the patient has its terminal illness.
75
rehabilitation setting requirements
- the history and physical must include a functional history covering the patient’s functional status before an after injury or onset of illness.
- Additionally the history she described equipment the patient is at home, including orthotics and prosthetics. Is important that the physician outlined the goals for the patient care to coordinate the interdisciplinary team involved in the case
76
Rehabilitation services are
- often part of the long-term care plan
- The long-term care record must document a comprehensive assessment that includes items in a minimum data set to meet CMS requirements.
77
Individualized patient care plans must be developed and included
in the record and they must cover the potential for rehabilitation, your ability to perform activities of daily living, medication prescribed, and other aspects of care.
78
Source oriented health records:
Is the conventional or traditional method of maintaining paper base health records. Health records are organized according to the source, or originating, department that rendered the service. Example hybrid health record systems.
79
Distinctive feature is the problem list which serves as a record table of contents. All relevant problems that may have an impact on the patient are listed with a number. As the problems are resolved the resolution is noted on the list and new problems are added as they occur. The problem with serves as a permanent index that providers can quickly check to review the status of past and current problems.
Most recognizable component of the POMR is the SOA P format which is a method for recording progress notes. It is an easy acronym that helps providers remember the specific and systematic decision making process after reading documentation.
soap: subjective findings, objective findings, assessment, plan look to page 1 to 1
80
the POMR is compromised of the
problem list, the database which includes the history and physical examination and initial lab findings, The initial plan, and any progress notes organized so that every member of the healthcare team can easily follow the course of the patient treatment.
81
POMR (Problem oriented health record)
A Distinctive feature is the problem list is that it
- serves as the records table of contents.
- All relevant problems that may have an impact on the patient are listed with a number. As the problems are resolved the resolution is noted on the list and new problems are added as they occur. The problem with serves as a permanent index that providers can quickly check to review the status of past and current problems.
82
SOA P format which is a method for
- recording progress notes. It is an easy acronym that helps providers remember the specific and systematic decision-making process after reading documentation.
- soap: subjective findings, objective findings, assessment, plan look to page 101
83
Integrated health records
arranged in strict chronological order
The order of the record is determined by the date the information was entered, the date of service, or the date the report was received, rather than by the source department; the record gives the sequence of the patient’s care as delivered.
Although the system makes it difficult to find a particular document unless you know the date it does provide a better picture of the story of the patient care, physician offices often use this format
84
Abstracting:
process of reviewing the patient record and collecting pertinent data elements, usually in an electronic database.
85
The purpose of abstracting is to make information from the patient record
- readily available for internal and external reporting aids. At tracking support the secondary use of patient that of her registries, public reporting, research, another purposes.
- It is important for the HIM professional to understand the mission of the facility when determining both the amount of data to abstract from the health record inappropriate staff required for the abstracting.
86
Quantitative analysis: it is called a discharge analysis and it is a review of the health record for the completeness and accuracy.
it is called a discharge analysis and it is a review of the health record for the completeness and accuracy.
87
current analysis:
the record is analyzed during the patient’s day and the healthcare facility it has the advantage of HIM or other personnel being present in the clinical care units where the physician sees patients.
88
The record is often organized in
reverse chronological order with the most recent information in the front of each record section.
89
Amendments to the record
Any corrections or amendments to the records must be entered properly. For electronic entries, a procedure should be followed that explains how to correct errors and enter an addendum to the house record including the current date and reason for the information being added to the record.
90
Qualitative analysis:
review the quality and adequacy of record documentation and ensure that is in accordance with the policies, rules, and regulations established by the facility; the standards of licensing in accrediting bodies; and government requirements.
91
More in-depth review of health records although the processes may overlap it is done while the patient is in the facility or under active treatment is called open record revealed.
Joint commission requires an open record review to ensure that its documentation standards are met at the point of care delivery.
Open review process looked at requirements such as presence of the history and physical examination prior to surgery and whether it thoroughly describes the condition of the patient upon admission, completion of the post operative note with our requirements document, and many other aspects of care process as documented in the health record. Open record review should be done on a continuous basis.
Close record review it means that the qualitative review is done retrospectively following discharge or termination of treatment. The problems in the care process that are revealed through the review can be corrected immediately. It is important because it is a way to obtain information about trends and patterns of documentation.
92
Joint commission requires an open record review
to ensure that its documentation standards are met at the point of care delivery.
93
Open review process:
looked at requirements such as presence of the history and physical examination prior to surgery and whether it thoroughly describes the condition of the patient upon admission, completion of the post operative note with our requirements document, and many other aspects of care process as documented in the health record. Open record review should be done on a continuous basis.
94
Close record review it means
that the qualitative review is done retrospectively following discharge or termination of treatment. The problems in the care process that are revealed through the review can be corrected immediately. It is important because it is a way to obtain information about trends and patterns of documentation.
95
Criteria for adequacy of documentation:
Documentation must reflect the care rendered to the patient and patient’s response to care. It must be timely and legible and authenticated by the person who wrote it.
Timeliness and legibility are two of the main areas of focus for accreditation and licensure bodies.
96
Authentication for health record entries:
The joint commission allows rubberstamp fast mail signatures when there is a statement verifying that the position is the one who will use the stand and will maintain control of it. However many facilities no longer allowed to use of rubberstamp signatures or limited used to specific circumstances.
The signature is an electronic signature in to be used to sign a document
97
Although the facility's governing body has overall responsibility for patient care, responsibility for the delivery and documentation of patient care is delegated to
the medical staff
98
The providers are responsible for the documentation in
the medical record, authenticating it, and completing it
99
Storage, retrieval, and tracking of incomplete records:
Convenient for the providers as deficient health records maybe simultaneously ratted multiple for riders for a work love software. It is more efficient than the paper base routing of health records as it requires fever HIM personality locate, transport, and re-file the paper base house record. It is also more efficient for the provider she may access, authenticate, and complete the hybrid record or fully electronic health health remotely.
100
Records are considered deficient or incomplete immediately at
discharge
101
Delinquent health records are those records that are not
completed within a specific time frame for example within 14 days of discharge.
102
Most facilities require that records be completed within
30 days of discharge as mandated by CMS regulations and joint commission standards.
103
Unit numbering system
Most large facilities use a unit number in system and the patient is assigned a number during the first encounter for care and keep it for all subsequent encounter.
104
Serial unit numbering system
patient is issued a different number for each admission or encounter for care and the records of past episodes of care are brought forward to be filed under the last number issued.
105
Straight numeric filing system:
records are filed in numerical order according to the number assigned. The shortcoming of this is that most of the file activity is where the most recent numbers I’ve been assigned.
106
Terminal digit filing system:
records are filed according to a three part number made up of two digit pairs. It is red from right to left. Terminal DJ piling concepts maybe I’ll see you like to evenly distribute lose paperwork filing and the doctors in complete area.
107
Master patient index is a
permanent database including patient identify a little data for every patient ever admitted to or treated by the facility. Even though patient has records maybe destroyed after legal attention. Have been met, the information that came in the NPI must be kept permanently.
108
Overlap
occurs when a patient has more than one medical record number assigned across more than one database.
109
Overlay occurs
when one patient record is overwritten with dad from another patient record.
110
Open shelf filing is the least expensive option for storage of paper records. Shelves are usually arranged back to back like shelving in a library. Shelving uses space more efficiently than file cabinets because only 30 to 36 inches are needed for each aisle.
least expensive option for storage of paper records. Shelves are usually arranged back to back like shelving in a library. Shelving uses space more efficiently than file cabinets because only 30 to 36 inches are needed for each aisle.
111
Lateral files with drawers and doors also require
sufficient aisle space for opening the individual drawers in allowing personnel to pass.
112
Record retention involves
determining the schedule to be followed to protect and preserve active and inactive records.
113
Disposition involves the process of
destroying the records once the end of the retention period has been reached
114
The HIM professional must adhere to the strictest time limit of the
recommended retention
115
CMS requires health records to be
maintained for at least five years.
116
OSHA requires records of employees with occupational exposure to be maintained
for the duration of employment +30 years.
117
Radiology: the sign interpretation of the studies must be maintained in the record for
the full retention. Required by law.
118
Mammograms must be maintained maintain for
5 to 10 years depending on whether or not additional mammograms are performed.
119
Many states recommend that patient has records be retained
for 10 years following patient discharge or death. There are special requirements for minors. There are also special required meds for newborns.
120
Keep records to the
maximum or strictest time required
121
When the required retention schedule has been satisfied
a complete list of records to be destroyed should become filed and submitted to the individual designated to authorize the destruction
122
Quality is the degree to
which health services for individuals in populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
123
Performance is the
execution of a task
124
Performance improvement refers to
the continuous study in adaptation of a healthcare organization functions and processes to increase the likelihood of achieving desired outcomes.
125
Medical male practice liability refers to
insisting civil claims for damages against the healthcare provider successfully proves that the provider was negligent and their care of the patient leading to injury or death.
126
Title XIX of the social security amendments 1965 Created the
Medicare and Medicaid programs-providing health insurance coverage to Americans age 65 and older as well as those with disabilities and certain medical conditions, and the latter providing insurance coverage to low income individuals and families
127
Conditions for coverage CFC and conditions of participations COP
needed in order to begin and continue participating in the Medicare and Medicaid programs. They are Health and safety standards for each applicable provider setting.
128
adverse event refers
to instances in which medical care causes injury.
129
Health maintenance organization act of 1973:
allowed for federal funding in the exploratory implementation of health maintenance organization. The government believe that HMO is a health insurance model that uses approaches such as referrals only occurring at the request of her primary care physician and predetermined based rate of pre-payment to providers have the ability to influence healthcare delivery by lowering costs and increasing quality.
130
Institute for health care improvement IOH focuses on
applying scientific methods and quality management to improve healthcare is most challenging issues such as the capability for improvement in healthcare delivery; personal and family centered care; patient safety; and achieving quality, cost, and value.
131
Triple Aim
identifies that vast and systematic improvements are needed in order to improve experiences for patients in their pursuit of healthcare, enhance health among the population, and lower per capita cost.
132
Accreditation
voluntary process of organization review in which an independent body created for this purpose periodically evaluates the quality of the entities work against preestablish written criteria.
133
Accreditation Helps healthcare organizations
because it portrays them as committed to meeting high standards, and accreditation status can be used in marketing strategies to attract patients and as a pathway for healthcare organizations to maintain their participation in the Medicare and Medicaid programs. The federal grabber is the largest single payer for health services.
134
Emergency medical treatment and active labor act EMTALA
enacted to ensure public access to emergency service regardless of ability to pay.
135
Clinical laboratory improvement amendments CLIA enacted to ensure quality labor testing.
to ensure quality labor testing.
136
Medicare prescription drug, improvement, and modernization act was enacted to amend
title XVIII The Social Security act provide for a voluntary program for prescription drug coverage under the Medicare program to modernize the Medicare program to amend the internal revenue code of 1986 to allow deduction two individuals for amounts contributed to health savings security accounts and health savings accounts to provide for the disposition of unused health benefits in cafeteria plans and flexible spending arrangements and for other purposes.
137
Health information technology for economic and clinical health HITECH:
enacted as part of the American recovery and reinvestment act of 2009 to promote the adoption and meaningful use of information technology, address privacy and security concerns associated with the electronic transmission of health information.
138
Quality indicators are standards
against which actual care may be measured to identify a level of performance for that standard
139
Value based payments can be thought of as
any method of healthcare reimbursement that either financially incentivizes providers we’re good quality outcomes are penalizes providers for an adequate quality an unfavorable outcomes.
140
Benchmarking is the
systematic comparison of the products, services, and outcomes of one organization with those of a similar organization, or the systematic comparison of one organizations outcomes with regional or national standards.
141
internal benchmarking is used to
identify best practices within an organization to compare best practices within an organization and to compare current practice overtime.
142
External benchmarking occurs when
an organization uses comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations.
143
Explicit knowledge includes
documents databases and other types of recorded and documented information and tasset knowledge is the actions experience ideals values and emotions of an individual that temp to be highly personal and difficult to communicate.
144
The healthcare quality improvement act of 1986 is a federal law that establishes
standards and requirements related to peer review among physicians in the legislation peer review is also referred to as professional review. When an incident has occurred and it is believed that peer review should occur healthcare organizations must follow standards to ensure that any actions taken against the physician are appropriate and justified.
This includes that the review is occurring to advance quality that reasonable efforts to obtain a relevant facts pertaining to the Internet have been made that the position under review is given advance notice and is afforded as fair hearing and there any actions taken are justified based on facts.
145
The healthcare quality improvement Act of 1986 also provides
legal immunity to other positions who participate in P-Review activities this helps ensure that competent physicians will willingly participate in review of their peers without the threat of legal implications when the review occurs in accordance with the law.
146
The national practitioner data bank is an information clearinghouse…
To collect and release certain information related to the professional competence and conduct of positions, dentist, and, in some cases, other healthcare practitioners. It is a database to provide medical malpractice payments; adverse licensure actions including revocation, suspensions, reprimand, censures,, probation, and surrenders of licenses for quality of care purposes only; in certain professional review actions taken by healthcare entities such as hospitals against physicians, dentist, and other healthcare providers.
147
Entities making malpractice payments, including insurance companies, boards of medical examiners, and entities such as hospitals and professional societies, must report to
the NPDB.
include information on the practitioner, they’re reporting into, and the judgment or settlement went applicable.
148
Credentialing
screening process to evaluate and validate a physicians qualifications for staff membership.
149
Tracer methodology:
it is a process that the joint commission surveyors used during the on-site survey to analyze an organization systems with particular attention to identify priority focus areas, by following individual patients through the organization childcare process in the sequence experience by patient; an evaluation that follows or traces the hospital experiences of specific patients to assess the quality of patient care; part of the new joint commission survey process.
150
Tracer Methodology allows for
Allow for peers within organizations to assess care processes, evaluate the environment of care, and contact benchmarking with accreditation standards is why healthcare organizations use tracer methodology.
151
Outcomes and effectiveness research OER:
describes interprets and predicts the impact of healthcare interventions on any points that matter to patients families and caregivers providers private and public payers and purchasers healthcare regulatory agencies healthcare accrediting organizations and society generally
152
Comparative effectiveness research:
the purpose of it is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnosed, treat, and monitor a clinical condition for true improved the delivery of care. It is to help consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve healthcare about the individual and population levels.
153
Patient centered outcomes research Institute PCORI is an
entity funded through the patient center research trust fund which was established by the ACA at 2010. It helps in form and make sure that information is available for healthcare decision making.
154
AHRQ
to support health services research design to improve the outcomes and quality of healthcare, reduce costs, address patient safety and medical errors, and broaden access to effective services. The research that they provide it helps people make better decisions about healthcare.
HCUP
155
evidence-based practice is
the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care.
156
Clinical pathways are sometimes referred to as
critical pathways and they are structured multidisciplinary care plans that details essential steps in the care of patients with a specific clinical problem.
157
The use of clinical pathways in patients has been shown to
reduce readmissions, improve outcomes, as well as support consistency and clinical care. They expand the concept of a care plan because the pathway is established with the intent that the care plan accounts for the needs of the patient as well as promotes the interdependent nature of the health professions to achieve more cohesive patient care.
158
Case management:
The collaborative process of assessments, planning, facilitation, care coordination, evaluation, and advocacy for options and services to me and individuals and families comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
offers a solution to help ensure that the needs of patients are met during a hospitalization or other care episode as well as after they are discharged from the healthcare setting.
Chronic conditions and helps reduce readmissions.
159
Care coordination:
It is the act of organizing patient care activities and sharing information among all of the participants concern with the patient’s care to achieve safer and more effective care.
It is necessary to ensure that a patient is provided care at the appropriate level as well as to ensure that the care is coordinated and thoughtful and proactive ways and reflects an opportunity to provide healthcare services in a way that is proactive versus reactive in nature.
160
DaTa stewardship and information governance are
strategic concepts in the management of health information.
161
Help data stewardship pertains to
the responsibilities that best insure appropriate use of help data.
Effective data stewardship and information governments are necessary to maximize the value of health information available in health records used to evaluate and measure quality of care.
162
Data analytics:
Effective at data analytics only occurs when those performing the analysis fully comprehend the complexity, limitations, meaning, and uses of healthcare data
RHIA
flashcards
Decks in class (2)
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