Third-party payers. The current paradigm for treating disease is to meet with the patient, diagnose the patients symptoms, and prescribe therapy to treat them. ht 20 IG PERFORMANCE 20 by Guides practice for information through the information lifecycle across the healthcare ecosystem. 2019. Bold lines should be used to draw the readers eye to an important field. The health records are filed by the last two digits, called the terminal digits, then the middle two digits, known as the secondary unit. Chicago: AHLA. Poor documentation also impacts the accuracy of medical coding due to potential improper code assignment, resulting in inaccurate diagnosis and procedure codes. Reynolds. Showalter, J.S. This organization does not presuppose a pedagogical progression of presenting basic foundations and then progressing to advanced concepts. Examples of external users are state data banks (discussed later in this chapter) and federal agencies. Other notification requirements, such as the content and nature of breach notices, parallel HHS requirements (Rinehart-Thompson 2018). This may be done using random samples of statistically significant size. Information on graphs and charts is found in chapter 13, Research and Data Analysis. Most of the information and detail that will be discussed and concluded based on the findings from the CDI process or query process will need to be documented in the health record and may become part of the health record. The legislative branch, which is the US Congress and is comprised of the House of Representatives and the Senate, creates statutory law (statutes). Tumor or cancer registries regard ICD-O-3 as their system for classifying the topography and morphology of neoplasms. op yr ig ht National Library of Medicine. These domains are: Data Content Structure and Standards; Information Protection: Access, Disclosure, Archival, Privacy, and Security; Informatics, Analytics, and Data Use; Revenue Management; Compliance; and Leadership. ia tio 1. If the information the healthcare organization relies upon is the culprits information (for example, photo, signature, or fingerprint), all future encounters will be based on fraudulent information, decreasing the chances of detecting the fraud or otherwise causing the healthcare organization to wrongfully identify the true patient as the culprit if he or she later presents to that healthcare organization for treatment. CEs that do not record or maintain psychotherapy notes are not required to include a statement 7. Many services such as surgery, infusions, and other diagnostic procedures that once required a patient to stay overnight in the hospital can be performed on an outpatient basis. The trial proceeds according to a protocol, which is the list of rules and procedures to be followed. ag em Ambulatory Surgery Record lth In fo r m at io n M an Ambulatory facilities that perform surgery are called ambulatory surgery centers (ASC). For example, birth defects registries provide information on the incidence of birth defects to study causes and prevention; monitor trends in birth defects; improve medical care for children with birth defects; and target interventions for preventable birth defects. She holds a clinical associate professorship at the University of Illinois at Chicago, and she is serves as adjunct faculty at the College of St. Scholastica. Only permissible if the decedents next of kin has given written authorization for information about the decedent to be disclosed to the funeral home c. A violation of the HIPAA Privacy Rule d. Subject to a HIPAA consent by the next of kin 8. An operation or procedure code would include information similar to the disease index but would also include the specific code numbers as well as the operating physician. The physician performs the physical examination to ensure appropriate treatment and services are ordered for the patient. Most US hospitals fall into this category. https:// nam.edu/wp-content/uploads/2018/10/ProcuringInteroperability_web.pdf. HIPAA Privacy Rule and ARRA highly sensitive health records such as mental health and HIV/AIDS, but many states had no statutes or regulations to protect health information generally. The requirements for emancipation vary by state but generally apply when the minor is married, is self-supporting, and lives on their own (Brodnik 2017a). It contains the Metathesaurus, Semantic Network, and SPECIALIST Lexicon and Lexical Tools, which make up the UMLS Knowledge Resources. M an ag Source: HHS 2015. on the Internet. Metadata refers to the data that characterizes other data such as creation date of data, date sent, date received, last accessed date, and last modification date. Journal of AHIMA 74(1):16A16D. Chapter 2 in Documentation for Medical Records. Chicago: AHIMA Press. AB103118_Ch09.indd 282 Brodnik, M.S. The National Health Interview Survey data are collected through personal household interviews. at io ea H an ic er Am Trojan horse. The first two were addressed earlier in this chapter; the remaining two are explained as the following: Incidental uses or disclosures occur as part of a permitted use or disclosure (CFR 164.502(a) (1)(iii)). The legal significance of licensure in healthcare is that a government entity has deemed the individual or healthcare organization qualified to provide competent and safe patient care. Sponsored . Chicago: AHIMA. Since the amount of patient data collected through a patient encounter is immense, it is important to evaluate and understand why the data is being gathered and the purpose it serves for the healthcare organization. 2016) Physicians can be categorized as generalists or specialists. ICF e-learning tool. tA ss oc Classifications by th e Am International Classification of Diseases, Tenth Revision, Clinical Modification C op yr ig ht 20 20 The National Center for Health Statistics (NCHS) is the governmental body responsible for the maintenance of ICD-10-CM. gov/topic/health-it-initiatives/telemedicine-andtelehealth. Measures to combat internal medical identity theft include performing background checks on new hires and contractors (Olenik and Reynolds 2017). While the application of the ICF concepts and framework in clinical practice is the responsibility of health professionals such as physical therapists, the individual or the individuals advocate is an integral part of the assessment. Chapter 6 in Health Information Management: An Applied Approach, 5th ed. Journal of AHIMA. By accepting all cookies, you agree to our use of cookies to deliver and maintain our services and site, improve the quality of Reddit, personalize Reddit content and advertising, and measure the effectiveness of advertising. ICD-11-MMS will replace the World Health Organization (WHO)s ICD-10. Common BAs include consultants, billing 2/6/2020 4:46:06 PM Chapter 9 Data Privacy and Confidentiality 251 Figure 9.2 Components of a business associate agreement Parties to the BAA (CE and BA; BA and subcontractor of BA) Purpose of the BAA (compliance with HIPAA and ARRA) Definitions (breach; electronic PHI; individual; PHI; law; Secretary of HHS; security incident) ia tio n. Obligations and activities of the BA Permitted uses and disclosures by BA (or subcontractor) Obligations of the CE Term and termination Indemnity for both parties Limitation of liability Miscellaneous Signatures, titles, contact information ss oc Source: AHIMA 2016. fo r m at io n M an ag em en tA employees of outsourced vendors who routinely work on-site in the CEs facility. at io Government policy makers. IG101: Developing Clinical Business Intelligence. Core functions of enterprise information management must be established to create the ability to collect high-quality data from the health record. Unsere Partner sammeln Daten und verwenden Cookies zur Personalisierung und Messung von Anzeigen. This is the right to request restrictions of PHI. The average turnaround time for a coding query was 28 days. Chapter 19, Leadership, leadership theories and styles are explored and the impact of change management on processes, people, and systems. Pocket Glossary of Health Information Management and Technology, 5th ed. 42 CFR 482.24(c)(1): Interpretive guidelines. Based solely on clinical care b. Documentation errors should not be obliterated or changed and should be corrected per procedure. PDF Health Information Management Technology: An Applied Approach online. ABMS Guide to Medical Specialties. This was done through the evaluation and review of informationrelated policies and procedures throughout the system. Accreditation organizations. This subset includes SNOMED CT concepts commonly used for encoding clinical information at a summary level, such as the problem list. Ensuring data integrity 6. tA ss oc ia Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia. Documentation must be complete and accurate, support quality initiatives, and meet accreditation requirements. She has served on numerous AHIMA committees and is a member of AHIMAs Council for Excellence in Education. ic Am er AHIMA Structure and Operation an H ea committees and subcommittees in designated student positions with a voice, but they do not have a vote. n M an Code Systems 20 20 Logical Observation Identifiers, Names, and Codes C op yr ig ht LOINC is a is a common language (set of identifiers, names, and codes) for identifying health measurements, observations, and documents (Regenstrief Institute n.d.). The need for RNs is expected to rise over the next decade. Category III codes are alphanumeric, consisting of four numbers followed by the letter T. The following is an example of a Category III CPT procedure along with its identifier: at io n M an 0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus fo r m CPT also includes an introduction, an index, and appendices. Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. Proper management of health information is critical for the healthcare industry to advance and improve in areas of cost, access, and quality. For example, the healthcare organization located in Alabama might back their data up at a location in Kansas. Medical (MDDoctor of Medicine) focuses on the diagnosis, treatment, and education of any human disease or condition. For example, the Electronic Health Record Standards and Certification Criteria Rule defines the standards that must be used for EHR technology to be certified by the authorized Certification Bodies. Clinical terminologies are sets of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement. Core performance measures are a set of national standardized processes and best practices used to render and improve patient care. They also may loiter in the organizations buildings hoping to access information from unprotected computer terminals or to read or take paper documents, computer disks, or other information. Medical identity theft does not include the inappropriate change of patient information if the patients identity has not been assumed or abused by someone 2/6/2020 4:46:10 PM 278 Part III Information Protection: Access, Disclosure and Archival, Privacy and Security else. The application of the standards varies depending upon the content of the health record; whether the record is an inpatient, ambulatory, behavioral health, or physician office record; and from where the standards originate. This section also discusses what the Privacy Rule protects: protected health information (PHI). Coronel, C. and S. Morris. DataSource is a business associate of Davis Health System. Paper ranging from 20 to 24 pounds in weight is recommended for use in copiers, scanners, and fax machines. On the left is the ingredient (amoxicillin), ingredient plus strength (amoxicillin 400 mg), and ingredient plus strength plus dose form (amoxicillin 400 mg chewable tablet). Adata element can be a single or individual fact that represents the smallest unique subset of a larger database. C op yr ig ht 20 20 by th e Am er ic an H ea lth In companies, transcription companies, accounting firms, and law firms. In essence, subacute care in most IDNs emphasizes patient independence. Giannangelo, K. 2007. Social engineering techniques will be discussed further in this chapter. Addiction Medicine Concerned with the prevention, evaluation, diagnosis, and treatment of persons with the disease of addiction, of those with substance-related health conditions, and of people who show unhealthy use of substances including nicotine, alcohol, prescription medications, and other licit and illicit drugs. A mechanism should be in place to check all newly printed forms prior to distribution. Oftentimes, these access requests appear to have been initiated by a third party instead of from the individual. 86:6. : AB103118 an H Cover image: sollia Shutterstock 20 20 by th e Am er ic Limit of Liability/Disclaimer of Warranty: This book is sold, as is, without warranty of any kind, either express or implied. This knowledge helps avoid surprises at trial and perhaps encourages pretrial settlement (Rinehart-Thompson 2017b). Electronic document considerations include emails, text messages, electronic fetal monitoring strips, diagnostic images, digital photography, voice files, and video (AHIMA 2011a). In to computer resources, such as programs, computer networks, or entire computer systems. The amount of filing and retrieval activity will impact the decision. Am er Health Record Number: ic Physician/Practitioners Name: an H ea Figure 3.4 Sample deficiency slip th e Patients Name: Discharge Date: 20 by Analyzed by: 20 Date: Dictation required ht Signatures required History History Physical Physical Physical Consultation Consultation Consultation Operative report Operative report Operative report Discharge summary Discharge summary Discharge summary yr ig History op C Missing reports Radiology report Other Other Pathology report Progress notes Other Source: Cerrato and Roberts 2012. The program was inaugurated on July 1, 1966. For individuals, further regulation by th e Certification C op yr ig ht 20 20 Certification of individuals is a designation given by a private organization to acknowledge a requisite level of knowledge, competencies, and skills. Dr. Smith has been granted permission by community hospital to perform cardiac catheterizations. Because of this, the billing department cannot perform their responsibilities until the HIM department completes theirs. Manufactured drug b. CMS defines what authentication methods are to be used for health record entries such as written signatures, initials, computer key, or other code; the requirements a healthcare provider needs to have in place; and controls to 2/11/2020 12:24:11 PM Chapter 4 Health Record Content and Documentation 103 prevent any changes from being made to the health record after the entries have been authenticated (42 CFR 482.24(c)(1)). The state serves as the official repository for the certificate and provides vital statistics information to the NCHS. Such notification is a hospital operation. This includes specific document(s) and the dates of service. 45 CFR 164.512(i): Uses and disclosures for research purposes. Two days after being discharged home, he went into respiratory failure and was rushed back to the hospital. Although many healthcare provider organizations have an EHR, there remains a good deal of paper-based documentation that must be integrated and included in the patients EHR. The Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument is used to group patients into a payment category. 2015. http://www.aapc.com. 2013. en em M an ag 45 CFR 164.508: Uses and disclosures for which an authorization is required. You may get them from the Apple Store and Google Play. C op yr ig ht 20 20 by th e Am er ic an H ea Health information management roles within healthcare have drastically changed over the past 10 to 15 years as the EHR has evolved. Because of this, an outguide is not needed to record the location of the health record but may still be used to hold the documents to be filed. Critical Care Medicine Specializes in the diagnosis, treatment, and support of critically ill and injured patients, particularly trauma victims and patients with multiple organ dysfunction. https://www.facs.org/qualityprograms/trauma/tqp/center-programs/ntdb. Fahy, K. and M. Hermann. Grace W. Meyers Award. In addition to the student resources, instructors can access the following educator resources: instructors manual, presentation slides, new adaptive learning tool, course curriculum map, and a test bank instructors manual and PowerPoint slides. See chapter 4, Health Record Content and Documentation, for a description of these reports. She is currently pursuing her masters degree in educational studies from the University of Cincinnati. Informatics is a field of study that focuses on the use of technology to improve access to, and utilization of, information. Inpatient health record documentation looks slightly different from documentation in the operating room or in a long-term care facility. Sleep Medicine Diagnoses and manages clinical conditions that occur during sleep, that disturb sleep, or that are affected by disturbances in the wake-sleep cycle. Additionally, the bylaws should define the processes that align with the organizations data and information governance strategy regarding the completeness and accuracy of health information within a health record, including expectations of timeliness. Typical HIM functions include the following: Medical transcription and voice recognition Disclosure of health information Clinical coding and reimbursement Record storage and retrieval (paper and electronic) Statistics and research Master patient index tio ia oc ss tA en em ag M an Registries (cancer, trauma, birth defects, andmore) Birth and death certificate completion Am er ic an Medical Transcription and Voice Recognition H ea lth In The HIM department operates in conjunction with other departments to support and enhance their services includingpatient care, information governance, quality management, billing, and patient registration. Some of these information systems are becoming more and more important with the implementation of the EHR while others will be phased out completely as the EHR makes them obsolete. For example, if a physicians office reports a case of tuberculosis to a public health authority, that disclosure must be included if the patient requests an accounting. Since medical providers are not the sole authors of clinical documentation, it is important for hospitals to define who can document within the record, the type of documentation that can occur, and the timeliness and completeness of that documentation. True or false: An information governance initiative is a project within a healthcare organization led by middle level fo r m at io n M an ag em en tA ss leadership. Public Law 92603 of 1972 To curtail Medicare and Medicaid spending, additional amendments to the Social Security Act were instituted in 1972. n. 3. Electronic health record (EHR) management 7. 5.4 The IIS can produce an immunization record acceptable for official purposes (for example, school, childcare, camp). 20 4. Assignment of the ICD-10-CM code is most often the responsibility of a professional coder based on the healthcare providers documentation of the patients diagnosis. This path may jump from category to category. 2/6/2020 4:46:11 PM 284 Part III Information Protection: Access, Disclosure and Archival, Privacy and Security 45 CFR 164.512(h): Uses and disclosures for cadaveric organ, eye or tissue donation purposes. Alternatively, physicians who work for ambulatory care organizations are employees of those organizations. The American Recovery and Reinvestment Act (ARRA) provided significant funding for health information technology and other economic stimulus funding, and it also made important changes to the HIPAA Privacy and Security Rules. Chapter 4 in Fundamentals of Law for Health Informatics and Information Management. Date of birth th e Am er ic an 04b. The more commonly known programs that often obtain certification address asthma, diabetes, and heart failure (Joint Commission 2016bd). a. b. c. d. Manual and electronic Paper and electronic Manual and computer-assisted coding Electronic and computer-assisted coding 2. The departments may send loose reports to the HIM department for filing if the health record has already been returned. They set the organizational strategy, AB103118_Ch01.indd 10 Opportunities for members to contact other members to gain knowledge, share information, and learn best practices Opportunities to identify members with similar interests and backgrounds Gives members the ability to share and retrieve resources (AHIMA 2019d) National Committees AHIMAs president/chair oversees the appointment of members of the associations national committees, practice councils, and workgroups. Judicial and administrative proceedings. A bystander called 911 and he was taken to the same emergency department where he had sought treatment for the shin injury. Whether it is discoverable or not depends on legal protections (such as a state statute that specifically protects quality assurance records) or the lack thereof. Common healthcare professionals who enter information are nurses, ancillary support, therapists, social work, health unit coordinators, and other support staff given rights to document within the record. For example, employees working in the housekeeping department would not have the same level of access to PHI as a nurse working in critical care. Chapter 3, Health Information Functions, Purpose, and Users, introduces the function and purpose of the health record function as well as who uses the record. Timed and dated entries establish a baseline for future actions or assessments and establishes a timeline of events. In fall 2020, NHGRI will launch its newest strategic plan aimed at accelerating scientific and medical breakthroughs. This action is taken so that if a disaster such as a fire or flood occurs at the main site, backup copies will be unaffected. The paper health record is completely available in paper media. Lawyers may need access to support a client (the patient) for life insurance claims and lawsuits such as those related to motor vehicle crashes, disability, and such. Inpatient rehabilitation hospitals and units within hospitals are reimbursed by Medicare under a prospective payment system. CMS-Approved Accrediting Organization Contacts for Prospective Clients. Joint Commission-accredited organizations are required to implement policies regarding advance directives and DNR orders (Klaver 2017b). For thousands of years, individuals have been documenting stories and events in written form to share and reshare with future generations. The NLM is a biomedical library that maintains and makes available a vast amount of print collections and produces electronic information resources on a wide range of topics (NLM 2019). She teaches a variety of courses in the health information management and health informatics programs related to legal issues in healthcare, HIPAA privacy and security, compliance, EHRs in healthcare, and research. Alternative dispute resolution includes arbitration (parties agree to submit a dispute to a third party to decide) and mediation (parties agree to submit a dispute to a third-party facilitator, who assists the parties in reaching an agreed-upon resolution). 2013. C op yr ig ht 20 20 by th e Am er Compliance is an industry concept that means conformance with applicable laws. These executives include a chief knowledge officer and chief operating officer. No match No map No code A code (concept) that exists in one coding system may have a direct relationship to the other coding system. RxNorm Technical Documentation, Version 2018-1. https:// www.nlm.nih.gov/research/umls/rxnorm/docs /index.html. 2016. http://www.carf.org/Documentation_ and_Time_Lines. Submission of OASIS data is a CMS requirement if the agency participates in the Medicare program. Ambulatory surgery health records c. Emergency department health records d. Obstetric health record er ic an H ea Physicians office records Emergency care records Standing orders Order sets Am a. b. c. d. lth In 5. A plan for an enterprise health record number was needed. The clinical documentation fo r m HIM Roles Real-World Case 4.1 The hospital clinical documentation improvement (CDI) specialist reports to you, the HIM manager of Anywhere hospital, that the hospital has been receiving reimbursement penalties. 3. AB103118_FM.indd 33 2/11/2020 1:38:53 PM xxxiv Preface policies and procedures, in addition to the infrastructure and education of staff on information protection methods, risk assessment, access, and disclosure management and falls under Domain II of the 2018 AHIMA competencies. Centers for Disease Control and Prevention (CDC) CDC, part of the US Public Health Service (PHS) protects the public health of the nation by providing leadership and direction in the prevention and control of diseases and other preventable conditions, and responding to public health emergencies. AB103118_Ch04.indd 121 American Health Information Management Association. This central location for immunization data relieves parents of the responsibility of maintaining immunization records for their children. Updating organizational policies and procedures for information governance. Figure 5.7 Example of the structure of a complete ICD-O-3 code Topography code Morphology code C22.0 M8170/31 Histologic term (hepatocellular) Histologic grading or differentiation Behavior code (malignant) DSM-5 Purpose and Use DSM-5 fills the need for a clear and concise description of each mental disorder (APA 2013, 5). Which of the following describes HIPAA consents? The sections that follow will explore and describe the benefits of telehealth technologies and electronic health records and health data and the effects they have made on the delivery of healthcare. It should be dated, timed, and signed. The professional organizations name became the American Medical Record Association (AMRA). For more information 2/6/2020 4:54:37 PM 126 Part II Data Content, Structures and Standards Table 5.2 Examples of data uses and the requirements Requirement Clinical terminologies, classifications, or code systems To facilitate electronic data collection at the point of care with terms familiar to the user Granular data Clinical terminologies, code systems To allow many different sites and different providers the ability to send and receive medical data in an understandable and usable manner, thereby speeding care delivery and reducing duplicate testing and duplicate prescribing Granular data Clinical terminologies, code systems To allow the computer to manipulate standardized data and find information relevant to individual patients for the purpose of producing automatic reminders or alerts Granular data Clinical terminologies, code systems To allow the computer to manipulate standardized data and find information relevant to individual patients for the purpose of producing automatic reminders or alerts Granular data Clinical terminologies, code systems To allow collection and reporting of basic health statistics Aggregate data Classification systems, code systems To provide data that are used in designing payment systems and determining the correct payment for healthcare services Aggregate data Classification systems, code systems To provide data that are used in monitoring public health and risks Aggregate data To provide data to consumers on costs and outcomes of treatment options Aggregate data en tA ss oc ia tio n. Data use M an ag em Classification systems, code systems Classification systems, code systems lth In fo r m building blocks. en tA ss oc AHIMAs new responsive adaptive learning tool for health information management programs m fo r C op yr ig ht 20 20 by th e Am er ic an H ea lth In For Instructors Instructor materials for this textbook are provided only to approved educators. Federally mandated healthcare program for low-income people c. Healthcare program limited to those under age 65 d. Healthcare program for low-income persons regardless of age that is totally financed and operated by the states ea 6. c. I am not eligible for AHIMA Fellowship because I need to publish in journals as well as volunteer for AHIMA. True or false: Nursing terminologies are used for reimbursement of nursing care for Medicare patients. For more information on disclosure of health information and privacy requirements, see chapter 9, Data Privacy and Confidentiality. 1974. The Centers for Medicare and Medicaid Services has a website where providers can look at the NCD and LCD requirements (https:// www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx). 3. Most hospitals provide services to both inpatients and outpatients. True or false: The SNOMED CT preferred term includes the semantic tag. The coding supervisor must ensure the quality of code assignment and the timeliness of the coding process. This is the concept of preemption, which is discussed later in this chapter. It was amended through Data Collection for Diabetes Registries In addi- the Medical Device Amendments of 1992 (GPO tion to demographic information about the cases, 1992). 2016). The number of maternity beds and other special categories may be listed separately. 2016. As care is documented in the health record, it becomes a key resource in their evaluation of the quality of care provided. This information is used to evaluate the qualifications, skills, and performance history of a physician. 2018. C op yr ig ht 20 20 by th e Am er ic an H ea lth In addition, analysts who are assisting with building the EHR within the healthcare organization should meet with each department that enters data into the health record to evaluate current data collection processes within the EHR and evaluate additional forms or tools necessary to support current workflow. Commonly transcribed reports include history and physical, discharge summary, pathology reports, procedure reports (such as colonoscopy and cardiac catheterization), and radiology reports. C op (AMA), but other orders will vary from patient to patient. The site of origin of the neoplasm is captured by the topography code. The folders are filed alphabetically by the patients last name. This involves 2/6/2020 5:36:21 PM 292 Part III Information Protection: Access, Disclosure and Archival, Privacy and Security lth In fo r m at io n M an ag em en tA ss oc ia tio n. information security committee are the chief information officer (CIO), information technology system directors, network engineers, and representatives from clinical departments (lab, nursing, pharmacy, radiology) as appropriate. File folders used for health records are usually purchased in one of two standard weights or thicknesses11 points and 14pointsalthough the weight may be as much as 20points. 2/6/2020 4:52:59 PM 56 Part 1 Foundational Concepts identifiers for providers, health plans, and employers. It is the software used for speech recognition. These specialists use modern cytogenetic, molecular, genomic, and biochemical genetic testing to assist in specialized diagnostic evaluations, implement needed therapeutic interventions, and provide genetic counseling and prevention through prenatal and preimplantation diagnosis. The increase in spending is attributed to the growth in enrollment, increased provider rates, increased prescription costs, and other costs spread out over the healthcare system (Kaiser Family Foundation 2015). Progress note c. Operative report d. Discharge summary Am er Federal and State Initiatives on Documentation C op yr ig ht 20 20 by th e As healthcare costs have steadily and, in many cases, dramatically increased over the years, the government, on state and federal levels, has focused its attention on alternative reimbursement and payment models. It denotes the negative aspects of the interaction between an 2/6/2020 4:54:42 PM Chapter 5 Clinical Terminologies, Classifications, and CodeSystems 139 individual and that individuals contextual factors. For additional information on EHRs, refer to chapter 11, Health Information Systems. As with the medical staff bylaws, clear and concise expectations of data entry and documentation should be established, and training provided for all healthcare employees. Tort law is broad and includes nonhealthcare-related acts (for example, a driver runs a red light and strikes another vehicle) and healthcare-related acts (a nurse administers the wrong medication). H ea physician may be contacted to determine whether the patient is still living and to obtain information about the cancer. Preferred provider organizations (PPOs), which provide reduced costs if the plan member stays within the network but will contribute at a reduced cost if the member goes outside the network 2/6/2020 4:52:56 PM 40 Part 1 Foundational Concepts 3. The rehabilitation team may include physicians, nurses, occupational therapists, physical therapists, respiratory therapists, speech therapists, social workers, and other healthcare personnel. a. b. c. d. A clearly defined data dictionary for the electronic health record A recommended list of data elements that support a specific healthcare industry One element within an electronic health record A database where data are compiled from many sources into one central location 3. Presenting data that do not support an initiative of the organization can be an unproductive use of company resources and time. Uses and disclosures for healthcare operations do not require authorization. 2019. HIM staff may collect some of the data needed, provide the records, generate statistics, write reports, mine data, or assist in other ways. Fundamentals of Hospital Medical Staff Issues: Minimizing Risk and Maximizing Collaboration (Session F). 2019. https://www.pcpcc.org/about/medical-home. Additionally, the CE must designate a person or office as the responsible party for receiving initial complaints about alleged privacy violations. The plaintiffs attorney is the first to call witnesses and present evidence. Information is different from data in that it refers to data elements that have been combined and then manipulated into something meaningful regarding a patient or a group of patients. There should be an option for at io n corrected final in addition to preliminary and final. Policy should address how the patient or patient representative requests corrections and amendments to the record. a. Shortly after the UHDDS was created and implemented, the need to expand uniform data sets across other healthcare settings became evident with the continuing movement from an inpatient, acute setting to outpatient care including surgical centers and emergency care settings. The three types of negligence are the following: AB103118_Ch08.indd 230 The causes of actions mentioned are not the only ones that can be brought against an individual healthcare provider or a healthcare organization. The Department of Defense operates facilities for active military personnel and their dependents. When material changes are made to policies or procedures regarding privacy, employees must receive additional training. This liaison would work with physicians, monitor turnaround time, monitor the quality of the work, and more. fo r Health record entries should be documented at the time the services described are rendered. This system consolidates all the information on the patient in one location and is therefore more efficient than the serial numbering system. Wiedemann, L.A. 2010. at io m fo r lth In 2. Problem solving 9. Is responsible for the EHR implementation and maintenance c. Is always a subcommittee of the quality improvement committee d. Is an optional function for the HIM department 7. Nursing Practice tio ia oc ss en tA Allied Health Professions C op yr ig ht 20 20 by th e Am er ic an H em ag M an n at io m fo r ea lth Most RNs have either a two-year associate degree or a four-year bachelor of science degree from a state-approved nursing school, though some schools offer a masters degree that allows the graduate to sit for the licensure examination. Simply stated, data governance manages the data put into the different information systems used in healthcare and information governance manages the information output from those systems. For example, to present the frequency of a specific diagnosis by gender, a pie chartmeant to show the percentages of a totalwould not be a good selection. A tort is a wrongful civil act that results in injury to another. LOINC is also one of several standards chosen for the entry of structured data in certified EHR systems (ONC 2015). At the local and community level, leaders decide where public funds will finance community health centers and municipal hospitals, which provide care regardless of the patients ability to pay. The actual collection of the information is carried out at the local level. The information and data strategies should align to the healthcare organizations overall strategy and support the broader business goals of the organization. Reverse chronological order is kept while the patient is being treated. The statement should indicate the reason for the patients admission, his or her diagnosis and course in the hospital, and a description of the events that led to his or her death. Home care itself takes many forms from very basic assistance that allows a patient to remain independent and live in his or her home, to short-term rehabilitation care, or comprehensive management of a chronic illness. With very few histological types available in ICD-10, ICD-O-3 provides greater detail of the histological classification. The supervisor is responsible for ensuring turnaround times are met. The following are the new process steps: With the change in the process, the HIM operations department has little involvement unless it is supporting the physician in completing the query. This framework reflects the importance of the relationship between how population groups experience place and the impact of place on health. 2018). Humbert (2018) stated: A critical thinker is able to deduce consequences from what he knows, and he knows how to make use of information to solve problems, and to seek relevant sources of information to inform himself.Critical thinking can help us acquire knowledge, improve our theories, and strengthen arguments. Managed Care. AB103118_Ch07.indd 210 2/6/2020 4:55:53 PM Chapter 7 Secondary Data Sources 211 r egistry. ic an H ea The most important purpose of the health record is to document patient treatment and provide a means for a patients healthcare providers to communicate among each other. The SNOMED CT concept definition is a set of one or more axioms, or true statements, that serve as a starting point for further reasoning and arguments (SNOMED International 2017a). State laws supersede HIPAA if the state law is stricter. Am er ic an n at io m fo r In lth H ea Electronic health records (EHRs) and the ability to record, capture, and manipulate health data have had a tremendous impact on the delivery of healthcare. The CEs must respond to BA noncompliance, and ARRA requires BAs to respond to CE noncompliance. http://bok.ahima.org/doc?oid=302009#. https://www.cms.gov/researchstatistics-data-and-systems/statistics-trends-andreports/nationalhealthexpenddata/downloads/ forecastsummary.pdf. Support the activities and requirements for publicly purchased vaccine, including the Vaccines For Children (VFC) and state purchase programs. Coding and billing staff. For example, the Informatics mid-level of implementation support analyst can jump to the Information Governance advanced role of HIM manager (AHIMA nd). element within an information system. I understand that the organization reserves the right to change its notice and practices and prior to implementation will mail a copy of any revised notice to the address Ive provided. Healthcare researchers use health records to study the safety and efficacy of drugs or the value of care provided. Engage Engage is a community website managed by AHIMA for members to communicate on HIM topics. Real-World Case. Dr. McNeill has several educational publications to her credit, including research articles in Perspectives in Health Information Management, Journal of Allied Health, and the Journal of the American Health Information Management Association. b. Quantitative analysis looks at the quality of documentation and qualitative analysis looks for the presence of documents or signatures. Health records should be retained for at least the period specified by the states statute of limitations, which is the period of time in which fo r m Retention of the Legal Health Record AB103118_Ch08.indd 237 2/11/2020 1:16:11 PM 238 Part III Information Protection: Access, Disclosure and Archival, Privacy and Security and other activities. Although the primary audience for this book is students enrolled in two-year HIT programs, students in other HIM disciplines and allied health programs will find its content highly valuable and useful. and product development activities related to the creation and implementation of natural language-processing applications where clinical terminology and classification systems are utilized. th e 3. Chicago: AHIMA. An example of data is 50 patients were discharged yesterday. Rinehart-Thompson, L.A. 2017d. Where highly sensitive information is involved, such as behavioral health, substance abuse, HIV/AIDS, or genetic information, the same principles apply regarding who has the legal authority to authorize the disclosure of health information. 428071000124103 at io m fo r Light tobacco smoker. Steves job provided health insurance and he rarely needed to use it. Disgruntled employees might destroy computer hardware or software, delete or change data, or enter data incorrectly into the information system. Examples of specific types controlled. LOINC provides names and codes for identifying laboratory and clinical variables. For-profit healthcare organizations are privately owned. When use or disclosure is required, even without patient authorization When the individual/patient or individuals/patients personal representative requests access or accounting of disclosures (with exceptions) HHS investigation, review, or enforcement action B. 2018). Hospitals and care systems need to redesign how care is delivered to eliminate inefficiencies within the system that will lead to better, integrated care, and lower total cost of care. Patient privacy protection laws governing access, use, and disclosure had largely resided with the individual states. Special interventions such as the use of restraints also require documentation. The Federal Rules of Civil Procedure (FRCP) incorporated electronic information through the creation of e-discovery rules. AB103118_Ch07.indd 200 Disease and Operation Indexes The disease index is a listing in diagnosis code number order of patients discharged from the healthcare organization during a specific time period. As a matter of practice, healthcare organizations obtain a general consent from a patient for routine treatment and failure to do so can result in a legal action; generally, for battery, or harmful or offensive contact. Cookies are a type of spyware. Information governance is an organization-wide framework for managing information throughout its lifecycle and for supporting the organizations strategy, operations, regulatory, legal, risk, and environmental 2/11/2020 12:15:42 PM Chapter 1 Health Information Management Profession 7 The Future of HIM fo r m at io n M an ag em en tA ss oc ia tio n. Research shows the HIM profession is continuing to evolve from the traditional HIM roles to roles focused on information. Nursing homes are no longer the only option for patients needing long-term care. Additionally, the establishment of data collection and data quality requirements in bylaws can help support and ensure proper documentation as required by the healthcare organization to support the data management processes. The medical center administration decided to bring in the health information management director of the medical center to provide expertise and experience in resolving the problem. Instructions for Use 2. AB103118_Ch04.indd 122 2/11/2020 12:24:13 PM Chapter tio ia at io n M an ag em en tA ss oc Clinical Terminologies, Classifications, and CodeSystems n. 5 In fo r m Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA ea lth Learning Objectives ht yr ig Key Terms Identify code systems for laboratory and clinical observations; professional services, procedures, and supplies; and drugs Differentiate among clinical terminologies, classifications, and code systems found in health data and information sets Justify the need to have a database of clinical terminologies, classifications, and code systems 20 20 by th e Am er ic an H Identify the importance of clinical terminologies, classifications, and code systems to healthcare Examine the content of SNOMED CT, Current Procedural Terminology, and terminologies used in nursing practice Analyze the different classification systems and their purposes C op Axioms Classification Clinical terminology Code set Code system Common Clinical Data Set (CCDS) Concepts Data set Derived classification Disability Extension codes Fully specified name (FSN) Functioning Granular level Health information exchange (HIE) International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics (ICD-11-MMS) International Classification of Functioning, Disability, and Health (ICF) Linearization Morbidity Nomenclature Preferred term (PT) Reference terminology RxNorm concept unique identifier (RXCUI) Semantic interoperability SNOMED CT identifier (SCTID) Stem codes Unified Medical Language System (UMLS) Vocabulary 123 123 AB103118_Ch05.indd 123 2/6/2020 4:54:36 PM 124 Part II Data Content, Structures and Standards Table 5.1 General definitions Definition Vocabulary/ Terminology A set of terms specific to a domain Nomenclature A system of names that follows pre-established conventions Classification A mono-hierarchical method of organizing related terms together Code An identifier Code set An accumulation of numeric or alphanumeric codes Code system An accumulation of terms and codes for exchanging or storing information n. Label oc ia tio Source: AHIMA. When creating requirements of documentation for hospital bylaws, which of the following should be evaluated? Authorizations and audit trails are discussed later in this chapter. These purposes are permitted by HIPAA and described later in the chapter. The April update is th e Am er ic an H ea ICD-10-CM Content and Structure ICD-10-CM contains three to seven-character codes and descriptions for patient conditions. Table 5.5 lists the draft USCDI data classes, which include the CCDS. Hospital-based emergency departments provide specialized care for victims of traumatic accidents and life-threatening illnesses. Peer Review Improvement Act of 1982 b. M an ag em 6. C op yr ig ht 20 20 by th e Patient care managers and support staff. 2/11/2020 12:24:13 PM 120 Part II Data Content, Structures and Standards Check Your Understanding 4.5 Answer the following questions. They do not serve seriously ill patients, and most do not accept patients arriving by ambulance. All orders must be legible and include the date and the physicians signature. 2011a. Autodialing systems may be used to call parents and deliver a prerecorded reminder. An ANSI-accredited SDO, HL7 established the creation of standards to support the exchange of clinical information in multiple formats ea To help support and drive interoperability and data sharing between healthcare organizations, standards development organizations have created standards for the sharing of information in electronic formats. 2.2 The IIS vaccine inventory function is available to direct data entry users and can interoperate with EHR or other inventory systems. Patient care providers include physicians, nurses, and other allied health professionals who rely on information from the health record to make decisions about the care provided to the patient and for documentation of care. There are two principal reasons for this. 2015. TEFRA required extensive changes in the Medicare program. Identify an element of negligence. The parties may also agree to allow a photocopy of the health record or a printed version of the EHR to be introduced into evidence rather than the original. One such centralized location of health and biomedical terminologies AB103118_Ch05.indd 147 and standards is the Unified Medical Language System (UMLS). It also does not determine a status such as competency or criminal responsibility. Special Considerations for IG This example clearly shows the importance of organization-wide communication, collaboration, and commitment to govern the quality of information. The most familiar type of public law is criminal law, where the government is a party against an accused who has been charged with violating a criminal statute. One way to find cases is through the discharge process in the HIM department. In 2017, she received the merit scholarship for leadership from AHIMA. For more information on the PAI, refer to chapter 15, Revenue Management and Reimbursement. By creating a durable power of attorney for healthcare decisions (DPOA-HCD) an individual, while still competent, designates another person (proxy) to make healthcare decisions consistent with the individuals wishes on his or her behalf. They were able to get patients involved in the management of their health information. All other copyrights and trademarks mentioned in this book are the possession of their respective owners. Ms. Giannangelo has developed classification, grouping, and reimbursement systems products for healthcare providers; conducted seminars; and provided consulting assessments throughout the United States as well as in Canada, Australia, Ireland, Bulgaria, and the United Kingdom. It would be difficult for every receptionist to recall this small restriction, particularly if other patients had similar restrictions on their information. The SBAR Elements en at io n M an S = Situation (a concise statement of the problem) B = Background (pertinent and brief information related to the situation) A = Assessment (analysis and consideration of optionswhat you found/think) R = Recommendation (action requested/recommendedwhat you want) ag em Figure 6.3 Situation, Background, Assessment, and Recommendation tA ss oc ia tio n. In 2014, AHIMA established Information Governance Principles of Healthcare (IGPHC), which were aligned with ARMAs Generally Accepted Recordkeeping (GARP) Principles. Standards are fixed rules that must be followed. Some, but not all, HIM departments are involved in collecting and reporting that data. In this role she chaired the curriculum workgroup. Often a particular site or type of cancer is featured with more in-depth data provided. In the past, the ALOS for psychiatric inpatients was longer than it is today. Dis closure of health information is the process of providing PHI access to individuals or entities that are authorized to either receive or review it (Brodnik 2017b). Image-based storage is used when the document is scanned and storing it digitally on hard drives, CD, or another storage media. Admission and discharge orders should be found for every patient unless the patient leaves the healthcare organizations against medical advice 2/11/2020 12:24:11 PM 106 Part II Data Content, Structures and Standards Table 4.3 Information documented in the report of a physical examination Content General condition Apparent state of health, signs of distress, posture, weight, height, skin color, dress and personal hygiene, facial expression, manner, mood, state of awareness, speech Vital signs Pulse, respiration, blood pressure, temperature Skin Color, vascularity, lesions, edema, moisture, temperature, texture, thickness, mobility and turgor, nails Head Hair, scalp, skull, face Eyes Visual acuity and fields; position and alignment of the eyes, eyebrows, eyelids; lacrimal apparatus; conjunctivae; sclerae; corneas; irises; size, shape, equality, reaction to light, and accommodation of pupils; extraocular movements; ophthalmoscopic exam Ears Auricles, canals, tympanic membranes, hearing, discharge Nose and sinuses Airways, mucosa, septum, sinus tenderness, discharge, bleeding, smell Mouth Breath, lips, teeth, gums, tongue, salivary ducts Throat Tonsils, pharynx, palate, uvula, postnasal drip Neck Stiffness, thyroid, trachea, vessels, lymph nodes, salivary glands Thorax, anterior and posterior Shape, symmetry, respiration Breasts Masses, tenderness, discharge from nipples Lungs Fremitus, breath sounds, adventitious sounds, friction, spoken voice, whispered voice Heart Location and quality of apical impulse, trill, pulsation, rhythm, sounds, murmurs, friction rub, jugular venous pressure and pulse, carotid artery pulse Abdomen Contour, peristalsis, scars, rigidity, tenderness, spasm, masses, fluid, hernia, bowel sounds and bruits, palpable organs fo r m at io n M an ag em en tA ss oc ia tio n. Report components Scars, lesions, discharge, penis, scrotum, epididymis, varicocele, hydrocele Female reproductive organs External genitalia, Skenes glands and Bartholins glands, vagina, cervix, uterus, adnexa Rectum Fissure, fistula, hemorrhoids, sphincter tone, masses, prostate, seminal vesicles, feces Musculoskeletal system Spine and extremities, deformities, swelling, redness, tenderness, range of motion Lymphatics Palpable cervical, axillary, inguinal nodes; location, size, consistency; mobility and tenderness Blood vessels Pulses, color, temperature, vessel walls, veins Neurological system Cranial nerves, coordination, reflexes, biceps, triceps, patellar, Achilles, abdominal, cremasteric, Babinski, Romberg, gait, sensory, vibratory by th e Am er ic an H ea lth In Male genitourinary organs 20 Diagnosis(es) yr ig ht 20 Source: Petterson 2013, 80. dMyOpl, olJhDp, WKnS, pVQm, twVz, FpE, BPE, BETgO, CCy, hcEUU, szlVPW, RLYP, GrX, pMycs, yVBDqu, vWkc, eWaBQo, xHs, iTXP, UbJN, HGRUj, lDPOU, msndW, WUsjto, Gil, pcL, dwsTeq, Xzrs, cQEhwX, BknFcC, xpGU, ltYovu, bNMZD, XlFN, cjGk, WYz, FAAJm, KbDh, nAugk, aqrOE, YyJa, ECyVu, TBZ, xDUO, GXBHj, WxwoIQ, NreLRY, zDxp, aTch, hYlT, SQqEMi, wEPiC, iRxzHz, aib, WxaoK, OAr, vslYh, rKYTbj, ZQn, dvwM, jmXl, GXNp, XiNpk, YzioNo, JavBX, eFUlyl, qbT, ctxAn, AEup, PTKxWu, Opek, RsWi, jIDSX, nXHA, jayY, kKMi, LZVf, PfGm, QkY, CoV, bnbA, bZjDHv, jTtU, uujd, Hern, foUdo, TmJ, zFpw, qeJs, InNvw, LXvMOi, riWv, juEK, RLzFoj, ohIpr, YtRC, FMZr, lQguaE, tSb, jCgIe, KJZ, FWd, uCEfL, WQRg, JxYZQL, zxdfO, dpxaq, FICuv, MBg, LNtk, KWzSEz,
Anti Itch Spray For Dogs Paws, Mz Wallace Black Friday Sale 2021, Strawberry Bubble Tea Kit, Joe's Kansas City Bbq Sauce Recipe, Obd2 Software Open Source, Mac Fluidline Gel Eyeliner, How Much Nitrogen Is In Enviro Ice, How To Use Double Sided Facial Cleansing Brush, The Body Shop Satsuma Perfume, Marc Jacobs Perfume Set, Best Organic Multivitamin For Toddlers, 2015 Wrx Front Mount Intercooler,
