M05_GART2674_01_SE_C05.QXD
5
8/10/09
9:52 AM
Page 98
Healthcare Records
LEARNING OUTCOMES
After completing this chapter, you should be able to:
䊏
Discuss the functions that healthcare records serve
H primary and secondary health records
䊏
Explain the difference between
䊏
Identify different forms used
I to record patient information
䊏
Discuss standard data elements and standard data sets
G
䊏
Explain how health records assist in the continuity of care
G
䊏
Define a RHIO
䊏
Describe the various formsSof telemedicine
䊏
Explain an E-visit
,
ACRONYMS USED IN CHAPTER
5
S
H
Acronyms are used extensively in both medicine and computers. The following
A
acronyms are used in this chapter.
ALOS
Average Length of Stay
N
NCVHS
CDC
Centers for Disease Control
I
and Prevention
National Committee on Vital
Health Statistics
NHIN
National Health Information
Network
OASIS
Outcome and Assessment
Information Set
CMS
CPR
CT
Centers for MedicareC
and
Medicaid Services Q
Cardiopulmonary Resuscitation
U
Computed Tomography (also
A
CAT, Computerized Axial
PACS OR PAC SYSTEM Picture Archiving
and Communication System
Tomography)
PET
Positron Emission Tomography
DEEDS
Data Elements for Emergency
Department Systems 1
PHI
Protected Health Information
PHR
Personal Health Record
DNR
Do Not Resuscitate
RAI
Resident Assessment
Instrument
RHIO
Regional Health Information
Organization
SNF
Skilled Nursing Facility
SOAP
Subjective, Objective,
Assessment, Plan
UACDS
Uniform Ambulatory Care
Data Set
ECG
EEG
EHR
EKG
HEDIS
1
Electrocardiogram (also EKG)
0
Electroencephalogram
5
Electronic Health Record
T ECG)
Electrocardiogram (also
Health Plan EmployerS
Data and
Information System
HPI
History of Present Illness
IDN
Integrated Delivery Network
LOS
Length of Stay
MDS
Minimum Data Set
MPI
Master Patient Index
MRI
Magnetic Resonance Imaging
NCDB
National Cancer Data Base
UAMCMDS Uniform Ambulatory Medical
Care Minimum Data Set
UCDS
Uniform Clinical Data Set
UHDDS
Uniform Hospital Discharge
Data Set
98
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 99
HEALTHCARE RECORDS
99
Understanding Healthcare Records
Healthcare records have many purposes, the most important of which is to help healthcare
providers with patient care. The patient health record is the repository of data and information
about the patient, the condition of the patient’s health, the care and treatments the patient
received, and the outcome of that care. This chapter will familiarize you with some of the contents of health records and how they are used.
The term patient health record has replaced the term patient medical record because it
encompasses a holistic view of patient care. Though the terms are used almost interchangeably,
an acute care patient record is usually concerned with one stay or episode, whereas an outpatient
medical record is usually limited to one group or clinic. Later in this chapter we will discuss
efforts to overcome these limitations by regional providers sharing records electronically and the
growing interest by patients in maintaining lifelong personal health records.
In Chapter 4 the term data was used to differentiate the H
information the computer processes
from the software application. In this and future chapters theIword data does not just mean computer information, but rather the information in a health record. Additionally, the term health data
G
is sometimes used herein for what is technically health information.
In a more precise definition,
data and information are not the same thing. Data are records
G of facts. Information is data in a
useful form that conveys meaning. For example, the numeric values 68, 70, 72 are data.
S
䊏
䊏
If the data represent height in inches, they may be used to plot an adolescent’s growth rate.
,
If the data represent a patient’s pulse, they are used to provide information about the
patient’s heart rate measured at different intervals.
Health information, therefore, is not just the patient dataS
but the presentation of this data in a
useful form and the association of other relevant details with H
it. Figure 5-1 shows a standard form
used in pediatric practices. When patient height is recorded on this form, the doctor can easily see
A a boy’s height to the general popthe rate of growth over time. Curved lines on the form compare
ulation at the same age. In this chapter we will examine some N
typical health information forms and
further explore the concepts of data elements and data sets introduced in the previous chapter.
I
C
Functions of Healthcare Records Q
U
A patient’s health record provides accurate information not only about the patient’s treatment, but
also about the patient’s health history and previous treatments.
A As such, it serves as the primary
communication document among various providers who might care for the patient at different
times in different departments.
The patient record also provides the basis for all billing 1
and reimbursement. Coding professionals review the record of the patient visit and determine 1
what codes to put on the insurance
claim. CMS and other health insurance auditors follow the dictum that “if it isn’t documented, it
wasn’t done,” meaning that medical claims will not be paid0if the patient record does not have
enough detail about the encounter or treatment to support the5claim.
The health record is a legal document. Should a question arise as to the cause of a disease or
injury, or to determine if a medical error was made, relevant T
portions of the patient’s record may
become evidence in a court of law.
S
Healthcare records provide the basis for improvements in health. Individually, a patient’s
record is evaluated and used to develop care plans for the patient. Collectively, health records can
be used by the healthcare facility to improve the quality and processes of healthcare delivery.
Public health departments, Homeland Security, and law enforcement officials use information from health records to track births, deaths, communicable diseases, effects of exposure to
hazardous materials, bioterrorism threats, gunshot wounds, child abuse, and other crimes.
Researchers use patient records from clinical trials to monitor the effectiveness and safety of
new drugs.
De-identified health records are analyzed by researchers to find health trends in our society
and measure which treatments seem to have the best outcomes.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
100
8/10/09
9:52 AM
Page 100
CHAPTER 5
2 to 20 years: Boys
Stature-for-age and Weight-for-age percentiles
Mother’s Stature
Date
Father’s Stature
Age
Weight
Stature
BMI*
NAME
RECORD #
12 13 14 15 16 17 18 19 20
cm
AGE (YEARS)
95
90
75
50
25
in
62
S
T
A
T
U
R
E
60
58
56
54
52
50
48
46
44
42
40
38
cm
3
4
5
6
7
8
9
H
I
G
G
S
,
160
155
150
145
140
135
130
125
S
H
A
N
I
C
Q
U
A
120
115
110
105
100
95
36
90
34
85
32
80
30
80
W
E
I
G
H
T
70
60
50
40
30
lb
10
5
10 11
35
30
25
20
15
10
kg
2
3
4
5
6
7
8
9
1
1
0
5
T
AGE (YEARS)
10 11 S12 13
190
185
180
175
170
165
160
155
150
in
76
74
S
T
A
T
U
R
E
72
70
68
66
64
62
60
105 230
100 220
95
90
95 210
90 200
85
75
80
75
50
25
10
5
190
180
170
160
70
150 W
65 140 E
I
60 130 G
55 120
50 110
H
T
45 100
40 90
35
30
25
20
15
10
kg
14 15 16 17 18 19 20
80
70
60
50
40
30
lb
Published May 30, 2000 (modified 11/21/00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion
(2000).
http://www.cdc.gov/growthcharts
FIGURE 5-1
Pediatric Growth Chart of Boys’ Stature for Age and Weight for Age.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 101
HEALTHCARE RECORDS
101
Primary and Secondary Records
Health information professionals classify health records as primary or secondary records:
䊏
䊏
Primary records are those that are gathered directly from the patient and his or her
providers, as well as records obtained from devices and diagnostic tests performed on the
patient. Primary records are used for patient care and as legal documents.
Secondary records are those that are created later, by analyzing, summarizing, or abstracting from the primary records. Secondary records are used in billing, research, and quality
improvement.
Types of Primary Health Records
Primary records may be electronic medical records or paper forms, but what they have in comH
mon is that they document the patient’s history and state of health, the clinician’s observations
and actions, and all tests, treatments, and outcomes. As such,Ithe patient’s health record at a given
facility is actually a collection of documents or computer records,
G descriptions of which are provided later in this chapter.
G
As you have learned in previous chapters, there are differences
between inpatient and outpatient facilities. The type and quantity of information they keep
also
varies
by the type of facility.
S
For example, primary health records are generated and maintained by patients, doctors, nurses,
, chiropractors, and others.
home health providers, hospitals, rehabilitation facilities, dentists,
The following examples illustrate some of the differences between health records at different providers’ locations:
S
䊏
䊏
䊏
䊏
Acute care hospital charts contain admission and discharge reports, nursing notes, physician examination notes, all orders, test results, operativeHreports, pathology and radiology
reports, and administrative and demographic forms. However,
A in nearly all cases these are
concerned with the current stay.
N
Ambulatory care facilities (physician offices) tend to keep a single chart per patient, combinI
ing documents from all previous visits, medical history, consults,
lab results, and reports from
other providers. The principal document is the physician’sCnote, which details the observation
and findings, but often includes the physician’s orders and plan of treatment. In addition to
demographic and social history information, many officesQkeep records of communications
with the patient and their insurance plans in the chart as well.
U
Home care agency records are uniquely centered on a physician’s
orders for treatment at
A
home. CMS has standardized the details that are required about a patient’s home care. The
nurses or therapists visiting the patient at home keep notes from each visit concerning the
services performed and the patient’s progress. These are1updated in records maintained by
the home care agency.
1
Dental records generally contain very abbreviated notes about the treatments and proce0 ever had with the practice includdures performed, but usually cover all visits the patient has
ing dental hygienists and other dentists. Also, because dental
5 x-rays are small, most offices
store them in the patient’s chart. This is different from medical facilities where x-rays and
other diagnostic images are typically stored in a separateTlocation or computer system.
S
Types of Secondary Health Records
Secondary health records are those that are created by abstracting relevant details from the primary records. These secondary records are used for reimbursement (insurance claims), quality
improvement at the facility, reporting to accreditation and government agencies, and research.
The following are some examples of secondary health records:
䊏
Health insurance claims are created by selecting information from the patient record, such
as procedures and diagnoses, assigning codes to them, and assembling them with information
from the patient’s demographic and insurance information. These are then submitted to the
insurance plan for payment.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
102
8/10/09
9:52 AM
Page 102
CHAPTER 5
䊏
䊏
The master patient index (MPI) is typically a computerized system intended to prevent
duplicate registrations for the same patient. By taking key identifying facts from patient
demographic information such as full name, date of birth, gender, and sometimes Social
Security number, a list is created of all the patients registered anywhere in the healthcare
facility. By checking the MPI first, registration clerks can see if the patient is already
registered and thereby avoid creating duplicate records in the system.
Aggregate data is collected by gathering selected items of information from many
patients’ charts and then analyzing it. For example, in Chapter 1 we discussed ALOS or
average length of stay. By extracting the LOS of all of the patients in the hospital last
month, the hospital can calculate the average. Similarly, aggregate data can be analyzed
to determine the case mix or for quality improvement purposes. Case mix will be
described further in Chapter 9.
Transition from Paper to Electronic
H Records
Many social forces and practical reasons
I are causing healthcare providers to change from paper
health records to electronic health records (EHRs). Social reasons include an increasingly mobile
G doctors more frequently. Additionally, many patients
society where patients move and change
today see multiple specialists for theirG
care. This means their medical record no longer resides with
a single general practitioner who provides their total care. Thus, the ability to share examination
records and test results is increasinglySimportant to the patient’s continuity of care (discussed later
in this chapter).
,
Practical reasons for the move to EHRs include the fact that paper records cannot be easily
accessed or shared, the charts must be copied and faxed or transported from one office to another,
and handwritten portions of the record
S are often abbreviated, cryptic, or illegible. Finally, searching the contents of paper charts requires manually opening every chart and reading it.
H
Chapter 7 will cover ways EHR systems can be used to help improve patient health, the
quality of care, and patient safety by
Aproviding access to complete, up-to-date records of past
and present conditions. Though many facilities are moving toward electronic health records, the
N
transition will take several years.
I
C
Contents of Health Records
Q
Although the types of documents or data contained in medical records differ between inpatient
U
and outpatient facilities, many of them serve a similar purpose. However, clinical records are not
the only items stored in a patient’s chart.
A For example, many ambulatory offices store nearly any
document concerning a patient in the patient’s chart. Figure 5-2 compares a list of some typical
records in an inpatient and outpatient chart. Additional information and samples of many of the
1
forms are provided later in this chapter.
1 Data
Administrative and Demographic
Whether health records are paper or0electronic, certain administrative documents tend to originate as paper forms. Generally this5is the registration information provided by the patient or
relative and certain legal documents that the patient must sign. In an all-digital facility these
T
paper documents are subsequently scanned
as images and stored in the electronic record.
When a patient is first registered,
demographic
data such as name, address, phone numbers,
S
next of kin, and emergency contact information is recorded. Registration will also record information used for billing such as account guarantor and insurance plans. Though some facilities allow
the patient to enter this information directly using a web page, most facilities employ a registrar to
enter the data into a computer.
In a paper-based facility the patient demographics form is called the face sheet. In facilities
that are still transitioning from paper to electronic records, the information may be entered into
the computer then printed out to create a face sheet for the paper chart.
Demographic and billing information is verified and updated if necessary for each return
visit. Patients’ insurance cards may also be photocopied or scanned into the computer during
registration.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 103
HEALTHCARE RECORDS
Comparison of Contents of Patient’s Chart
Acute Care
Hospital
Registration Record
Consent Forms, Authorizations, Property list,
Advance Directives
Medical History (Admitting Doctor)
Physical Examination (Admitting Doctor)
Doctor’s
Office
103
FIGURE 5-2
Contents typical of
acute care versus
ambulatory patient
charts.
H
RegistrationIForm
G Authorizations, Advance
Consent Forms,
Directives
G
Medical History (From Patient)
S
Doctor’s Notes
, from each visit. (Complaint,
Symptoms, History, Review of Systems, Vital
Signs, Physical Exam, Assessment, Plan of Care)
Physician Orders
S orders and Test Results
Diagnostic Test
Clinical Observations:
Doctors’ notes, Nurses’ notes, Therapy notes
Flow sheetsH
(specialty specific—pediatric,
obstetric, etc.)
Surgery Report/Anesthesia Record
Medical Records from other providers
Consultation Reports
Test Results
Discharge Summary
Patient Discharge Instructions
A
N
ConsultationI Reports
Problem List
C
Medication Q
List
Immunization
U Record
Correspondence
A
Authorization forms to Disclose PHI
Copies of Insurance
Cards
1
1
Consent and Directives
0
A number of legal documents signed by the patient are included in the medical record. In some
5
cases these are simple permission statements included on the patient information form; in other
T filed in the chart or scanned into
facilities the patient signs many individual forms, which are then
the computer. Some typical examples include the following.
S
The patient acknowledges receipt of the Notice of
Privacy Practices discussed in Chapter 3. This consent or acknowledgment may be included on
the registration form or combined with another consent form.
HIPAA CONSENT TO USE AND DISCLOSE PHI
CONSENT TO TREATMENT A general consent to be treated by the healthcare practice or facility
is usually included in the registration form. Additional informed consent forms are required for
each operation or special procedure (discussed below).
CMS requires that patients be given a statement of
their rights under Medicare. Patients will sign an acknowledgment that they have received the
statement and their rights have been explained.
MEDICARE PATIENT RIGHTS STATEMENT
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
104
8/10/09
9:52 AM
Page 104
CHAPTER 5
ASSIGNMENT OF BENEFITS In order for a healthcare facility to be reimbursed by Medicare
and other insurance plans, the policy holder must sign a form permitting the plan to pay the
provider directly. This is called the assignment of benefits, and may be part of the insurance
portion of the registration form or may be a blank insurance claim form signed by the policy
holder. Note that a CMS-1500 paper insurance form has two signature blocks; one authorizes
the patient’s medical information to be sent to the plan and the other authorizes the
assignment of benefits to the provider. (Refer to Chapter 10, Figure 10-4, to view an example
of this form.)
Written consent forms are signed by the patient or patient’s legal
representative before any operation or special procedure. The informed consent describes what is
going to be done, the expected outcome, any risks associated with it, and possible alternatives to
the procedure. This is done to ensure the patient has a complete understanding before going
forward. Figure 5-3 shows a two-sided informed consent form.
INFORMED CONSENT
H
A patient may elect not to have a medically necessary procedure
I
done. In such a case, a form documenting
that the consequences of the decision are fully
understood by the patient is signed and
G added to the chart.
REFUSAL OF TREATMENT
An advance
Gdirective is sometimes called a living will and permits
patients to provide instructions regarding resuscitation and life-prolonging procedures in the
S
event the patient should become terminally ill or injured and unable to communicate his or her
,
wishes. The advance directive or separate
document may also grant another person the power
to make medical decisions on the patient’s behalf should the patient become incapacitated.
The advance directive may include instructions not to resuscitate the patient in the case of
death. When this is the case, inpatientSfacilities create a special order in the chart and clearly mark
it DNR (do not resuscitate). If a DNR
Horder is not present, consent to perform cardiopulmonary
resuscitation (CPR) is presumed.
ADVANCE DIRECTIVES
A
If a patient has agreed to donate organs or other tissues upon death, this is also
N specifying an organ donor status, the patient’s family
noted in the record. If a patient dies without
must be given the opportunity to authorize
organ donation.
I
ORGAN DONOR
PERSONAL PROPERTY LIST Inpatient
Cfacilities may create a list of personal property brought to
the facility by the patient such as jewelry, eyeglasses, hearing aids, and dentures. The form,
signed by the patient, may release theQfacility from responsibility for loss or damage to the items.
A similar disclaimer may absolve the
Ufacility of responsibility for a patient’s vehicle parked on
the premises while staying there.
A
As discussed in Chapter 3, HIPAA requires any disclosure of PHI for
purposes other than treatment, payment, or operations of the facility to be tracked and
1 authorizations permitting release of partial or complete
recorded. In addition, copies of signed
medical records are kept by the HIM
1 department, sometimes with the health record itself.
DISCLOSURE RECORDS
0
5
As you would expect, most of the information
in the patient’s medical record will be of a clinical
nature. In both paper and electronicTsystems, diagnostic images are stored separately from the
chart documents or data; however, some EHR systems may provide seamless access to images,
S within one system. In paper systems x-rays films are
giving the appearance that they are located
Clinical Documents
stored separately, usually in another part of the hospital.
The following are clinical documents typically found in the health record.
The primary source of a patient’s medical history is the patient or a relative.
A medical history at an acute care facility will be obtained through an interview of the
patient by the admitting doctor or a nurse.
At an ambulatory facility the history typically originates as a paper form that is filled out by
the patient in the waiting room, though some modern medical practices allow patients to enter
this data themselves on a computer using medical history software. A sample paper history form
is shown in Figure 5-4.
MEDICAL HISTORY
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 105
HEALTHCARE RECORDS
105
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
FIGURE 5-3a
Informed Consent (front side).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 106
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
FIGURE 5-3b
Informed Consent (back side).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 107
HEALTHCARE RECORDS
107
Date: ______________
Patient Name: ________________________________________________________
Date of Birth:
Race: ______________
❒ Male ❒ Female
Family Practice Medical Center
Anytown, USA
What is the reason you are here today?
___________________________________________________________________________________________________________________________________________________
Please check any of the following conditions which you have had
General
❒ Serious Infections
(e.g. pneumonia)
❒
❒
❒
❒
HEENT
❒ Glaucoma
❒ Allergies "hay fever"
❒ Frequent Ear Infections
❒ Frequent Sinus Infections
Diabetes Mellitus
Rheumatic fever
HIV Infection
Cancer
Respiratory
Cardiovascular
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒
High Blood Pressure
Congestive Heart failure
Heart Murmur
Heart Valve Disease
Angina
Heart Attack
High Cholesterol
Abnormal Heart Rhythm
Blood Clot in Veins
Blocked Arteries in Neck
Blocked Arteries in Legs
❒
❒
❒
❒
Asthma
Emphysema
Blood Colt in Lungs
Sleep Apnea
Musculoskeletal /
Extremities
❒
❒
❒
❒
❒
❒
Osteoporosis
Rheumatoid Arthritis
Degenerative Joint Disease
Fibrmyalgia
Neck Pain (herniated disk)
Back Pain (herniated disc)
GI/GU
❒ Stomach Ulcers
❒ Ulcerative Colitis
❒ Crohns Disease
❒ Bleeding from Intestines
❒ Diverticulitis
❒ Colon Polyps
❒ Irritable Bowel Disease
❒ Hepatitis
❒ Cirrhosis of the liver
❒ Liver Failure
❒ Pancreatitis
❒ Gallstones
❒ Kidney Stones
❒ Kidney Failure
❒ Prostate Disease
❒ Endometriosis
❒ Sex Transmitted Infection
H
I
G
G
S
,
S
H
A
Please check any of the following major illnesses in your family members:
N❒ Kidney Disease
❒ Tuberculosis
❒ Diabetes Mellitus
❒ Emphysema
❒ Thyroid Disease
I❒❒ Epilepsy
❒ Heart Disease
❒ Anemia
Neurological Disorder
❒ High Blood Pressure
❒ Hemophilia
C❒ Liver Disease
❒ Osteoporosis
❒ Other _____________________
❒ Other _____________________
Q
U
If you have had surgery please indicate the year:
Year
Surgery
Year
Surgery
Year
Surgery
A Neurosurgery
_____
Angioplasty
_____
Colonoscopy
_____
_____
_____
_____
_____
_____
_____
Appendectomy
Back or Neck Surgery
Bladder Surgery
Carotid Artery Surgery
Carpal Tunnel Surgery
Chest/lung Surgery
_____
_____
_____
_____
_____
_____
Coronary Bypass
Ear Surgery
Gallbladder
Hip Surgery
Inguinal Hernia
Knee Surgery
_____
_____
_____
_____
_____
_____
1
1
0
Please indicate when you had the following preventative services:
Date
Immunizations
Date
T ests
Date
5
_____
Flu Vaccine
_____
Chest X-ray
_____
_____
Hepatitis Vaccine
_____
EKG
_____
T
_____
Pneumonia Vaccine
_____
Echocardiogram
_____
_____
Tetanus Booster
_____
Stress Test
_____
S
_____
Other
_____
Cardiac
_____
Angiogram
S inus Surgery
S tomach Surgery
Thyroid Surgery
T onsillectomy
Trauma Related Surgery
Vascular Surgery
T ests / Exams
Colon Cancer Stool Test
Flexible Sigmoidoscopy,
R ectal Exam
Barium Enema
Prostate Cancer Blood
Test
Lymphatic / Hematologic
❒ Thyroid Goiter
❒ Over Active Thyroid
❒ Under Active Thyroid
❒ Transfusions
❒ Anemia
Skin / Breast
❒
❒
❒
❒
Acne
Eczema
Psoriasis
Fibrocystic Breast Disease
Neurological / Psychiatric
❒
❒
❒
❒
❒
❒
❒
Chronic Vertigo (Meniere's)
Peripheral Nerve Disease
Migraine Headaches
Stroke
Multiple Sclerosis
Depression
Anxiety
❒
❒
❒
❒
❒
Breast Cancer
Ovarian Cancer
Colon Cancer
Prostate Cancer
Other _____________________
Year
_____
_____
_____
_____
_____
_____
_____
Date
_____
_____
_____
_____
_____
Surgery
Tubal ligation
C-Section
Hysterectomy
Ovary Removed
Breast Surgery
T hyroid Surgery
Other
T ests / Exams
Breast Exam
Mammogram
P ap Smear
B one Density Test
Date of last Physical
Exam
Personal Habits
Tobacco
❒ Never
❒ Previous user
❒ Current user
# packs per day __________
FIGURE 5-4
Alcohol
❒ Never
❒ Previous user
❒ Current user
# drinks per day __________
Caffeine
❒ Never
❒ Previous user
❒ Current user
# cups per day __________
Illicit Drugs
❒ Never
❒ Previous user
❒ Current user
Outpatient History Form (paper version).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
108
8/10/09
9:52 AM
Page 108
CHAPTER 5
The patient’s history for an ambulatory visit includes:
䊏
䊏
䊏
䊏
䊏
䊏
Chief complaint (principal reason for the visit)
History of present illness
Past medical history, including previous illnesses, operations, serious injuries, childhood
diseases, drug and environmental allergies, and immunization records
Social history concerning living conditions and habits such as smoking, drinking or drug
usage
Family history to determine if close relatives have certain chronic diseases or allergies that
may be hereditary
Review of systems, which involves questions about one or more of 11 body systems.
The patient’s medical history will be reviewed and updated for each outpatient visit.
H
PHYSICAL EXAM Detailed records are
I made of each physical exam; these are generally encompassed in the physician’s note along with the medical history discussed above. The physician’s
note is sometimes called the SOAPG
note, which is an acronym for a recommended format for
physician notes. SOAP stands for: G
Subjective:
S
䊏 The patient’s description of symptoms and the chief complaint
,
Objective:
䊏 The findings of the physical exam and diagnostic tests
S
H
A
Plan:
N
䊏 Physician’s orders and plan of care for the treatment of the condition.
I
Generally a history and physical are conducted at every outpatient visit.
Cnotes are used to document the patient’s condition and
After the initial exam, progress
response to treatment and any modifications
to the plan of care or additional orders. Physician
Q
progress notes may follow the SOAP format as well.
Inpatient rules require a historyU
and physical within 30 days prior to admission or no more
than 24 hours after admission.
A
Assessment:
䊏 The physician’s diagnosis
Nursing progress notes for inpatients will usually be grouped elsewhere in a nursing notes
section of the chart (discussed later in this chapter.)
1
Each order for a medication, lab work, or other
1
diagnostic test will be recorded in the patient’s chart. Orders are also recorded for ancillary
0 and occupational therapy.
services such as respiratory, physical,
Orders must be dated and signed
5 (or electronically signed) by an authorized person.
Generally this is a physician, physician assistant, or certified nurse practitioner. A sample order
T
form is shown in Figure 5-5.
In hospitals, physicians often give
S or change orders verbally. The order is then entered and
DIAGNOSTIC AND THERAPEUTIC ORDERS
signed by a person authorized to receive verbal orders (usually a licensed nurse.)
Inpatient orders may also concern dietary restrictions, restraint, seclusion, and so on.
Inpatient facilities also require a discharge order when the patient leaves.
Outside the hospital, orders are also required for medical equipment, devices, and home
health services.
For each test or diagnostic study ordered, the chart
should also contain a report of the results. X-rays and other radiology studies will be interpreted
by a radiologist who will dictate a report; laboratory work will generate a lab results report or
pathology report.
DIAGNOSTIC AND THERAPEUTIC REPORTS
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 109
HEALTHCARE RECORDS
109
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
FIGURE 5-5
Form for Orders Following Surgery.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
110
8/10/09
9:52 AM
Page 110
CHAPTER 5
Physical, occupational, respiratory, speech, and other types of therapists record the patient’s
progress and the outcome of the ordered therapy. These too are part of the patient record. A nutritional or dietary plan will be part of inpatient records.
The actual images or data captured from ordered tests is retained as part
of the patient record. These are generally stored separately from the chart, though in an
electronic medical record they may appear integrated. If an x-ray is taken on film, the films are
stored in large envelopes called jackets, usually in a separate file room. Many hospital radiology
departments have eliminated film and either capture the x-ray directly into the computer, or scan
the film during processing and store the image electronically.
Radiology departments generally store images on a Picture Archiving and Communication
System (PACS). These include x-rays, CT scans, PET scans, and MRIs. Other diagnostic tests
may produce images that are stored in the medical record, but not on the PAC system. Examples
of these are EKGs, EEGs, and ultrasound
H images.
DIAGNOSTIC IMAGES
I
Surgical procedures
require records of the anesthesia, the actual
proceedings in the operating room (intraoperative
records), the period in the recovery room, and
G
a postoperative progress note. An informed consent for the procedure signed by the patient or
legal representative is required and isG
usually grouped with the operative records. If the operation
involves organ transplantation, additional
S transplant records are required. Refer to Figure 5-3 to
view an informed consent form.
OPERATIVE RECORDS
,
Information gathered by nurses on an outpatient visit may include the chief
complaint, past medical history, family history, and social history, and the vital signs. In an
Skept as separate nursing notes, but rather made a part of the
outpatient setting these are usually not
physician’s SOAP note.
H
In an inpatient facility, nurses provide most of the care and record most of the information
about the patient. Nursing notes areA
therefore grouped separately by most systems. In addition
to recording the patient’s medical, social,
N and family history upon admission, nurses document
the administration of medications, therapies, oxygen, and other treatments ordered by the
I
physician.
Nursing notes are the key to continuity
of care for the inpatient. Nurses document not only
C
the treatment interventions but the patient’s response to treatment, and record observations on
Q
changes in the patient’s status or deviations
from the plan of care. Any abnormal conditions or
new complaints that arise are recorded
by
the
nurses. In addition to frequent monitoring of vital
U
signs, nurses also record the level of pain the patient is experiencing and the input and output of
A
fluids by the patient.
A nursing assessment of the patient is performed at each work shift and all nursing notes are
signed by the nurse. Because nurses provide most of the direct treatment to the patient, nursing
1
notes usually make up the largest portion of an inpatient medical record.
Figure 5-6 shows a method for1recording nursing notes using a flow sheet. A flow sheet
records data in columns and rows, making
it easy to compare changes in values recorded over
0
multiple intervals of time.
NURSING NOTES
5
Specialists may be asked to see a patient or review a case. In both
T
inpatient and outpatient settings, consulting physicians will provide a document of their findings
for the patient’s medical record. A S
copy of the attending physician’s request for the consult,
called a referral, may be kept in the medical record as well. Some insurance programs require a
formal preauthorization for outpatient referrals; in such cases, a copy of that preauthorization is
also placed in the patient’s chart.
REFERRAL CONSULTS
CASE MANAGEMENT Case managers and social workers document care planning, coordination
of care, and discharge plans in an inpatient facility medical record.
DISCHARGE SUMMARY Inpatient stays of longer than 48 hours are concluded with a discharge
summary report created by a physician. Shorter stays may have a final discharge progress note or
short-stay report used in place of the discharge summary. A final physical exam is conducted. It
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:52 AM
Page 111
HEALTHCARE RECORDS
111
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
FIGURE 5-6
Nursing Flow Sheet chart used in a neonatal unit
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.qxd
112
10/5/09
7:43 PM
Page 112
CHAPTER 5
H
I
G
G
S
,
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
FIGURE 5-7
A Discharge Summary Form
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 113
HEALTHCARE RECORDS
113
may be recorded with the discharge summary or as a separate physician note. An example of a
discharge summary form is shown in Figure 5-7.
Elements in the discharge summary include:
䊏
䊏
䊏
䊏
䊏
䊏
Principal diagnosis and other diagnoses
Brief history justifying the need for hospitalization
Summary of laboratory, radiology, and other diagnostic results
Significant treatments and procedures as well as the patient’s response to them
Patient’s condition at the time of discharge
Plan of care: follow-up visits, dietary restrictions, referrals to other providers, prescriptions and orders for medications and durable medical equipment such as a wheelchair or
crutches, and orders for home oxygen or therapy.
H typically create prenatal records
Physicians who deliver maternity care
within the chart to document each pregnancy separately. These
I often take the form of a flow sheet
or grid on which observations at each visit are documented in columns, allowing for easy
G the term of the pregnancy.
comparison of the patient’s condition on multiple visits during
OBSTETRICAL RECORDS
G above, children’s health records
In addition to the documents discussed
also contain growth charts graphing a child’s rate of growth S
as compared to a national reference
group (shown in Figure 5-1). Children also receive a series of immunization vaccines intended to
prevent disease. Immunization records are kept in the child’s, chart. Copies of the immunization
record are used for admission to school, after-school programs, and sometimes summer camps.
Physicians may also be required to send immunization records to their state health departments.
PEDIATRIC RECORDS
S
Outpatient charts also include a problem list, which provides an up-to-date list
H
of both acute and chronic conditions that affect the patient’s care. Problem lists usually have an
onset date, a description of the chronic or acute condition,
Aand a status (for example, if the
problem is better, worsening, well controlled, or resolved.) Once a problem is resolved, it is
N
considered inactive or removed from the list.
I
Though chronic diseases that are poorly controlled or malignancies
take precedence in clinical decision making over mild conditions that are not life threatening,
the
idea of a problem list
C
is to make sure that every provider who touches the patient knows what conditions are present.
Q
A problem list is required by the Joint Commission for ambulatory
charts.
PROBLEM LIST
Uis also used in an outpatient chart.
Similar to a problem list, a medication list
Various prescription drugs can nullify the benefits of otherA
drugs or cause serious interactions
with other drugs. It is important to know all of the medications a patient is currently taking
before prescribing medication or changing a patient’s existing prescription. Healthcare providers
need a medication list for two reasons:
1
MEDICATION LIST
䊏
䊏
Outpatient charts tend to have orders buried in the plan section
1 of progress notes. A medication list brings them all together in one place.
0
Many patients receive prescriptions from multiple specialists. A medication list is necessary
to record drugs the patient is taking that were prescribed5
elsewhere.
Public Health Records
T
S
Several types of inpatient records are related to birth and death, as discussed next.
BIRTH Newborns are separate patients from their mothers and, therefore, have their own
medical record started at birth. This includes examination notes and several measures of the
child’s size and condition. A discharge summary is not usually required for infants born without
complications.
A baby’s birth also requires a document recording the birth, which is signed and sent to the
state health department.
When a patient dies in the hospital, a note of the time and date of death is entered in
the chart with a note by the attending physician. In all cases of death, a discharge summary is
DEATH
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
114
8/10/09
9:53 AM
Page 114
CHAPTER 5
required for the record. If an autopsy is performed, a report of the autopsy results will be
recorded as well. A record of the death is sent to the state health department.
DISEASE To prevent epidemics, cases involving certain serious communicable diseases are
reported to the public health department and/or the Centers for Disease Control and Prevention
(CDC).
Plan of Care
Though a plan of care is present in the outpatient’s progress notes and the inpatient’s discharge
summary, both long-term care facilities and home care agencies use a plan of care document that
is central to their chart.
In a skilled nursing facility (SNF) the form is called a Resident Assessment Instrument
(RAI). These are updated regularly, following reassessment of the patient at defined intervals or if
a significant change in the patient’s condition
occurs. A sample RAI form is shown in Chapter 9
H
Figure 9-14.
I
In home care, the principal document
is the home health certification/plan of care. The
patient’s doctor reviews and updatesG
the certification every 60 days. Home health agencies use a
standard called the Outcome and Assessment Information Set (OASIS) to document data that is
G every 60 days.
sent electronically to the state and CMS
S
,
Documentation Standards
S
Whether patient health records are paper or electronic, it is important for them to be uniform,
H and available. Several tools that HIM professionals use to
accurate, legible, complete, up to date,
ensure uniform quality patient records
A are standardized data elements, data sets, and HIM policies and procedures.
N
I
Data Elements
Chapter 4 introduced the term data C
elements. Remember that data elements are not necessarily
a data field, but rather a component of the record that may require several fields. For example, a
Q
standard data element is patient name. However, it is not uncommon for a paper form to have
separate boxes labeled “last name,” U
“first name,” and “middle initial.” A computer database will
certainly store the name as three or more fields. Yet the three fields together make up one eleA
ment: the patient name.
The concept of standard data elements applies equally to paper or electronic records.
Including standard data elements in a1form or database design makes it likely that the record will
have data similar to that of other healthcare systems. This not only improves interoperability, but
1
provides common elements for system-wide
reports.
The National Committee on Vital
0 Health Statistics (NCVHS) has developed a list of core
data elements from a comparison of several of the health data sets standards discussed below. The
5 in Figure 5-8.
NCVHS recommendations are provided
Data Sets
T
S
A data set is a list of data elements collected for a particular purpose. For example, an admission
record would need all the data elements of the patient demographics, insurance information, next
of kin, and so on. In a paper system, this would be done by making sure the paper form contained
all of the appropriate boxes and that they were filled in correctly.
In an electronic system, many elements of the data are entered only once, and then assembled
into the data set as needed. For example, the patient demographics and insurance and next of kin
information would be retrieved from the patient registration system without reentering the data.
Usually standard healthcare data sets represent the minimum list of data elements that
must be collected. Often the number of data elements collected and retained by a healthcare
organization vastly exceeds the requirements of the minimum data sets. Some data sets are
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 115
HEALTHCARE RECORDS
Core Data Elements Recommended by NCVHS
1. Personal/unique identifier
21. Attending physician identification (inpatient)
2. Data of birth
22. Operating clinician identification
3. Gender
23. Health-care practitioner specialty
4. Race and ethnicity
24. Principle diagnosis (inpatient)
5. Residence
25. Primary diagnosis (inpatient)
6. Marital status
26. Other diagnosis (inpatient)
7. Living/residential arrangement
27. Qualifier for other diagnosis (inpatient)
8. Self-reported health status
28. Patient’s stated reason for visit or chief
H (outpatient)
complaint
9. Functional status
10. Years of schooling
I chiefly responsible for services
29. Diagnosis
provided
G (outpatient)
11. Patient’s relationship to subscriber/person
eligible for entitlement
30. Other G
diagnosis (outpatient)
12. Current or most recent occupation and
industry
32. Birth weight
of newborn
,
115
FIGURE 5-8
Core data
elements
recommended by
NCVHS1.
31. External
S cause of injury
13. Type of encounter
33. Principle procedure (inpatient)
14. Admission date (inpatient)
34. Other S
procedures (inpatient)
15. Discharge date (inpatient)
35. Dates H
of procedures (inpatient)
16. Date of encounter (outpatient and physician
service)
A and services (outpatient)
36. Procedures
17. Facility identification
I of patient (inpatient)
38. Disposition
18. Type of facility/place of encounter
C (outpatient)
39. Disposition
19. Health-care practitioner identification
(outpatient)
Q expected sources of payment
40. Patient’s
20. Provider location or address of encounter
(outpatient)
A charges
42. Total billed
N prescribed
37. Medications
41. InjuryU
related to employment
1
required, whereas others are optional. Two minimum standard
data sets are compared in
Figure 5-9.
1
Data elements entered into a computer system can be used in many different reports and
0 must rewrite the information in
screens without reentering the data. A facility using paper forms
the appropriate box on each different form. This is sometimes
5 avoided by preprinting a number
of labels containing patient identification information, which can then be attached to blank forms,
thus saving the time and reducing the possibility of errors. T
In addition to the two data sets listed above, here is a more
S complete list of standard data sets
used in healthcare:
䊏
䊏
The Uniform Hospital Discharge Data Set (UHDDS) is used by acute care hospitals and
required by CMS.
The Uniform Ambulatory Care Data Set (UACDS) is used by ambulatory care facilities
and required by CMS.
1
Core Health Data Elements Report: Report of the National Committee on Vital and Health Statistics (Washington, DC:
National Committee on Vital and Health Statistics, August 1996).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
116
8/10/09
9:53 AM
Page 116
CHAPTER 5
UACDS
Uniform Ambulatory Care Data Set
UHDDS
Uniform Hospital Discharge Data Set
Patient identification
Patient identification
Residence
Date of birth
Date of birth
Sex
Sex
Race and ethnic background
Race and ethnic background
Residence
Living arrangement and marital status
Health care facility identification number
H
I
Provider Location or address
G
Provider Profession
G
S
Date, place, and address of encounter
,
Patient’s reason for encounter
Provider identification
Problem, diagnosis, or assessment
Admission Date
Discharge Date
Attending Physician Identification number
Surgeon identification number
Principal diagnosis
S
Other Diagnoses
H
Services
Date and Principal procedure
A
Other Procedures and dates
N
Disposition
Disposition of the patient at discharge
I
Expected sources of payment
Expected sources of payment
C
Total charges
Q
FIGURE 5-9 Comparison of elements in ambulatory care and hospital
U
charge data sets2.
A
䊏
䊏
䊏
䊏
䊏
䊏
The Uniform Clinical Data Set (UCDS) is used by quality improvement organizations and
1 in Medicare.
required in hospitals that participate
®
1 Commission and is required for accreditation. It is
ORYX was developed by the Joint
used to measure performance and
0 outcomes.
The Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) are used in
5 by CMS.
long-term care facilities and required
T
The Outcome and Assessment Information
Set (OASIS) is used by home health agencies
and required by CMS.
S
The National Cancer Data Base (NCDB) is used by hospital cancer registries and required
for accreditation.
The Data Elements for Emergency Department Systems (DEEDS) is used by hospitalbased emergency departments. Its use is optional.
2
“Appendix VI: Report of the Subcommittee on Ambulatory Care Statistics and the Interagency Task Force on
the Uniform Ambulatory Care Data Set,” in The National Committee on Vital and Health Statistics Annual Report,
1989, DHHS Publication No. (PHS) 90-1205 (Hyattsville, MD: National Center for Health Statistics, June 1990),
47–68.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 117
HEALTHCARE RECORDS
䊏
䊏
117
The Health Plan Employer Data and Information System (HEDIS) is used by managed
care plans and employer-sponsored plans to evaluate quality of care. Its use is optional.
The Uniform Ambulatory Medical Care Minimum Data Set (UAMCMDS) has added some
additional data elements to the UACDS. Its use is optional.
Data sets originally developed for uniform paper forms are considered by many to be inadequate for electronic systems. Remember that in most cases these are the minimum sets of data and
generally HIS application software uses a great many more data elements. Unfortunately, these
additional elements are not necessarily standard across various systems. NCVHS and others have
called for increased efforts to develop standardized data sets for an electronic environment.3
Policies and Procedures
As important as having the right elements and data sets on the forms or in the database is knowing how and when they are to be used and by whom. To accomplish
this, health information proH
fessionals, hospital administration, and the medical staff establish policies and procedures to
I
meet documentation requirements.
As we discussed in Chapter 2, a number of state and federal
G regulations govern healthcare
facilities. Among these regulations are requirements for minimum levels of documentation.
G
Accreditation organizations also have documentation requirements.
Much of their audit
process concerns determining if the facility’s standards are S
sufficient and if those standards are
being met.
,
Because significant overlap usually occurs among the documentation
requirements of different regulatory agencies, various accrediting bodies, and the hospital’s own internal needs,
healthcare organizations often develop policies that adhere to the strictest standards, thus
S
ensuring compliance with all documentation requirements. The facility’s policies concerning
Hmedical staff and conforming to
documentation are usually incorporated in the rules for the
them becomes a condition for doctor’s hospital privileges.
A
AHIMA has developed the following documentation guidelines that apply to both paper and
4
N
electronic health records:
䊏
䊏
䊏
䊏
䊏
䊏
䊏
䊏
Every healthcare organization should have policies that Iensure the uniformity of both the
content and the format of the health record.
C
The policies should be based on all applicable accreditation standards, federal and state
Q
regulations, payer requirements, and professional practice standards.
The health record should be organized systematically inU
order to facilitate data retrieval and
compilation.
A
Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record.
The authors of all entries should be clearly identified in 1
the record.
1
Only abbreviations and symbols approved by the organization and/or medical staff rules
and regulations should be used in the health record.
0
All entries in the health record should be permanent.
5
Errors in paper-based records should be corrected according to the following process: Draw
a single line in ink through the incorrect entry. Then printTthe word “error” at the top of the
entry along with a legal signature or initials; the date, time,
S and reason for change; and the
title and discipline of the individual making the correction. The correct information is then
added to the entry. Errors must never be obliterated. The original entry should remain legible and the corrections should be entered in chronological order. Any late entries should be
labeled as such.
3
Toward a National Health Information Infrastructure (Washington, DC: National Committee on Vital and Health
Statistics, June 2000), www.ncvhs.hhs.gov/NHII2kReport.htm.
4
Smith, Cheryl M., “Documentation Requirements for the Acute Care Inpatient Record,” Journal of American Health
Information Management (2001): 56A–56G.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
118
8/10/09
9:53 AM
Page 118
CHAPTER 5
䊏
䊏
Any corrections or information added to the record by the patient should be inserted as an
addendum (a separate note). No changes should be made in the original entries in the
record. Any information added to the health record by the patient should be identified as
an addendum.
The HIM department should develop, implement, and evaluate policies and procedures
related to the quantitative and qualitative analysis of health records.
Continuity of Care Records
One of the chief functions of the patient’s health record is as a communication tool among the
various care providers serving the patient. As the patient moves through different areas of a facility (for example, admitting, radiology, surgery), providers record their findings, actions, and
orders in the chart. As the patient isHseen subsequently by nurses, doctors, or therapists, each
provider can read what the previous care workers have observed and what has been done. In this
I
way the health record serves to provide continuity of care for the patient.
G notes from each visit, test results, and reports from conIn an outpatient setting, the progress
sulting physicians and outside facilities are compiled into the patient’s health record or chart.
G
Because intervals of months or even a year between doctor visits are not uncommon, the patient’s
record provides continuity of care S
by enabling the clinician to review information about the
patient’s previous visits and treatments.
, In larger group practices, the patient may see different
doctors on different visits. In those cases, the health record enables continuity of care among the
providers.
However, patients do not alwaysS
go the same doctors, the same medical practice, nor use just
one pharmacy. Thus, the patient’s health record becomes scattered among various facilities, with
H is more the norm than the exception today and is one of
no one having the complete record. This
the contributing causes of medical errors.
A The health system today is dependent on the patient’s
ability to reliably tell each provider what has been done by other providers and what treatments
N
and medications have been prescribed.
I
C
Several attempts have been made to ensure continuity of care when patients are treated at multiQ network or IDN was one. The IDN attempted to make
ple facilities. The integrated delivery
patient records available to providersUwho were members of a larger healthcare organization. In
most cases these were medical practices, surgical facilities, and hospitals owned by a nonprofit
A the patient was treated outside the network, the inforor for-profit corporation. However, when
Regional Health Information Organization (RHIO)
mation did not become part of the record.
In 2004, President George W. Bush signed an executive order establishing the position of the
1
National Coordinator for Health Information
Technology, to “develop, maintain, and direct the
implementation of a strategic plan 1to guide the nationwide implementation of interoperable
health information technology.”5 The purpose of the initiative is to eventually build a National
0
Health Information Network (NHIN).
Although it may take considerable
5 time to create a true NHIN, many areas of the nation
are attempting to create state or local versions. RHIO stands for regional health information
T as a “neutral organization that adheres to a defined
organization. HIMSS defines a RHIO
governance structure which is composed
of and facilitates collaboration among the stakeS
holders in a given medical trading area, community or region through secure electronic health
information exchange to advance the effective and efficient delivery of healthcare for individuals and communities.”6
RHIOs encourage the exchange of a patient’s health information across medical practices
and facilities that are owned by different entities for the better well-being of the patient. The for-
5
President George W. Bush, Executive Order #13335, April 27, 2004.
HIMSS RHIO Federation Definitions Workgroup, http://himss.org.
6
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 119
HEALTHCARE RECORDS
119
mation and operation of a RHIO must overcome numerous obstacles. These include technical,
economic, and political issues:
䊏
䊏
Technical:
Interfacing systems from different vendors in a hospital is not an easy task, but at least it is
managed by one IT department and shares a common network. The level of difficulty
becomes multiplied when unrelated hospitals and physician practices—each with numerous systems—attempt to translate data and share a common network.
Economic:
The translation of data from one system to another requires an interface engine and possibly a regional MPI. Who bears the cost of the networking, interface programming, and
maintenance of the translation and MPI systems? Also, many RHIOs operate on a volunteer basis, but require a paid IT director, employed by the RHIO, not one of its members.
H
䊏
Political:
I
Some participants in the RHIO are business competitors who may be leery about what data
G or case mix, volume of busiis shared and whether it can be analyzed to reveal their patient
ness, and so on. Additionally, state laws may affect whoG
can participate in the RHIO and
whether members can be in bordering states.
Who Owns the Record?
S
,
Historically, the provider, group practice, or facility considered itself to be the owner of a
patient’s health record. HIPAA did not challenge that ownership but circumvented it by giving
the patient specific rights. As we discussed in Chapter 3, under
S HIPAA patients have the right to
access their medical record, review it, request changes to inaccurate information, and obtain a
H
copy of their health record.
While the privacy of a patient’s health record is fully protected
in a RHIO, the question of
A
ownership becomes increasingly cloudy as information from multiple facilities becomes part of
N
the current provider’s record.
I
C
For some patients the solution to having health records in multiple places is to maintain their
Q have taken to carrying copies
own. In paper-based systems, a few chronic or seriously ill patients
of their own records from specialist to specialist, to ensure the
Umost expedient care and avoid the
long wait for paper records to be copied and transferred. Though most patients don’t go to this
A
extreme, the Internet may change that.
The Personal Health Record
A number of online services now offer patients the ability to maintain their own personal
health record (PHR) online. The Internet services allow patients to log on to a secure website to
create and update their records. The patient controls who has1the right to access the information
and can add or remove permission for clinicians they might 1
visit to view the online record.
The advantage of an online PHR is that is available everywhere. Wherever patients are traveling, if they need medical care, they can retrieve their own0records using the Internet. Another
advantage is that the online record can integrate information5about visits to many different doctors or about medications purchased at several different pharmacies. The disadvantage is that in
T
most cases patients must enter the information themselves. A sample of a personal health record
S
is shown in Figure 5-10.
Telemedicine
Telemedicine uses communication technology to deliver medical care to a patient in another location. A consulting health professional studies the patient’s case and offers advice or instructions to
the requesting physician or directly to the patient, neither of whom are at the consultant’s location.
Telemedicine can take many forms, ranging from a simple phone call between two doctors
to a videoconference. Even examinations or surgical procedures can be conducted remotely.
Telemedicine can be practiced in real time or in a store-and-forward manner.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
120
8/10/09
9:53 AM
Page 120
CHAPTER 5
FIGURE 5-10
Personal health
record
(Courtesy of Good Health
Network, Inc.)
H
I
G
G
S
,
S
H
A
N
I
C
Q
Real-time telemedicine requires the presence of all parties at the same time, for example, a
conference call. Store-and-forwardU
telemedicine allows one party to send information that is
saved and then reviewed and responded
A to later. A simple analogy of store-and-forward telemed-
icine would be voicemail. One doctor leaves a message stating the facts of the case; the other doctor listens to the message and then calls back, leaving a detailed response for the original doctor.
In practice, however, telemedicine is1not that simple.
When participants are located in different time zones, real-time telemedicine sessions can be
1
difficult to schedule. State laws can prohibit treatment of patients by providers licensed in another
0
state. Although store-and-forward telemedicine
works well for consults, it can involve delays when
additional information or tests are needed
and
one
must wait for the response to arrive. Also, it is
5
not suitable to remote, robotic, or even guided surgery, all of which must be conducted in real time.
T it makes high-level medical expertise available to remote
The benefit of telemedicine is that
and rural areas. Many communitiesS
do not have medical specialists. Even fewer, places in the
world have subspecialists, or sub-subspecialists who can recognize and treat rare or complex
medical problems. Using telemedicine, it is possible for a local physician to get advice from a
distant expert and guidance in treating the patient.
Teleradiology
Teleradiology is specifically concerned with the transmission of diagnostic images from one
location to another. Usually this is for the purpose of having the images “read” by a radiologist at
the receiving end. This may be to obtain a second opinion or consult, or because the sending facility does not have sufficient radiologists on staff and has contracted to have radiology interpretations done by another facility. In the latter case, state laws may require the radiologist to be
licensed by the state from which the images are sent.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 121
HEALTHCARE RECORDS
121
Patient Reporting and Telemonitors
Many patients with chronic conditions are monitored
at home using devices such as blood pressure monitors, glucose meters, and Holter monitors. Some of
these devices store the readings and transfer the data
to the doctor’s system either by using a modem and
phone line or by downloading from the device during
a patient encounter. For blood pressure monitoring, if
the device does not store the readings, the patient
may keep a log, which is then entered into the
patient’s medical record at the doctor’s office.
One example of a telemonitor is the Holter monitor, a device the patient wears for 24 to 72 hours to
H
measure and record information about the patient’s
heart. The data is then transferred either remotely or
I
in person to the doctor’s computer where it is
G
reviewed. Figure 5-11 shows a patient wearing a
Holter monitor.
G
When a patient is seen in a doctor’s office, meaS
surements of vital signs, a glucose test, or even an
ECG reflect only the patient’s condition at that particular time.
, The advantage of telemonitoring
is that it allows the provider to study these values measured many times over the course of the
patient’s normal daily activity.
S
H
One of the key technologies impacting our society is the Internet. It has changed the way people
A changes in healthcare. While
communicate, research, shop, and do business. It is also influencing
the banking, brokerage/investing, and travel industries have
Nmade Internet-based transactions
readily available to consumers, healthcare as a whole has not. That seems to be changing.
I offers interesting possibilities for
One of the developments brought about by the Internet that
enhancing the efficiency of providers and improving the quality
C of healthcare for the patients is
the E-visit. An E-visit allows the patient to be treated by a clinician for nonurgent health probQ
lems without having to come into the office.
Although communication between provider and patientU
using e-mail is insecure or must be
encrypted as required by HIPAA, an E-visit has advantages that e-mail lacks. Not only is the
A
message secure, but the E-visit gathers symptom and HPI information,
creating a documented
E-Visits
FIGURE 5-11
An IQholter™ worn
by the patient
gathers cardio data.
(Courtesy of Midmark
Diagnostics Group.)
medical record. When this information is integrated with the EHR, the E-visit becomes a part of
the patient’s chart, just like any other visit.
1
Also, e-mail is sent to a particular individual and therefore not likely to be accessible by
another provider. In contrast, E-visits can be handled by the “doctor
on-call,” allowing practicing
1
partners to share E-visit duty, just like they share other on-call services.
0
Equally as important to the clinician, the E-visits are reimbursed as a legitimate visit by Blue
5 in some states. A study by
Cross/Blue Shield plans and other private insurance carriers
PricewaterhouseCoopers predicted that more than 20% of allT
office visits could be replaced by an
online equivalent by 2010.7
S
To use E-visits, the patient must be an established patient with the
practice whose medical records are on file. E-visits would not be appropriate for a new patient
who has never been seen at the practice. Here is an example of the basic workflow of an E-visit:
WORKFLOW OF AN E-VISIT
䊏
䊏
A patient accesses the physician’s website and signs on. The patient is already registered as
an established patient of the practice.
The patient answers a few simple questions and selects the reason for the visit from a list.
From this information the software asks a set of questions appropriate to the complaint.
7
HealthCast 2010: Smaller World, Bigger Expectations (PricewaterhouseCoopers, November 1999).
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
122
8/10/09
9:53 AM
Page 122
CHAPTER 5
A REAL-LIFE STORY
Telemedicine at Mayo Clinics
By Marvin P. Mitchell and Ron Rea
Marvin P. Mitchell is the division chair of Media Support Services, Mayo Clinic, and Ron Rea
is an analyst for Systems & Procedures, Mayo Clinic. Mayo Clinic is the largest and most
prestigious not-for-profit group practice in the world. Its headquarters is in Rochester, Minnesota,
with clinics in Jacksonville, Florida, and Scottsdale, Arizona.
I
send images in their original high-resolution form. It may take an
think Mayo Clinic did its very first telemedicine consultation via
satellite back in the 1960s as a demonstration project with
Australia. When we opened our clinics in Jacksonville, Florida, in
1986 and Scottsdale, Arizona, in 1987 we got into it in a much bigger way.
Our goal was to be able to provide all the services that the Mayo
Clinic in Rochester, Minnesota, offers to all of our patients, regardless of whether they came to Rochester, Jacksonville, or Scottsdale.
We put into place the best technology available in the 1980s. That
was a very high resolution satellite broadcasting system equivalent
to what they now have at NBC or CBS, but with the transmission
encrypted for privacy and security.
We had our first telemedicine consultation two days after
Jacksonville opened their doors. We continued to do consultations
by this method, but one area we struggled with was getting x-rays
and larger diagnostic images to transmit with enough resolution
for what we do.
Our practice at Mayo is largely tertiary and quaternary care; that
is, very sick patients who have already been to family physicians
and specialists; they are coming here for a subspecialist or sub-subspecialist consultation. When you get to that level of care, the quality of imaging is absolutely critical.
We eventually found that face-to-face consultations via television didn’t work very well. First, because there are a lot of things the
consulting physician needs to go along with that: lab reports, diagnostic images, other examination records, and so forth. Second, it
was disruptive to our physicians because they had to leave their
practice and go to a special video studio. It was very difficult to get
two or more physicians on the video link at the same time; if
another opinion was needed, that specialist might not be available.
So we began to phase the video out of telemedicine because it just
wasn’t working and we began looking for a different approach.
In 1996 we were approached by the UAE (United Arab
Emirates) about doing telemedicine with their clinics. However,
they were 10 time zones from Rochester, so doing real-time, faceto-face consultation would be almost impossible. Dr. George Gura
(who is the medical director for the project) had the idea of creating a physician-to-physician, second-opinion service using what we
call store-and-forward telemedicine.
To use store-and-forward telemedicine, they package up the
case with all its inherent images, lab data, history, demographics,
and transmit it to Mayo. This allows us to use a data network to
hour for the image to get here, but it is an absolute perfect image,
H
not like you would get shooting it with a video camera and sendIing them over video link.
G The workflow is illustrated in Figure 5-12. The physician on the
other end does the necessary examinations and tests they would
G
normally do. If at some point they determine that they need a subspecialty consult, they get high-resolution images, scanned paper
S
documents, motion image capture, angiography, and those types
,of things that they can generate on their end. That is packaged in
an electronic format and transmitted with a consultation request to
the Mayo telemedicine office.
We tried to design a system that works as if the patient were
here. If, when Mayo’s telemedicine office receives the electronic
package, the patient has never been here before, we actually register this patient as though the person walked in the door. The
patient is given a Mayo Clinic number and an electronic medical
record is created.
When a patient comes to a Mayo clinic, we assign a personal
physician to handle the patient’s care; in most telemedicine cases
that will be Dr. Gura. He will review the case and forward the information to the appropriate Mayo physician(s) following our
processes here. For example, if they sent a CT scan, we actually create an order in the ordering system and the images are actually
passed on to our PAC system for handling; a notification is sent to
the techs to say there is a case waiting. They get the case up on the
screen for the radiologist to view; the radiologist interprets it; dictates a report. Similarly with other specialties, neurology for example, they would look at the neurologist’s reports, they would look
at other information that was sent, and they dictate their second
opinion into our clinical notes system. If a surgical consult is needed
those are done as well.
When all the subspecialists’ reports have been completed, a
second-opinion document is compiled from them and sent back to
the physician who requested the consult. That physician then has a
second opinion that can be worked into the diagnostic and treatment planning for the patient. A real-time interaction between the
physicians is not necessary.
One of the principal advantages of this workflow is that it is as
transparent to the Mayo physicians as possible. They don’t have to
learn a new system; they don’t have to change their practice model
to accommodate telemedicine. They see the patient’s records in the
same system they use everyday.
S
H
A
N
I
C
Q
U
A
1
1
0
5
T
S
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 123
HEALTHCARE RECORDS
Local physician
MD initial exam
123
MD reviews
clinical information
Consultation
Request
Telemedicine office
Tests
Procedures and
interpretations
MD
consults
MD diagnosis/
treatment plans
H
I
G
G
S opinion
Second
,
Subspecialty
interpretations
Mayo
Clinic
e-consult
service
S
Subspecialty
H
consults
Report &
A
treatment
Hospital
options
N
returned
I
Home
C
Q
U
FIGURE 5-12 Workflow of the Mayo Clinic telemedicine system
A
Surgery
CP1103574-20
(Courtesy of Mayo Clinic.)
1 advantage of keeping the patient’s home physician in control of
the patient care at all times.
1 Telemedicine provides easy access to Mayo Clinic subspecialty
0 care. It is like adding 1,600 subspecialists to the hospital with very
little impact to them. It has a positive impact on the patients,
5 improves the patient satisfaction with the hospitals, and avoids
travel and costs. I think similar savings could be realT unnecessary
ized using telemedicine more in the United States.
S Mayo Clinic has a model of care that we try to adhere to at all
One thing we require is that the physician on the other end ask
a specific question, rather that ask for a general opinion. For example, “Is this Bell’s palsy? Has the patient had a stroke?” That way
we can make sure we are targeting exactly what the physician
needs. Mayo provides value to the requesting physician, because
we do have that subspecialty expertise that they don’t.
This solution also solves the problem of licensure that has hindered telemedicine in the United States. Currently, most states
require a physician to be licensed by that state to treat patients in
that state. The regulations apply to telemedicine as well. Therefore,
either out-of-state patients must travel to Mayo or our doctor must
hold licenses in multiple states.
At Mayo, the telemedicine consultation is physician to physician; we are not giving advice to the patient, we are a resource for
their doctor. Therefore, no laws are broken. This has the additional
times; it is just how we practice medicine. Over time we felt that
the store-and-forward model of telemedicine worked best with our
Mayo model of care and its multi-specialty integration, how we
treat patients when they come through in that multi-specialty environment, and being able to ask other colleagues. That works best
with store-and-forward. It didn’t work well with video.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
124
8/10/09
9:53 AM
Page 124
CHAPTER 5
䊏
䊏
䊏
䊏
䊏
The patient answers the questions and can add free-text clarification at various points in the
interview.
• E-visits are only used for nonurgent visits. If the condition seems urgent, the software
advises the patient to seek immediate medical care and the provider is notified to determine the proper course of action.
• If the software determines that the condition is not urgent but the patient needs to be
seen in the office, the patient is given a message to that effect and automatically offered
a choice of available appointments.
When the interview is complete, the clinician is notified that an E-visit is ready to review.
The clinician reviews the patient-entered data and any relevant patient medical records and
then replies to the patient. The system allows the provider and patient to continue to
exchange messages, much like a question-and-answer session in the exam room, except for
the factor of time, which is sometimes
H delayed by one or both parties’ responses.
The clinician can also prescribe electronically during the E-visit just as he or she would during
I the clinician’s reply to the E-visit, they are prompted to
an office visit. When patients receive
select their preferred pharmacy from
G a list (if it is not already known to the EHR) and the prescription is electronically transmitted to the pharmacy by the doctor’s system.
G
The doctor’s response can also include patient education material and comments or care
instructions from the doctor, allS
of which are recorded in the care plan as well.
, into the doctor’s EHR to become part of the patient’s
Data from the E-visit can be merged
medical record. The doctor’s practice management system can verify the patient eligibility
for the E-visit and submit the claim electronically.
S
In an independent study sponsored by Blue Shield of California,8 most patients and doctors
in the study preferred a web visit to H
an office visit for nonurgent medical needs. Providers found
that the E-visit gathered the important
A details and eliminated multiple messages back and forth
that occur when trying to provide patient care via e-mail. The patients found that the time spent
N was eliminated with an E-visit. The reality of online
scheduling, driving, parking, and waiting
medical visits with your doctor is notI a question of if, but when.
Chapter 5 Summary
Understanding Healthcare Records
Healthcare records have many purposes, the most important
of which is the patient’s care.
• The patient health record is the repository of data and
information about a patient, the condition of the
patient’s health, the care and treatments the patient
received, and the outcome of that care.
• The term patient health record has replaced the term
patient medical record because it encompasses a
holistic view of patient care. Though the terms are
used almost interchangeably, an acute care patient
record is usually concerned with one stay or episode,
whereas an outpatient medical record is usually limited
to one group or clinic.
C
Q
U
A
• Data and information is not the same thing. Data are
1 records of facts. Information is data in a useful form
that conveys meaning.
1
Functions
of Healthcare Records
0
patient’s health record serves as the principal commu5• A
nication document among various providers who might
T care for the patient at different times in different
departments.
S• The
patient record provides the basis for all billing
and reimbursement. Medical claims will not be paid
by an insurance company if the patient record does not
have enough detail about the encounter or treatment to
support the claim.
8
The RelayHealth Web Visit Study: Final Report (RelayHealth, January 2003), www.relayhealth.com. ©2002–2003
RelayHealth Corporation.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
8/10/09
9:53 AM
Page 125
HEALTHCARE RECORDS
125
• The health record is a legal document; relevant porDemographic data is often gathered on paper forms,
tions of the patient’s record may become evidence in a
then transferred into the computer by the registration clerk.
court of law.
In a paper-based system, this principal document will be
• Healthcare records provide the basis for improvements
called a face sheet. In an electronic system, the forms may be
in health.
scanned into a document image system.
Clinical data include documents created by the patient,
• Individually, a patient’s record is evaluated and used
nurses,
clinicians, and other providers. Some standard types
to develop care plans for the patient.
of
clinical
documents include:
• Collectively, health records can be used by a healthcare facility to improve the quality and processes of
• Medical history
healthcare delivery.
• Physical exam
• Public health departments, Homeland Security, and
• Diagnostic and therapeutic orders
law enforcement officials use information from health
• Diagnostic and therapeutic reports
records.
• Diagnostic images
• Researchers use patient records from clinical trials to H • Operative records
monitor the effectiveness and safety of new drugs.
I • Nursing notes
• De-identified health records are analyzed by researchers
consults
G •• Referral
to find health trends in our society and measure which
Case management
treatments seem to have the best outcomes.
G • Discharge summary
Obstetrical records
S •• Pediatric
records
Primary and Secondary Records
,
•
Problem
list
Health information professionals classify health records as
• Medication list
primary and secondary records:
• Public health records.
S
• Primary records are those that are gathered directly
from the patient and his or her providers and from
H Documentation Standards
devices and diagnostic tests. Primary records are used
professionals seek to ensure uniform quality patient
A HIM
for patient care and as legal documents.
records. Some of the ways to accomplish this are to use stan• Examples of primary records include admission
N dardized data elements, data sets, and HIM policies and
and discharge reports, nursing notes, physician
I procedures.
examinations and notes, all orders, test results,
operative reports, pathology and radiology reports, C • Data elements define specific units of information that
may consist of several fields. For example, the patient
and administrative and demographic forms.
Q name element would typically include first, middle,
• Secondary records are those that are created later, by
and last name and a suffix.
analyzing, summarizing, or abstracting from the pri- U • Standard data sets are a collection of data elements
mary records. Secondary records are used in billing, A
determined to be the minimum necessary for a particuresearch, and quality improvement.
lar purpose.
• Examples of secondary records include insurance
• HIM policies and procedures establish documenta1
claims, master patient index, and ALOS reports.
tion requirements for health records and are typically
included in the rules medical staff must follow.
1
Contents of Health Records
0
Patient health record data consists of administrative and
demographic data and clinical data. Administrative data5
includes a number of legal documents signed by the patientT
or their representative. These may include:
•
•
•
•
•
•
•
•
•
•
HIPAA consent to use and disclose PHI
Consent to treatment
Medicare patient rights statement
Assignment of benefits
Informed consent
Refusal of treatment
Advance directives
Organ donor
Personal property list
Disclosure records.
S
Continuity of Care Records
Clinical data in the patient record helps provide a continuity
of care as the patient is seen at different times by different
healthcare workers.
• In an inpatient facility, the patient moves through different departments of a facility, for example, admitting,
radiology, or surgery. Because providers record their
findings, actions, and orders in the chart, subsequent
caregivers can read what the previous nurses, doctors,
or therapists have observed and what has been done.
• In an outpatient setting, a lapse of months or even a
year between doctor visits is not uncommon. The exam
notes from each visit, test results, and reports from
consulting physicians and outside facilities are filed in
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
M05_GART2674_01_SE_C05.QXD
126
8/10/09
9:53 AM
Page 126
CHAPTER 5
the patient’s chart. This information about the patient’s
previous visits and treatments enables the clinician to
provide continuity of care over a longer period of time.
However, because patients do not always go to the
same doctors, the same medical practice, nor use just one
pharmacy, a complete health record for the patient does not
exist in any one place. A regional health information organization (RHIO) is one way for different providers to share
patient records. One issue for a RHIO is who owns the data?
Historically, the provider, group practice, or facility considered itself to be the owner of a patient’s health record, but
information sent via a RHIO is merged into the receiving
facility’s patient records, clouding the issue. Though the
provider owns the patient record, HIPAA gives patients the
right to review, copy, and amend their health record.
Patients are also creating personal health records
through neutral online entities that allow them to make their
records available to different providers they visit.
Telemedicine
Telemedicine uses communication technology to deliver medical care to a patient in another location. Telemedicine can
provide high-level medical expertise to remote and rural areas.
Telemedicine can be practiced in real time or in a storeand-forward manner.
• Real-time telemedicine requires the presence of all
parties at the same time, for example, a conference
call.
• Store-and-forward telemedicine allows one party to
send information that is saved and then reviewed and
responded to later.
Teleradiology is telemedicine specifically concerned
with the transmission of diagnostic images from one location to another. Usually this is for the purpose of having the
images “read” by a radiologist at the receiving end.
H Telemonitoring allows doctors to study vital signs or
tests measured many times in the course of the patient’s norImal daily activity using devices such as blood pressure monitors,
G glucose meters, and Holter monitors. The devices store
the readings and transfer the data to the doctor’s system
G
either by using a modem and phone line or by downloading
from
S the device during a patient encounter.
E-visits are being used in some states to allow the
,patient to be treated by a clinician for nonurgent health problems without having to come into the office. E-visits are conducted over the Internet.
S
H
A
Critical Thinking Exercises
N
1. CMS takes the position that “if it isn’t documented, it wasn’t done.” What does this
mean and why would it matterI to CMS?
2. Chapters 4 and 5 discussed data
C sets. Design a basic demographic data set. Make a list
of just the fields you would need for the patient information. (You do not need to
Q
include insurance information.)
U
A
Testing Your Knowledge of Chapter 5
1. Health records are classified as primary or secondary
records. Give an example of each type.
2. List two ways in which healthcare records provide the
basis for improvements in health.
3. Provide an example of patient health record data that is
administrative or demographic data.
4. Provide two examples of types of clinical data in a
patient’s chart.
5. What is a RHIO?
6. What are some differences between the contents of
patient records at an inpatient facility versus a doctor’s
office?
7. What does the acronym PHR stand for?
8. There are two methods of telemedicine. Which method
is used by the Mayo Clinic?
1
19. Describe the difference between a data element and a
data set.
0
10. How do HIM policies and procedures help ensure qual5 ity patient records?
T11. Name three functions of patient health records.
12. The patient record provides the basis for all billing and
S
reimbursement. What will happen if the patient record
does not have enough detail?
13. What is the difference between data and information?
14. Provide an example of how the patient record helps
provide continuity of care.
15. What is an E-visit?
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Instructions: This assignment must be done in APA format. A minimum word count
for the overall assignment is 1600 words (not including reference portion). A
minimum requirement of 4-6 references (with in-text citations) is required.
Although this assignment is APA format, it must keep the answer and question
format. See details below.
Format for Assignment:
Question: XYZ
Answer: XYZ
Reference: XYZ
Instructor Notes: In professional writing avoid using first person "I" and third
person "we", as they detract from the quality and turn professional researched
statements into opinions. Instead of "I" use, for example, use "the writer, the
author or the researcher".
Instructors General Note:
1. Also give examples of what these records are used for
2. Beyond the two examples how are these data used? Clinical
diagnoses? Treatment plan? Who uses them
3. Give specific differences and how each uses the records.
Benefits/downsides of the records. Can they be combined into one
database? How? By whom?
4. Be specific about the quality of the record. What makes it a quality
record? Who decides this? Give an example of a quality record vs one
not quality
5. Beyond naming them, describe the functions and what output they
support. Give examples e.g diagnosis? Treatment? Payment?
Please answer these as 5 separate, numbered questions. Thanks
Questions
1. Health records are classified as primary or secondary records. Give an
example of each.
2. Provide two examples of types of clinical data in a patient's chart.
3. What are some differences between the contents of patient records at an
inpatient facility versus a doctor's office?
4. How do HIM policies and procedures help ensure quality patient records?
5. Name three functions of patient health records.
Reference Book: Gartee, R. (2011). Health information technology and
management. Upper Saddle River, NJ: Pearson.
Part Two
Instructions: Write an 150 word response to each post. A minimum of one (1)
reference is to be used (with in-text citatation). Each reference has to be
different. Be sure to wrote as of your talking to the person. Please be detailed as
possible.
1. “Information and data that is reported or retrieved from the patient, medical
staff or diagnostic tests while being used for patient care are classified as
primary records” (Gartee, 2011, p. 101). Primary records may be thought of
as ‘first hand’. An example of a primary record is the vital sign recordings
such as blood pressure, heart rate, and oxygen levels in which a nurse or CNA
records in the patient chart. “Patient health record data can be classified as
demographic data which is “patient identification information such as their
name, date of birth, and address” (Gartee, 2011, p. 102).
“Secondary records are created at a later time based off of the primary
records and used for reimbursement, insurance claims, research, and quality
improvement” (Bethel University, n.d.). An example of a “secondary record
is the submission of a health insurance claim which requires information to
be pulled from the chart such as patient demographics, insurance
information, and procedure codes” (Gartee, 2011, p. 101). Submitting a
health insurance claim is vital because this will prompt the process of
reimbursement for the healthcare facility.
There are vast amounts of clinical data in a healthcare record. The primary
concern is patient care; therefore, it is important that medical providers and
staff involved in the patient’s care review each other’s notes, orders, and
patient response to the treatment plan set forth (Gartee, 2011). For
example, it is important that the nurses read and carry out the doctor’s order
while documenting the progress and outcomes in relation to the
order. When the doctor visits the patient, it is equally important for the
doctor to assess the patient and review the nurses’ notes and any other
necessary clinical documentation or reports to evaluate the progress while
determining if changes need to be made to the patient’s treatment
plan. Furthermore, it is important that all documentation is completed on
the right patient while painting the best picture of the patient so that the
best treatment plan is ordered and carried out. Thus, the ultimate goal is to
provide the highest quality of care for all patients.
Monitoring quality of care is important for every healthcare facility. Because
many healthcare organizations have converted to electronic medical
records, this has enabled facilities to pull and analyze the necessary data to
monitor for trends and patterns in various areas of performance so that
quality improvements can be made accordingly which can improve their
patients’ health. This, of course, is determined if the system is set up to
perform these functions. A facility may note that their infection and
mortality rates are higher when compared to facilities that are comparable
with a certain population, or the healthcare facility may notice a trend rising
over the past couple of years. As a result, further research can be completed
to assess and identify the cause and decide what changes needed to be done
to improve one’s health. Then, the facility can monitor those specific
statistics in response to the actions taken. For example, Piedmont hospital’s
website reports they “submit data from medical records about core
measures to be compiled and benchmarked with hospitals at the state and
national level” (Piedmont, 2019, para. 1). After identifying areas of
improvement with their treatment for pneumonia, Piedmont initiated an
“evidence-based pneumonia care pathway that resulted in a 56.5 percent
relative reduction in mortality rate among adult patients with a diagnosis of
pneumonia” (Health Catalyst, 2018).
2. Healthcare records come in two different categories, primary and
secondary. Primary records are obtained directly from the patient, provider,
and tests while the secondary records are obtained at a later time via data
or information abstraction from the primary record (Gartee, 2011). Primary
records are things such as lab results, medical history, previous visits, and
assessment notes. This type of information and records can be acquired in
many different healthcare settings from inpatient to outpatient to home
visits. These records are obtained due to direct patient care and interaction.
Secondary records are things such as insurance claims, billing, quality data,
and information reported to various agencies. These two types of records
are also crucial in improvements throughout the hospital. Primary records
are sent from provider to provider and organization to organization to
improve the health of patients. This happens with a primary care provider
sends a patient to a specialist or when a hospital transfers a patient to a
different level of care to aid in the health of the individual. This transfer of
information can be completed at the blink of an eye via a network and the
use of electronic health records. Secondary records are used to help improve
the quality of care an organization provides. By reviewing records and
aggregating data the hospital is able to find ways to improve. This is also
achieved by utilizing an electronic health record. Secondary records help
improve much more than the quality of care provided by an organization.
Secondary records aide in research, public health management, and safety
monitoring, which is only a glimpse of its potential improvement uses
(Sandhu, Weinstein, McKethan, & Jain, 2012).
The health record has come a long way from paper to the electronic
variation. Using an electronic health record is best practice. There are many
different types of EHRs across the globe which are utilized by countless
healthcare entities. An EHR has many uses when it is utilized correctly and is
much more effective than its paper form. The information is shared,
available, and “easily” accessible from almost anywhere. And with all of the
information in one place it can be sorted and analyzed must faster which is
beneficial when it comes to improvement. More than 95% of hospitals use a
certified HER technology but there are still issues with integrating it with
other systems to reap the full benefit (Shashank, 2018).
Healthcare records contain specific types of data such as demographic and
administrative. Demographic data is exactly what it says it is which is the
patient’s information. This would be information such as the patient’s name,
address, birthday, and social security number. This information would be
complied on something many organization call a face sheet which would
become part of the chart and record. The demographic data can be used to
create administrative data such insurance claims and billing statements.
There are other types of administrative data...
Purchase answer to see full
attachment