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MANAGING HEALTH INFORMATION Chapter 4 © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED
LEARNING OUTCOMES: WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE TO 4.1Classify various uses of computer technology. 4.2Recall reasons for maintaining a medical chart and documents that compile the medical chart. 4.3Identify components of a paper-based medical record and explain how the same components will be compiled in an electronic health record format. 4.4Distinguish among active, inactive, and closed files. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-2
LEARNING OUTCOMES: WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE TO (CONTINUED) 4.5Differentiate among records management systems that may be used in a medical office 4.6Discuss the advantages and challenges of electronic health records implementation 4.7List three medical abbreviations not to be used that have been targeted by JACHO 4.8Discuss various input technologies used to create medical documentation © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-3
accession book closed files active filescoding AHIMAcolor-coding alphabetic filingcross-reference sheet application software database ARMAdead storage assessmentdiagnosis (Dx) CHEDDARelectronic health records (EHR’s) e-mailinactive files family history (FH)indexing file serverinspecting documents foldersinternet graphics applicationlabel guidelaptop history of present illness (HPI) lateral files impressionmainframe © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED KEY TERMS 4-4
KEY TERMS (CONTINUED) medicolegalobjectivepasswordrecords management micrographicsonlinepast medical history (PMH) releasing minicomputeropen-shelf filespersonal computerretention mobile-aisle filesoperating system physical exam (PE)review of systems (ROS) networkingout guideplanrule out (RO) numeric filingoutput deviceproblem oriented medical record (POMR) © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-5
KEY TERMS (CONTINUED) social history (SH)subjectivevertical files sortingsupercomputervirus spreadsheettab cutsvoice-recognition technology programstabswireless communication storingtemplateword processing subject filingtranscriptionprogram © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-6
KEY TERMS accession book --a book of consecutive numbers indicating the next available number to be assigned active files -- pertaining to current patients AHIMA -- exists to serve health information management professionals. The organization offers credentials such as Registered Health Information Administrator alphabetic filing -- the arrangement of names, titles, or classifications in alphabetic order © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-7
KEY TERMS (CONTINUED) application software --includes word processing, graphics, spreadsheet, and database management software, applies the computer’s capabilities to specific applications ARMA -- the organization is to set standards for the filing and retention of records assessment -- used interchangeably with the terms diagnosis (Dx) and impression and gives a name to the condition from which the patient is suffering CHEDDAR -- format also breaks down the components of a patient encounter into seven detail-oriented sections: chief complaint, history, exam, details of problem, drugs/dosages, assessment, and return information © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-8
KEY TERMS (CONTINUED) closed files -- those of patients who have died, moved away, or terminated their relationship with the physician coding -- is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed color-coding – Each letter of the alphabet is a different color cross-reference sheet -- prepared to indicate where the original material is filed and where in the files other copies may be found © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-9
KEY TERMS (CONTINUED) database -- are collections of related data dead storage -- a storage area separate from the area where active files are kept diagnosis (Dx) -- gives a name to the condition from which the patient is suffering electronic health records (EHRs) -- the assimilation and interoperability (electronic systems working together) of various healthcare databases compiled over the course of different patient encounters © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-10
KEY TERMS (CONTINUED) e-mail -- a telecommunications system for exchanging written messages through a computer network family history (FH) - - Facts about the health of the patient’s parents, siblings, and other blood relatives that might be significant to the patient’s condition file server -- stores the computer programs and data to be shared by all the computers in the network folders -- hold the items that are filed graphics application -- allow the user to create illustrations from scratch electronically. Others are designed to mix and match already created images, text, video, sound, and animation © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-11
KEY TERMS (CONTINUED) guide -- rigid dividers placed at the end of a section of files to indicate where a new section or category of files begins history of present illness (HPI) -- Information about the symptoms troubling the patient—location, quality, severity, timing, duration, context, modifying factors, and any associated signs and/or symptoms impression -- gives a name to the condition from which the patient is suffering inactive files -- related to patients who have not seen the physician for 6 months or longer indexing -- is the mental process of selecting the name, title, or classification under which an item will be filed and arranging the units of the title or name in the proper order © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-12
KEY TERMS (CONTINUED) inspecting documents -- document should be in good physical condition, and the information should be complete. Internet -- is an enormous computer network that links computers and smaller computer networks worldwide Label -- Oblong pieces of paper, frequently self-adhesive laptop -- physicians are using to enter patient data, research medical resources lateral files -- the drawers or shelves open horizontally and files are arranged sideways, from left to right, instead of from front to back mainframe -- store massive databases, which many users can access at the same time © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-13
KEY TERMS (CONTINUED) medicolegal -- providing documentation of medical care, and they are admissible in a court of law. micrographics -- miniaturized images of the records. minicomputer -- are designed for single users, but many operate with tens or even hundreds of terminals. mobile-aisle files -- open-shelf files that are moved manually or, more often, by a motor. networking -- provides a means of communicating, exchanging information, and pooling resources among a group of computers numeric filing -- one in which each patient is assigned a number. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-14
KEY TERMS (CONTINUED) objective -- The physician’s examination of the patient contained in the SOAP record; results of the examination may be shown under the heading “Physical Examination (PE).” online -- connected to a computer network for purposes of communicating, gathering, or exchanging information. open-shelf files -- Shelves that hold files, may be adjustable or fixed. operating system -- The internal programming that tells the computer how to use its own components by controlling the basic functions of the computer. out guide -- A card placed as a substitute for a file folder; serves that indicates that a file has been removed. output -- Processed data sent back to the user by the computer. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-15
KEY TERMS (CONTINUED) password -- A code assigned to a computer user as a security measure. past medical history (PMH) – A listing of any illnesses a patient had in the past. personal computer -- A computer designed for one user. physical exam (PE) -- complete examination of the patient in which findings for each of the major areas of the body are stated. plan -- The treatment, as stated in the SOAP record, listing prescribed medication, instructions given to the patient, recommendation for surgery or hospitalization. problem oriented medical record (POMR) -- A patient record organized around a list of the patient’s complaints or problems. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-16
KEY TERMS (CONTINUED) records management -- The systematic control of the steps in the life of a record. releasing -- The indication, by initial or by some other agreed upon mark, that a document has been inspected, acted upon, and is ready for filing. retention -- The length of time that records are kept. review of systems (ROS) -- The physician’s specific questions to the patient about each of the body’s systems. rule out (RO) -- A possible diagnosis that must be proved or “ruled out” by further tests. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-17
KEY TERMS (CONTINUED) social history (SH) -- Information that may be pertinent to treatment regarding the patient’s marital history, occupation, interests, and eating, drinking, smoking habits. sorting -- The arrangement of documents in the order in which they will be filed. spreadsheet -- Software used for financial planning and budgeting. programs -- Computer programs that apply the computer’s capabilities to specific uses. storing -- placement of an item in its correct place in a file; also called “filing.” subject filing -- A system of document storing whereby the placement of related material is alphabetic by subject categories. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-18
KEY TERMS (CONTINUED) subjective -- The patient’s description of the problem or complaint including symptoms. supercomputer -- The most powerful computers available. tab cuts -- Are to the positions of the tab. tabs -- Are the projections that extend beyond the rest of the folder. template -- A standard electronic version of a frequently used document. transcription – The physician, or other provider of medical care, dictates the medical data into a recording device, to be transcribed by a keyboardist who specializes in medical data keyboarding. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-19
KEY TERMS (CONTINUED) vertical files -- Drawer files, contained in cabinets of various sizes; files are arranged from front to back. virus -- is a program written with the intent of damaging another user’s data, software, or computer. voice-recognition technology -- A program used along with a word processing application to transcribe spoken words into text without the use of a keyboard. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-20
KEY TERMS (CONTINUED) wireless communication– The use of radio waves rather than wires or cables to transmit data through a computer network. word processing -- Software used to enter, edit, format, and print documents © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-21
4.1 CLASSIFY VARIOUS USES OF COMPUTER TECHNOLOGY : Computer usage in a medical environment has increased tremendously in recent years: Scheduling Medical data entry Communications Research © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-22
Examples of documents that may be found in a medical chart are: — Chart notes. — History and physicals. — Clinical forms. — Medical reports. — Communications with the patient or with other medical personnel concerning the patient. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-23 4.2 RECALL REASONS FOR MAINTAINING A MEDICAL CHART AND DOCUMENTS THAT COMPROMISE THE MEDICAL CHART
4.3 IDENTIFY COMPONENTS OF A PAPER-BASED MEDICAL RECORD AND EXPLAIN HOW THE SAME COMPONENTS WILL BE COMPILED IN AN ELECTRONIC HEALTH RECORD FORMAT Notes from the patient encounter, such as the chief complaint, history, examination, impression/diagnosis, and treatment plan are documented in a patient medical chart using various formats, such as SOAP. Electronic input. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-24
4.4 DISTINGUISH AMONG ACTIVE, INACTIVE, AND CLOSED FILES. Active files Inactive files Closed files As each medical specialty has its own requirements, a retention schedule should be developed by the practice based on its needs and state statutes. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-25
4.5 DIFFERENTIATE AMONG THE RECORDS MANAGEMENT SYSTEMS THAT MAY BE USED IN A MEDICAL OFFICE Records management is the systematic control of records from their creation through maintenance to eventual storage or destruction. Records may be managed electronically or manually (paper records). Alphabetic filing Numeric filing Subject filing © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-26
4.6 DISCUSS THE ADVANTAGES AND CHALLENGES OF ELECTRONIC HEALTH RECORDS IMPLEMENTATION. The need to store large amounts of medical data and to protect that data efficiently is a primary concern of the medical and governmental communities. Mandatory implementation of electronic health records (EHRs) is part of national healthcare reform. Advantages of Electronic Health Records Challenges of Electronic Health Records © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-27
4.7 LIST THREE MEDICAL ABBREVIATIONS THAT HAVE BEEN TARGETED BY JACHO Similar medical abbreviations may contribute to a misdiagnosis or misinterpretation. JACHO has distributed a listing of “Do Not Use” abbreviations. U IU Q or q. MS © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-28
4.8 DISCUSS THE VARIOUS INPUT TECHNOLOGIES USED TO CREATE MEDICAL DOCUMENTATION. Voice-recognition software Wireless technology Transcription © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 4-29
PATIENT MEDICAL RECORDS
The Medical Record, Documentation, and Filing
Medical Records Management
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Word Processing Word processing packages such as Microsoft Word are text based. When text is entered via a keyboard, the characters are displayed on screen.
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