chap 7 cont'd
Terms
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- The MPI or pt. directory serves as?
- it serves as a link to the patient record and facilitiates pt. identification that is critical to the quality and safety of pt. care
- When an org is ready to replace or upgrade a EHR or paper record system, it must consider its policies on 3 things regarding info.
- accessibility, retention and destruction of info.
- It is acceptable for a draft of a dictated/transcribed note or report to be changed before authentication unless?
- there's a reason to believe the changes are suspect and wouldn't reflect actual events or action or that it has been relied upon for pt, care
- Which 4 ways does AHIMA recommend to destroy paper h recs?
- burning, pulping, shredding or pulverizing
- Why doesn't deleting info from its orginal location or file folder work?
- It can still be accessed from the hard drive or storage media.
- AHIMA recommends, when pt recs cannot be transferred on before closure, a reputable commercial storage firm should be considered only if it (3 things):
- 1. has experience in handling confidential pt into 2. guarantees the security & conficently of the recs. 3 ensures that pts and other legitimate requestors will have access to the info.
- A state's stat of limitations may also be extended for indivs who are
- legally deemed incompetent by virtue of a mental disability.
- One exception in which the statute of limitations can exceed the normal time frame for records to be retained is in the case of
- minors. The statute of limitations does not begin to run until the minor reaches the age of majority.
- Define an addendum
- it's a type of late entry where info is added to support, clarify, or add to a previously existing entry.
- Discharge analysis happens
- once the pt. has been discharged from the h care facility. HIM dept. check for completeness.
- One of the foremost reasons why documentation within the h rec. may need to be changed is?
- entries that are incomplete or contain erroneous info,
- ? and ? should define the process for making changes and the time period in which they can be made in regard to the h rec.
- Policies and procedures like professional guidelines (AHIMA)
- State med assocs & the AMA code of ethics made it clear that pts must be given?
- info about the practice status of a departing physician and the physician's new address & the opport to have recs forwarded to him at the new location in a timely manner w/o interference.
- To facilitate accurate and timely retrieval of pt. health recs. the concept of a ??? has been debated extensively.
- a universal identifiier unique to each individual (like a social security card)
- Deletions to the EHR happen sometimes - name 2 instances it might occur.
- Documentation is entered in the wrong pt record or info can be deleted to preserve confidentiality like the adopted person's real birth mother.
- The retention of h recs. in any format involves 3 things.
- involves mechanisms for storing the recs., provides for timely retrieval and establishes the length of times that various types of records will be retained by the hcare org.
- A retention schedule should include guidelines that specify 3 things.
- what info should be retained, the time period for which it should be retined, and the storage medium on which it is to be retained.
- Concurrent analysis in regard to EHR completeness means
- the record is reviewed by HIM staff during the pts. stay in a hcare facility to determine if sigs or other pertinent info is missing.
- When correcting an error in the EHR, ? should be done to indicate there was a change?
- A notation or flag shd be visible with the new info to indicate there was a change along with a link to the orig incorrect info,.
- Orgs may decide to retain recs for different periods of time based on what?
- the media types on which they reside (EHRs, digital images, etc)
- Ahima recommends that hcare orgs develop retention schedules that meet the org's ???
- Operational needs. The paramount need is patient care.
- In addition to health info, data that is inherent to EHR systems such as ?, ? and ? should be addressed in a retention policy
- metadata, alerts and reminders
- Regarding entries to the EHR, list 5 steps to how late entries should be documented
- 1. Identify the new entry as a late entry 2. Enter the current date & time. 3. Identify or refer to the date and incident for which the late entry is written 4. If the late entry is used to document an omission, give the source of addt'l info (where you obtained the info) 5. When using late entries, document as soon as possible.
- Many states recommend that pt. h recs be retained for
- 10 years following pt. discharge or death.
- Strict control of printing policies should include 4 determinations to be made.
- 1. justification for printing paper internally, 2. who has authority to print? 3. how printing will be tracked in an audit trail. 4. the format & version of docs that may be printed.
- With regard to the transfer of h recs, HIPAA Privacy Rule does not require the pt's authorization because
- circumstances like sales & transfers are within the HIPAAs definition of hcare operations.
- In addition to Fed & state laws and other legal issues, hcare orgs must take into account the compelling requirements of orgs like
- the Joint Commission and recommended standards published by AHIMA.
- When an org cannot produce a h rec, its risk of liability increases, particularly when?
- the rec is needed for pt care purposes or evidence in a legal action
- What 4 things should be considered when a hcare org carries out destruction of h recs?
- Fed laws, State laws, org's apporved retention schedule & org's destruction policy.
- The Nat'l Archive report outlines 3 alternatives to be considered in the developmt of a retention policy which include
- 1. maintain recs in a software-independent format 2. Reformat and migrate records to new software systems 3. Maintain nec. hardware & software to make the info. accessible.
- Revisions to h rec. entries involve doing what?
- replacing incorrect info with correct info in a manner which ensures that the original entry is preserved and the revision is relied upon for future readers.
- Disposition involves what?
- the removal of recs from a rec storage systemm usu a result of a rec becoming inactive due to cessation of pt encounters.
- Version management refers to
- how an org handles the numerous versions of a doc that may be made.
- Medicare requires recs to be maintained for atleast how many years?
- Five years.