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C810 - Foundations of Data Management
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C810 - Foundations of Data Management C810 - Foundations of Data Management C810 - Foundations of Data Management
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C810 - Foundations of DataManagement
What is a health record? - answer A complete, accurate, and current report of the medical history,
condition, and treatment that a particular patient receives during an inpatient or outpatient
encounter with a healthcare provider
True or False?
The health record may reflect one episode of care or an accumulation of all episodes of care
(longitudinal record) - answer True
What is included in demographic information collected at time of admission or registration for
treatment? - answer - Name
- Sex
- Age
- Insurance information
- Emergency contacts
What is included in clinical information? - answer - Patient's complaint
- History of present illness
- Medical history
- Family history
- Social history
- Physician progress notes and orders
- Reports of diagnostic tests
- Surgery and other procedure reports
- Nursing documentation
- Final diagnosis(es)
What is the rentention of the health record? - answer - The retention period refers to how long
health records must be kept
- The health record serves several purposes and must be retained to meet them
,- Such purposes include patient treatment, proof of services provided to justify reimbursement and
evidence in legal proceedings
- Federal and state statutes and regulations often determine retention periods
Who owns the health record? - answer - The organization that creates and maintains the physical
record is the legal custodian and is legally responsible for all aspects of it, including its integrity,
security and completeness
- Although the organization owns the record, patients have the right to access the record with
exceptions noted in HIPAA
What is express consent? - answer - Consent communicated through words, either written or
spoken
What is implied consent? - answer - Consent communicated through conduct or a mechanism other
than words
What is informed consent? - answer - Ensures the patient has a basic understanding of his or her
diagnosis; the nature of the treatment or procedure along with the risks, benefits, and alternatives;
and individuals who will perform the treatment or procedure
- The document must be signed and dated by the patient, the provider rendering the treatment, and
a witness
What is advance directive? - answer A special type of written consent that communicates an
individual's wishes to be treated or not treated should the individual become incapacitated and
unable to communicate on his or her own behalf
What is a durable power of attorney for healthcare decisions? - answer A document in which a
competent adult designates another person to make healthcare decisions consistent with the
individual's wishes on the individual's behalf if he or she is unable to
What is a living will? - answer - A document executed by a competent adult that expresses the
individuals wishes to limit treatment should the individual become afflicted with certain conditions
(such as a persistent vegetative state or a terminal condition) and no longer able to communicate on
his or her own behalf
- Often address extraordinary lifesaving measures such as ventilator support and either the
continuation or removal of nutrition and hydration
, What is a do-not-resuscitate (DNR) order? - answer - A document that always specifies an
individual's wish to not receive treatment, specifically cardiopulmonary resuscitation (CPR)
- It directs healthcare providers to refrain from performing the otherwise standing order of CPR
should the individual experience cardiac or respiratory arrest
- Most often used by the elderly or chronically ill
What is metadata? - answer - Electronic data about data that include information not previously
available in paper documents
- Such as time stamps that show when and by whom a document or entry was created, accessed, or
changed
What is the typical time frame for completing the history and physical examination? - answer - The
facility must have a policy that establishes a time frame for completing the history and physical
- Usually it is within the first 24 hours following admission and must be completed by the
practitioner who is admitting the patient
- CMS Conditions of Participations requires that the history and physical examination be completed
no more than 30 days before or 24 hours after admission and the report must be placed in the
record within 24 hours after admission
- The Joint Commission requires the history and physical examination to be recorded and made part
of the patient health record prior to any operative procedure
What are progress notes? - answer - Chronological statements about the patient's response to
treatment during his or her stay in the facility
- Each progress note should include changes in the patient's condition, findings based on the facts of
the case, test results, and response to treatment, as well as an analysis of the findings
- The final part of the note contains the decisions or actions planned for future care
What are consultation reports? - answer - Consultations are opinions of physicians with specialty
training beyond general board certification such as oncologists, cardiologists, or dermatologists
- After the specialist sees the patient, they have to write a report that shows evidence of the
consultant's review of the record, examination of the patient, and any pertinent findings, opinions,
and recommendations
- Must also show that the physician requesting the consultation reviewed the report
What is charting by exception? - answer - Also known as focus charting
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