Health Information Management Technology 4th Edition By Sayles -Test Bank
To Purchase
this Complete Test Bank with Answers Click the link Below
If face any problem or
Further information contact us At tbzuiqe@gmail.com
Sample
Test
Health
Information Management Technology
An Applied Approach
Fourth Edition
Instructor’s Manual
Chapter 3
Content and Structure of the
Health Record
Lesson
Plan
Background
and Instructional Delivery
This chapter introduces the student to the content of the health
record in various healthcare settings. The foundation for this chapter has been
provided in chapter 2 through the discussion of the purposes of the health
record, its functions, and its primary and secondary users. In this chapter,
students will learn what the health record contains and how it achieves its
purposes and fulfills its functions.
This chapter also introduces students to content requirements
mandated by various accrediting and state and federal regulations, and shows
that content is important not only for the purposes listed in chapter 2 but
also for fulfilling mandated rules and regulations.
While the focus of the first part of chapter 3 is on content of
health records, this chapter also describes appropriate documentation
practices; several record formats, the pros and cons of each record format, and
provides examples of documentation from both paper and electronic records.
Chapter
Outline
Learning Objectives
Key Terms
Introduction
Theory into Practice
Documentation Standards
Types
of Standards
Standards Organizations
Standards for Health Record Documentation
State Regulating Agencies
Medicare and Medicaid Programs
Accreditation Organizations
The Joint Commission
American Osteopathic Association
Accreditation Association for Ambulatory Healthcare
Commission on Accreditation of Rehabilitation Facilities
National Committee for Quality Assurance
Other Accreditation Groups
Acute Care Health Record Documentation
Basic Acute Care Content
Clinical Data
Medical History
Physical Examination Report
Diagnostic and Therapeutic Orders
Clinical Observations
Physician Notes
Nursing and Allied Health Notes and Assessments
Reports of Diagnostic and Therapeutic Procedures
Diagnostic Reports
Procedure and Surgical Documentation
Patient Consent Documentation
Anesthesia Report
Procedure and Operative Reports
Recovery Room Report
Pathology Report
Consultation Reports
Discharge Summary
Patient Instructions and Transfer Records
Autopsy Reports
Obstetrics and Newborn Documentation
Administrative Data
Demographic and Financial Information
Other Administrative Information
Consents, Authorizations, and Acknowledgments
Consent to Treatment
Notice of Privacy Practices
Authorizations Related to Release and Disclosure of Confidential
Health Information
Advance Directives
Acknowledgments of Patient’s Rights
Specialized Health Record Documentation
Emergency Care Documentation
Ambulatory Care Documentation
Basic Ambulatory Documentation
Obstetric/Gynecologic Care Documentation
Pediatric Care Documentation
Ambulatory Surgical Care Documentation
Long-term Care Documentation
Home Healthcare Documentation
Hospice Care Documentation
Behavioral Healthcare Documentation
Rehabilitation Services Documentation
Documentation of Services Provided in Correctional Facilities
End-stage Renal Disease Service Documentation
Principles and Practices of Health Record Documentation
Basic Documentation Principles
Clinical Documentation Improvement
Format of the Health Record
Paper-Based Health Records
Source-Oriented Health Records
Problem-Oriented Health Records
Integrated Health Records
Future of Paper-Based Health Records
Electronic Health Records
Definition of the Electronic Health Record
Electronic Health Record Core Capabilities
Transitions in Record Practices
Hybrid
Records
Definition
of Hybrid Record
Documenting Transitions
Examples of Hybrid Systems
Ambulatory Record Systems
Hospital Systems
Personal Health Records
Real-World Case
Summary
References
Additional Resources
Learning Objectives
·
Identify the content of health records in various healthcare
settings
·
Describe the purpose, use, and documentation requirements for
customary reports, observations, orders, notes, authorizations, and consents
included in a health record
·
Explain documentation best practices as applied to the content
of health records in paper-based, hybrid, and electronic environments
·
Summarize the documentation requirements of accreditation
organizations and state and federal government agencies
·
Describe the clinical documentation improvement process
·
Describe the different formats used for health records in
healthcare organizations and the strengths and weaknesses of each
·
Discuss the core capabilities of an electronic health record
·
Identify the advantages of electronic health records over
paper-based and hybrid records
·
Explain the purpose and elements of a personal health record
Key Terms
Accreditation
Accreditation Association for Ambulatory
Health Care (AAAHC)
Accreditation Commission for Health Care (ACHC)
Advance directive
American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF)
American Correctional Association
American Osteopathic Association (AOA)
Anesthesia report
Authorization to disclose information
Autopsy report
Care area assessments (CAAs)
Care plan
Centers for Medicare and Medicaid Services (CMS)
Certification
Commission for the Accreditation of Birth
Centers
Commission on Accreditation of Rehabilitation Facilities (CARF)
Community Health Accreditation Program
Computer-based patient record (CPR)
Conditions for Coverage
Conditions of Participation
Consent to treatment
Consultation report
Deemed status
Discharge summary
DNV (Det Norske Veritas)
Electronic health record (EHR)
Electronic medical record (EMR)
Expressed consent
Hybrid record
Implied consent
Integrated health record
Joint Commission
Licensure
Medical history
Medical staff privileges
Medicare Conditions of Participation or
Conditions for Coverage
Minimum Data Set (MDS) for Long-Term Care
National Commission on Correctional Health Care
National Committee for Quality Assurance
(NCQA)
Operative report
Outcomes and Assessment Information
Set (OASIS)
Palliative care
Pathology report
Patient assessment instrument (PAI)
Patient history questionnaire
Patient Self-Determination Act (PSDA)
Patient’s bill of rights
Personal health record (PHR)
Physical examination report
Physician’s orders
Problem list
Problem-oriented health record
Progress notes
Recovery room report
Resident assessment instrument (RAI)
Source-oriented health record
Subjective, objective, assessment, plan
(SOAP)
Transfer record
Activities
Theory
into Practice
Discuss the case provided in Theory into Practice as an example
of the transition from a paper-based to a computer-based health record. Have
students identify the record components that are found on paper and those that
are introduced electronically. Identify the authors of the sections that are
paper and those that are electronic and the mode of data input (for instance,
data entry or dictation) for each of those formats. Are there any conclusions
that can be drawn?
Guest
Speakers
·
Invite health information management professionals from a
variety of types of healthcare settings to discuss documentation practices and
record formats in their specific setting
·
Invite a health information management professional whose
department has recently undergone an accreditation, certification, or licensure
survey to describe the preparation, process, and findings
·
Invite a health information management professional whose site
is transitioning to an electronic record to speak about the steps, timeline,
and related human and procedural issues
Field
Trip or Site Visit
Students can better envision differences in health record
documentation and health record content between settings if they are exposed to
the setting. Visit any of the settings discussed in the chapter to not only
spend time with the record, but to tour the facility and come to an
understanding of the types of care provided and the healthcare professionals
who contribute to the record.
Lecture
Use the enclosed PowerPoint slides as a lecture guide.
Analysis
Using Web Resources
·
Figure 3.1 in the text lists major accreditation associations
and their website addresses. Have students access the listed association web
sites and prepare reports comparing characteristics.
·
Medicare Conditions of Participation can be found at www.access.gpo.gov/nara/cfr/index.html.
Have students access the Conditions of Participation for two different types of
facilities and compare documentation requirements.
·
The AHIMA Body of Knowledge is also an excellent resource for
numerous articles about documentation practices and policies, the electronic
record, hybrid records, and personal health records.
Class
Discussion
·
Have students review a sample inpatient health record so that
they become familiar with its content. As students review a simplified
inpatient record, have them summarize the chronology of events during the
patient stay. Using the results, discuss how the content and flow of the
analyzed health record fulfills the purposes of the health record established
in chapter 2.
·
Have students review an ambulatory care health record so that
they become familiar with its content. As students review the record, have them
summarize the chronology of events during a series of visits.
·
Have students contrast the inpatient and ambulatory record. What
is similar? What is different? Why do differences exist?
Literature
Review/Additional Readings
AHIMA publishes several texts that provide in-depth descriptions
of health record documentation in focused settings. These books include:
·
Abraham, P. R. 2001. Documentation
and Reimbursement for Home Care and Hospice Programs. Chicago,
IL: AHIMA.
·
AHIMA. 2005. Documentation
and Reimbursement for Behavioral Healthcare Services. Chicago,
IL: AHIMA.
·
Fahrenholz, C. G. 2011. Documentation
for Medical Practices. Chicago, IL: AHIMA.
·
James, E. 2008. Documentation
and Reimbursement for Long-Term Care. Chicago, IL: AHIMA.
·
Odom-Wesley, B., Brown, D., and Meyers, C. L. 2009. Documentation for Medical Records.
Chicago, IL: AHIMA.
Each of the accrediting associations noted in the text publishes
pertinent standards, often with interpretive guidelines. These references must
be purchased directly from the sponsoring group. See also the reference list at
the end of chapter 3 and the AHIMA Body of Knowledge for pertinent practice
briefs and electronic record, hybrid record, and documentation resources.
Project
Instruct students to assemble a crosswalk matrix to analyze the
standards for any of the specialty facilities reviewed in chapter 3. If
standards are available for a number of these healthcare settings (for
instance, standards are available from CARF and Medicare for rehabilitation
settings and from Joint Commission and Medicare for assisted living behavioral
settings), break the students into subgroups to perform analysis, one group per
setting, and have them present their findings to the rest of the class.
Keys
Real-World
Case Discussion Questions
1. Suppose
the electronic record design team decides to tailor computer screen views to
end users’ needs. This would allow end users to view only the minimum necessary
information they need to perform their jobs. What questions should the design
team ask? Where can they find guidance for their screen design project?
The design team should ask questions similar to the following:
·
What information is necessary
in this type of health record?
·
Who are the authors of the
information?
·
What standards pertain to the
information?
·
Who enters the information
and how do they enter it?
·
Who needs this particular
information on a regular basis?
·
Which parts of the record
does each type of health professional refer to most frequently? Why? (The
design team may request that individuals log all contacts.)
·
Which parts of the record
does each type of health professional refer to least frequently? Why?
·
Which parts of the record
does this type of health professional never refer to? Why?
·
Do needs vary by patient, by
diagnosis, and/or by patient age? If so, how do they vary?
·
Do needs vary for medical
patients versus surgical patients? If so, how do they vary?
·
Do needs vary during a
patient’s stay? If so, how do they vary?
Guidance can come from many areas including certification,
licensure, and accreditation standards; medical staff rules and regulations;
books (health information and other textbooks, professional texts); vendors of
pertinent products including the electronic system in use; employees and
consultants with expertise in the area; and colleagues with experience in this
type of project.
2. Suppose
the design team realizes that too much information is overwhelming the end
users. How can the team decide on the appropriate amount of information to
present to the end user? Where can it find guidelines for health information
retention and archiving? How should historical health information be organized,
presented, and retrieved by the end users?
To determine the appropriate amount of information, ask the end
users for their input, monitor and log the use of information and retain the
information that has the most usage, and test a new model and obtain feedback
on it.
Retention and archiving references include state and federal
laws and regulations, facility and health information department policies and
procedures, health information management texts and practice standards, and
vendors with pertinent products.
Questions such as the following will help determine historical
record formats:
·
For what purposes are
historical records accessed?
·
How frequently do requests
for access take place?
·
What information is usually
required and by whom?
·
What equipment, supplies and
personnel are required?
3. Assume
that the design team wants to organize the computer screen view in a format
that is logical, sequential, and intuitive to the end users. How would the team
determine the most appropriate format? Where would team members find guidance
to assist them in screen view design?
Format and design guidance can come from sources such as the end
users themselves, profession specific experts, and screen design software
manuals, as well as sources mentioned in question 1.
Application
Exercises
1. Identify
the acute-care record report where the following information would be found.
1. HEENT:
Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head
trauma. CHEST: Good bilateral chest sounds.
physical examination
1. Microscopic:
Sections are of squamous mucosa with no atypia
pathology report
1. Admit
to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6°PRN
admission order
1. Following
induction of an adequate general anesthesia, and with the patient supine on the
padded table, the left upper extremity was prepped and draped in the standard
fashion.
operation report
1. MD in
in AM. Discharge instructions given to patient and he verbalized understanding.
Discharged to home with family. Gait steady.
nursing discharge note
12. CBC:
WBC 12.0H, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93
laboratory report
1. c/o
slight tingling in fingers, better when arm out of sling, fingers warm, color
pink, wiggles
fingers, will monitor
nursing progress note
1. I
authorize and direct William Smith, MD, my surgeon, and/or associates of his
choice to
perform the following operation upon me.
operative consent
9. 38
weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry, to room with mom
newborn record
1. Vital
signs: Time: 0120 T 36, P 144, R 46
0430 T 37, P 132, R 36
0800 T 37, P 112, R 50
nursing flow record
1. Diagnoses:
chronic atrial fibrillation, congestive heart failure, old myocardial
infarction. She
will be followed by me in the office.
discharge summary
1. Atrial
fibrillation with rapid ventricular response, left axis deviation, left bundle
branch block
ECG report
1. PA
and Lateral Chest: the lungs are clear. The heart and mediastinum are normal in
size and
configuration. There are minor degenerative changes of the lower thoracic
spine.
radiology report
1. I was
asked to evaluate this Level I trauma patient with a open left humeral epicondylar
fracture. Recommendations: Proceed with urgent surgery, for debridement,
irrigation, and
treatment of open fracture.
consultation report
1. Spoke
to the attending re: my assessment. Provided adoption and counseling
information.
Spoke to CPS re: referral.
Case manager to meet with patient and family.
social work note
2. Identify
the specialty facility record where the documentation noted would most
frequently be found.
1. aide
recording of bathing, cooking, and cleaning; nursing and therapy assessments
home healthcare
1. emergency
care given to a patient prior to arrival and pertinent history and physical
findings
and vital signs upon arrival
emergency care
1. care
plan, physical and psychosocial assessments, bereavement documentation
hospice care
1. patient’s
legal status, individualized treatment plan, documentation of seclusion or
restraints, psychologist notes
behavioral healthcare
1. RAI
and care plan, nutritional, services and activities, documentation
long term care
1. functional
and disability diagnoses, evidence of patient, family participation in
decisions, staff
conference, reports
rehabilitative care
1. documentation
of the patient’s nutritional, anemia, vascular access, and transplant status;
dialysis doses
end stage renal disease
1. documentation
of all medications including over the counter drugs provided, dental
examination, medical and psychological evaluations
correctional facility
care
1. patient
acute and chronic problem list, patient history questionnaire, progress notes
ambulatory care
1. preoperative
studies, operative report, anesthesia report, documentation of follow-up phone
calls
ambulatory surgery
3. Identify
the organizations that accredit or certify each of the following types of
facilities following the example provided:
|
Type of Healthcare
Setting |
Accrediting and
Certifying Organizations |
|
Acute care hospitals |
AOA, DNV, Joint Commission,
Medicare |
|
Ambulatory care/physician
office settings |
AAAHC, AOA, Joint
Commission, NCQA (managed care), Medicare (rural clinics) |
|
Ambulatory surgery
facilities |
American Association for
Ambulatory Surgery Facilities, AOA (office-based), Joint Commission
(office-based), Medicare |
|
Long-term care facilities |
CARF (rehab-focused
programs), Joint Commission, Medicare (skilled nursing) |
|
Behavioral healthcare
facilities |
AOA, CARF (rehab-focused
programs), Joint Commission, Medicare (some providers) |
|
Healthcare in correctional
facilities |
American Correctional
Association, National Commission on Correctional Healthcare |
|
End stage renal disease
care settings |
Medicare, see also specific
setting where dialysis care is provided |
|
Home health organizations |
Accreditation Commission
for Healthcare, Community Health Accreditation Program, Joint Commission,
Medicare |
|
Hospice organizations |
Accreditation Commission
for Healthcare, Community Health Accreditation Program, Joint Commission,
Medicare |
|
Obstetric/gynecologic care
settings |
American College of
Obstetricians and Gynecologists, see also ambulatory care |
|
Pediatric care settings |
see ambulatory care |
|
Rehabilitation services
organizations |
AOA, CARF, Joint
Commission, Medicare |
Review
Quiz
Instructions: For each item, complete
the statement correctly or choose the most appropriate
answer.
1. Which
type of standard is required of hospitals by states prior to providing any
healthcare?
2. Accreditation
3. Certification
4. Licensure
5. Medical
staff bylaws
2. Which
of the following clinical data elements is not usually documented in the acute
care health record?
3. Clinical
observations
4. Discharge
information
5. Medical
history
6. Records
of immunizations
3. Which
of the following is not a function of the discharge summary?
4. Providing
information about the patient’s insurance coverage
5. Ensuring
the continuity of future care
6. Providing
information to support the activities of the medical staff review committee
7. Providing
concise information that can be used to answer information requests
4. Results
of a urinalysis and all blood tests performed would be found in what part of a
healthcare record?
5. Autopsy
report
6. Laboratory
findings
7. Pathology
report
8. Surgical
report
5. Which
of the following would not be considered clinical data?
6. Progress
notes
7. Physician
orders
8. Admission
diagnosis
9. Name
of insurance company
6. Which
of the following federal laws resulted in the new privacy regulations for
healthcare organizations?
7. Health
Information Access and Disclosure Act
8. Health
Insurance Portability and Accountability Act
9. Patient
Self-Determination Act
10. Social
Security Act
7. Which
of the following includes names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed?
8. Operative
report
9. Anesthesia
report
10. Pathology
report
11. Laboratory
report
8. Which
of the following materials is not documented in an emergency care record?
9. Patient’s
instructions at discharge
10. Time
and means of the patient’s arrival
11. Patient’s
complete medical history
12. Emergency
care administered before arrival at the facility
9. Which
of the following types of facility is not generally governed by long-term care
documentation standards?
10. Subacute
care facilities
11. Assisted
living facilities
12. Skilled
nursing facilities
13. Nursing
facilities
10. Which
of the following specialized patient assessment tools must be used by
Medicare-certified home care providers?
11. Patient
assessment instrument
12. Minimum
data set for long term care
13. Resident
Assessment Protocol
14. Outcomes
and Assessment Information Set
11. Which
regulations are most commonly applied in end-stage renal disease treatment?
12. Medicare
Conditions for Coverage
13. Commission
on Accreditation of Rehabilitation Facilities
14. Accreditation
Association for Ambulatory Healthcare
15. Joint
Commission
12. Which
of the following statements is not true of the process that should be followed
in making corrections in paper-based health record entries?
13. The
correction should be dated and signed or initialed.
14. The
reason for the change should be noted.
15. The
incorrect information should be obliterated.
16. The
word error should be noted on the entry.
13. Which
of the following types of healthcare facilities may seek accreditation from the
Joint Commission?
14. Acute-care
hospitals
15. Psychiatric
hospitals
16. Home
care providers
17. Ambulatory
care organizations
18. All
of the above
19. The
federal Conditions of Participation apply to which type of healthcare
organization?
20. Organizations
that are accredited
21. Organizations
that treat Medicare or Medicaid patients
22. Organizations
that provide acute care services
23. Organizations
that are subject to the Health Insurance Portability and Accountability Act
15. Which
of the following is not a traditional health record format?
16. Integrated
health record
17. Problem-oriented
health record
18. Source-oriented
health record
19. Process-oriented
health record
16. Which
health record format is most commonly used by healthcare settings as they
transition to electronic records?
17. Integrated
records
18. Problem-oriented
records
19. Hybrid
records
20. Paper
records
17. Which
of the following is an example of administrative information?
18. An
admitting diagnosis
19. Blood
pressure records
20. Medication
records
21. The
patient’s address
18. The
health record contains the statement: The patient will be placed on IV
antibiotics and blood cultures will be taken. This statement is:
19. Subjective
20. Objective
21. Assessment
22. Plan
19. “Acute
allergic reaction” would be documented in which part of a SOAP note?
20. Subjective
21. Objective
22. Assessment
23. Plan
20. What
is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization?
21.
Certification
22.
Licensure
23.
Accreditation
24.
Deemed status
25. Progress
notes of physicians, nurses, therapists and other authorized individuals would
be found together in chronological sequence in a(an) ________ paper record.
26.
Integrated
27.
Source-oriented
28.
Problem-oriented
29.
Hybrid
22. 22.
Which part of a medical history documents the nature and duration of the
symptoms that caused a patient to seek medical attention as stated in that
patient’s own words?
23. Present
illness
24. Social
and personal history
25. Past
medical history
26. Chief
complaint
23. Which
of the following creates a chronological report of the patient’s condition and
response to treatment during a hospital stay?
24. Physical
examination
25. Physician
order
26. Progress
notes
27. Medical
history
24. Which
of the following determines who can receive and transcribe verbal orders?
25.
Accreditation standards
26.
Certification regulations
27.
Medical staff bylaws
28.
Licensure standards
Test
Bank
with
Key
Instructions: For each item, complete
the statement correctly or choose the most appropriate answer.
1. Which
of the following is not usually a component of acute care patient records?
2. Medical
history
3. Nurse
assessment
4. Problem
list
5. Progress
notes
2. The
attending physician is responsible for which of the following types of acute-
care documentation?
3. Consultation
report
4. Discharge
summary
5. Laboratory
report
6. Pathology
report
3. A
nurse is responsible for which of the following types of acute care
documentation?
4. Operative
report
5. Medication
record
6. Radiology
report
7. Therapy
assessment
4. Which
of the following is an example of clinical data?
5. Admitting
diagnosis
6. Date
and time of admission
7. Insurance
information
8. Health
record number
5. The
number of ligatures, sutures, packs, drains, and sponges used and specimens
removed would be found in the:
6. Anesthesia
report
7. Progress
notes
8. Operative
report
9. Recovery
room report
6. Which
type of specialized record includes care provided prior to arrival at a
healthcare setting and times and means of arrival?
7. Ambulatory
care record
8. Emergency
care record
9. Ambulatory
surgery record
10. Pediatric
record
7. Documentation
standards and guidelines are published by a variety of private and public organizations,
including the:
8. Joint
Commission
9. American
Health Information Management Association
10. National
Committee for Quality Assurance
11. All
of the above
8. Which
of the following is true of computer-based records?
9. Is
usually supported by all healthcare providers
10. Can
be accessed by multiple end users simultaneously
11. Uses
clear, consistent content standards
12. Permits
minimal risks to healthcare privacy and security
9. Which
of the following represents documentation of the patient’s current and past
health status?
10. Physical
exam
11. Medical
history
12. Physician
orders
13. Patient
consent
10. Which
of the following contains the physician’s findings based on an examination of
the patient?
11. Physical
exam
12. Discharge
summary
13. Medical
history
14. Patient
instructions
Comments
Post a Comment