Chapter 2 Assignment (1) (1)
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MEDS 1420-91: Health Information Foundations
Name: Alece Collins
Chapter 2: Healthcare Delivery Systems (25 points)
Associate Degree Competency:
I.1 Describe health care organizations from the perspective of key stakeholders
Instructions
: Watch the HIM Department Virtual Tour, document/type your answers, save, and upload to the corresponding D2L Dropbox by the date/time indicated on your syllabus. Assignment
:
1.
Define ambulatory visits: When a patient comes to the hospital and has a outpatient surgical procedure and goes home after a short recovery period.
2.
Describe outpatient diagnostic encounters: When a patient comes to the hospital and has testing done such as blood test or x-ray.
3.
Identify the difference between a medical record number and an account number:
Medical record number is forever assigned to the patient any and every time they receive care. An account number is different every time you have an encounter at the hospital and receive care you get a different account number.
4.
List at least two types of documents that might require scanning: Consent forms and Telemetry strips
5.
Describe the 3 steps required to scan a document into the EHR:
prepping - not torn, no staples, etc make sure there are atl east two patient identifiers (name, DOB, MRN, account number, etc)
Start scanning documents
indexing and quality assurance the documents that you have scanned
6.
Identify the two acceptable ways of paper record destruction discussed in the video: Using a vendor that specializes in processing giant shredders or disintegrating documents
7.
Describe the three mandatory Conditions of Participation components for physician order completion. (HIM analysis technicians must ensure these three components are present on every physician order).
Having all documents dated, timed and signed
8.
During record analysis, an HIM professional must check for these three common (generally physician-created) medical record reports. Name these three common reports.
History and physical Discharge summary
Operative report
9.
Describe what an electronic flag used for during medical record analysis: Flag encounter
Enter deficiency code in EHR
Electronically attach deficiency code to the appropriate physician to for them to complete 10.
Identify why most new coders start their coding career coding outpatient records and then move to ambulatory or inpatient records: A lot easier to work with and less complex than accounts like inpatient accounts
11.
Describe how electronic charts are routed to a coder: Through a work que on a work computer
12.
List the types of credentials required of coders in this facility: RHIT, CCS, and RHIA
13.
The Joint Commission standard requires that charts are completed within ____ days after discharge.
30 days after treatment
14.
Identify the difference between a deficient record and a delinquent record: Deficient records are still needing completion but are still within that 30 day threshold after discharge.
Delinquent records are records needing completion but have met that 30 day threshold since discharge
15.
What are the consequences imposed on providers (typically physicians) who do not complete their record delinquencies? Providers will get a message stating they will have their admitting and surgery privileges suspended
16.
HIPAA mandates require that medical records must be maintained for how long: Minimum of 6 years
17.
Describe the HIPAA mandates for record retention for a minor child’s health record. When the patient turns 21 years old plus 6 years
18.
List four of the common requestors of medical records: Patients
Health care providers
Attorneys
Insurance companies
19.
Define data breach: Release of unauthorized PHI
20.
What does the acronym RAC stand for? Recovery Audit Contractor
21.
Define transcription: Where the spoken work is translated either by voice recognition or word processed into the written word correctly into the patient’s EHR.
22.
What credential is needed for an HIM professional to work in a cancer registry: CTR ( Certified Tumor Registrar) which requires additional education on top of your 2 year degree plus passing a national exam.
23.
What does the acronym MPI stand for?
Master Patient Index
24.
The Data Quality Manager is responsible for: Double checking documentation in the health record is correct and coding meets compliance standards
25.
Describe data visualization (AKA) Visualized data designs:
Graphics that break down large amounts of complex data into clear digestible chunks for the
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