HealthInformation Management Assignment 3
What are the three formats commonly used for a paper-based health record?
Theformats used in a paper-based health record are Unstructured or lessstructured free text and the standardized format which mainlyinvolves coding.
How can the data in a health record assist the media?
Datain a health record can be used in cases where diagnoses for patientsare needed for decision making, record keeping and in aidingtreatment.
What are the features typically found in a personal health record?
Apersonal health record has to include details of the visits to thehealth facility, the family history, information about any conditionsof the patient, drug taken and information of any other diseases orany procedures administered to the patient.
What forms design issues exist with regard to the electronic health record context?
Usability,safety, quality, and efficiency
What is an incident report? Is it filed with the health record? Why or why not?
Anincident report is a form usually filled to record any occurrenceswhether illness, accidents or any damages of an individual. Yes, itis filed in a health record for decision-making purposes.
Name some examples of a numeric record identification system.
Theyinclude serial numbering and unit numbering.
What advantages are offered by a digital imaging system?
Fasterscanning, better image qualities, more storage options, Images storedcan easily be transferred hence portable.
What is a certificate of destruction and why is it important?
Acertificate of destruction shows records of the items destroyed, thenumber of documents destroyed, the method of destruction employed,and the date which they were destroyed. It is provided by thedestruction or record storage company mandated to destroy thoseitems. It serves to show the listed items were destroyed and it isimportant in cases of an audit.
What are the similarities and differences between a master patient index and a number index?
Bothhold relevant information about the patients and the staff. A masterpatient record does not provide a clear flow of information exchangehence can lead to the disruption of information.
How does a cancer registry differ from other registries?
Itdiffers with other registries in that the cancer registry works bygathering information about the patient. This information includesthe name of the patient, address, age, race, ethnicity the insurancepolicy and any other information. It sends it to the central cancerregistry the state keeps checking the information to ensure it iscorrect and none is missing, and then it sends to the Nationalprogram of Cancer Registries.
Why did SNOP fall out of favor with the health care field?
SNOPentails the systematic nomenclature in pathology. Brought up by theAmerican College of Pathologists, this system has been vital in theclassification of pathological specimens. Although preferred by manypathology departments, it lost favor gradually because it was focusedon systematized nomenclatures by accrediting agencies.
Explain the role of the Metathesaurus in the Unified Medical Language System.
Metathesaurusgives an integrated and uniform distribution format for over onehundred biomedical classifications and vocabularies and also linksdifferent names for the same concept. It is, therefore, importantsince UMLS serves to enable computer systems to understand variousmedical meanings and in the process allow medical professionals toretrieve information from different electronic databases.
How do vocabularies and nomenclatures differ from classification systems?
Avocabulary consists of many phrases or words and their respectivemeanings that have been accepted by certain groups, discipline, ororganizations to organize, express and index concepts (Peden, 2013).A classification system acts to relate same terms to each other. Anomenclature can only include terms deemed to be proper in thenomenclature whereas a classification system accommodates all termsthat can fall within a classification system.
What is meant by saying that DRGs are both statistically consistent and medically meaningful?
DRGsare statistically consistent since patients are grouped in a distinctDRG consume the same amount of resources which can, in turn, bequantified by use of the financial cost and the length of stay. DRGsare very useful in the medical field since patients suffering fromthe same conditions can be grouped into a distinct DRG.
What are the three purposes served by DRGs?
Thepurposes of the DRGs include evaluating the quality care offered,calculating reimbursement, and assessing the utilization of theservices provided.
Name four approaches taken by health information management professionals to address the complexities brought on by the introduction of PPS and DRGs.
Thefour approaches employed by the HIM professionals to address thesecomplexities include the use of new resources according to codingguidelines, using encoders, developing a compliance program, andfocusing on the ethical issues regarding coding.
Peden,A. H. (2013). Comparativehealth information management.Australia: Delmar Learning.