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Assignment 1

AHIMA traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to elevate standards of clinical records. The organization has had three name changes since then to reflect contemporary medical record use and practices: in 1938 it became the American Association of Medical Record Librarians, in 1970 the American Medical Record Association, and in 1991 the American Health Information Management Association. Its current name captures the expanded scope of clinical data beyond the single hospital medical record to health information comprising the entire continuum of care.

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340 views

Assignment 1

AHIMA traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to elevate standards of clinical records. The organization has had three name changes since then to reflect contemporary medical record use and practices: in 1938 it became the American Association of Medical Record Librarians, in 1970 the American Medical Record Association, and in 1991 the American Health Information Management Association. Its current name captures the expanded scope of clinical data beyond the single hospital medical record to health information comprising the entire continuum of care.

Uploaded by

Tommie
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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1) What are the name changes and the year of the change for our professional

association? (AHIMA)

- The organization traces its history back to 1928 when the American College of
Surgeons established the Association of Record Librarians of North America (ARLNA)
to "elevate the standards of clinical records in hospitals and other medical institutions."
The organization has had three name changes in its history, all were justified with an
explanation that reflected the progression of contemporary medical record use, practices
and perceptions. In 1938 the association became the American Association of Medical
Record Librarians (AAMRL). In 1970, the association became the American Medical
Record Association (AMRA) and in 1991, the title American Health Information
Management Association (AHIMA) was adopted. Incorporation occurred in 1943 and
became effective the next year. Its current name captures the expanded scope of clinical
data beyond the single hospital medical record to health information comprising the
entire continuum of care.

2) Give a brief history of AHIMA

- AHIMA traces its history back to 1928 when the American College of Surgeons
established the Association of Record Librarians of North America (ARLNA) to "elevate
the standards of clinical records in hospitals and other medical institutions

3) Health data set for home health

- include a vast amount of medical data, various measurements, financial data, statistical
data, demographics of specific populations, and insurance data, to name just a few,
gathered from various healthcare data sources

4) Ambulatory health data set

- regulates the area of ambulatory care. The set includes reasons for the encounter, living
arrangements, and marital status. The UACDS is a recommended set, not a mandatory
one.

5) Acute care health data set

-  is a branch of secondary health care where a patient receives active but short-term


treatment for a severe injury or episode of illness, an urgent medical condition, or during
recovery from surgery. In medical terms, care for acute health conditions is the opposite
from chronic care, or longer term care

6) Emergency department health data set

- These data are collected for billing and other administrative purposes, rather than for
asthma surveillance. Some cities and counties have begun to pool ED data for the
purpose of syndromic surveillance unrelated to asthma, yet these data also could serve as
another source of information about ED asthma visits. For all of these ED databases, the
data variables and the number of years that data are available vary by location

7) Long term care health data set

- It is a standardized, primary screening and assessment tool of health status that forms
the foundation of the comprehensive assessment for all residents in a Medicare and or
Medicaid-certified, long-term care facility. The set is used to collect demographic and
clinical data on nursing home residents that must be completed for every resident at the
time of admission and during reassessment periods. It is used to develop care plans and
document placement at the appropriate care level.

8) Briefly describe the credentialing process including Medical Staff Bylaws and the
National Practitioner Databank

- the process of obtaining, verifying, and assessing the qualifications of a practitioner to


provide care or services in or for a health care organization. Credentials are documented
evidence of licensure, education training experience, or other qualifications. Examples of
credentials are: a certificate, letter, or experience that qualifies somebody to do
something. They can be a letter, badge, or other official identification that confirms
somebody's position or status.

9) What is chart pick-up and reconciliation of the paper record?

- These personnel would work a shift at the hospital which began at 5 or 5:30 in the
morning. They would take little shopping carts and go up to the patient units and pick up
the charts of the patients which were discharged the previous day. Then they would check
them off against a list of discharges. If any charts were missing, they would track them
down. Then the chart preppers would take over. (At some hospitals, those that did chart
pick-up and reconciliation would also prep charts.)

10) What is chart prepping of the paper record?

- s the process of disassembling the physical chart, removing paper from prongs, placing


paper in the correct sequence, organizing into categories, and removing staples and other
clips. If a determination was made to eliminate parts of the chart that are not medically or
legally required, they will be removed during chart prep.

11) What is scanning of the paper record into the hybrid record including barcoide
triggers?

- Scanning is a relatively simple method for capturing electronic images of paper


documents and storing them for reference via on-line screens. While scanning supports
the efficient capture of paper chart information for viewing within the new EHR system,
scanning stores the data as images rather than discrete data elements, which limits its use
to the clinicians. The hybrid system is used in order to better track record of the patients.

12) Why is the processing of the paper record considered a longitudinal process as
opposed to multiple user access?

- recordkeeping is an essential component for a variety of purposes, such as audits, legal


issues and for preservation purposes also. But maintaining the huge number of records
within a medical institution, in a proper manner is a fairly challenging exercise where
human lives are involved.

13) What does "cold fed"  mean in terms of radiology and lab reports?

- Cold Feeding is scanning documents created on paper and making their images
available for viewing on a computer monitor (computer output to laser disk). Point of
Care (POC) data entry however, because of the urgency of the occupation, physicians
must make critical decisions on the fly at the point-of-care (POC), meaning data entry
during the patient encounter.

14) What is the role of the Health Data Analyst/quantitative analysis?

- sometimes called healthcare business analysts or health information management (HIM)


analysts—gather and interpret data from a variety of sources (e.g., the electronic health
record, billing claims, cost reports, and patient satisfaction surveys) to help organizations
improve the quality of care, lower the cost of care, and enhance the patient experience. 

15) What is the difference between a deficiency and a delinquency?

- A "deficiency" is the difference between the amount owed on a loan and the total


amount received/collected at the closing of a loan. Delinquencies occur when a borrower
fails to make the required loan payments on time.

16) How are the delinquencies addressed by the compliance officer?

- When a taxpayer does not pay his or her tax liability after receiving a stream of
delinquency notices, the IRS may assign the collection case to a revenue officer (RO) in
the Collection Field function.

17) What are DRG's and how are they driven by the principal diagnosis?

- The relative weight determines the reimbursement associated with that DRG and
reflects the patient's severity of illness and cost of care during hospitalization. A higher
relative weight is associated with longer length of stay, greater severity of illness, and
higher reimbursement. For the principal diagnosis with a not-so-major comorbid
condition. This is known as a DRG with a CC or a comorbid condition. A higher-paying
DRG for the principal diagnosis with a major comorbid condition, known as a DRG with
an MCC or major comorbid condition.

18) What is the relative weight and how is it driven by the secondary diagnoses?

- relative weights are estimates of the relative resource intensity of each DRG.


These weights are computed by estimating the average resource intensity per case for
each DRG, measured in dollars, and dividing each of those values by the average
resource intensity per case for all DRG's, also measured in dollars.

19) What is the difference between complications and comorbidities?

- A complication is a medical condition that may be difficult. A comorbidity is presences


of more than one medical complication.

20) what is the process for correcting paper records? hybrid records? electronic health
records?

- This process for making this type of correction can be as simple as just letting your
doctor know that something was recorded incorrectly so your doctor can change it. But
sometimes corrections aren't so simple, and you need to familiarize yourself with the
rules for amendment of protected health information so that you can get the corrections
taken care of. There are two ways to make correcting entries: reverse the incorrect
entry and then use a second journal entry to record the transaction correctly, or make a
single journal entry that, when combined with the original but incorrect entry, fixes
the error.
-

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