CHAPTER 7Data Access and Retention

The main purpose of the health record is to provide communication between health care providers!

SPECIFIC USES:

Patient care Clinical coding Billing Statistical analysis Other operational processes

TYPES OF RECORD IDENTIFICATION SYSTEMS

Alphabetic Patient Identifiers Small facilities Alpha order by last

name Not a good security

measure

Numeric Patient Identifiers Serial Numbering

Different but unique number for every admission

Unit Numbering Unique number used

for all encounters Serial-Unit Numbering

Numbers assigned serially but records brought forward and filed under the last number assigned

FILING EQUIPMENT AND SPACE MANAGEMENT

Open shelf Motorized units Compressed units

Space Retrieval issues Centralized vs.

decentralized filing system

HEALTH RECORD FILING SYSTEMS

Most familiar Work well for small

spaces

Number broken down into two digit pairs

Read right to left Example: 670187

would be written 67-01-87

87 is the primary number 01 is the secondary 67 is final File first in location 87,

then on shelf 01, and then on the 67th place on the shelf

Alphabetic and Straight Numeric

Terminal Digit

MASTER PATIENT INDEX (MPI)

Permanent database including every patient ever admitted to or treated by the facility

Kept permanently

RECORD TRACKING

Signing out or checking out records

Tracking those not returned

Strict policies and procedures

Should be able to locate a chart in 15 minutes

RECORD RETENTION

Policies and procedures depends upon: State laws Medicare regulations Other federal regulations Accreditation standards Facility policies

CHAPTER 14Data Analysis & Use

DATA SETS

Defined by the government

Required to be collected

Used to provide comparative data across the country, state, healthcare community, etc

SECONDARY DATA SOURCES

Facility-specific indexes

Registries (either facility or population based)

Other healthcare databases

They provide information that is not easily available by looking at individual health records

FACILITY-SPECIFIC INDEXES

Master Patient Index (MPI) Chapter 7

Disease Index Sequenced according to ICD-9-CM code numbers

Operation Index Numerical order by the patient’s procedure

codes using ICD-9-CM or CPT codes Physician Index

Arranged according to physician code number assigned by healthcare facility

REGISTER VS. INDEX

Focuses on a specific group of people and collects information on just that group i.e. Cancer Registry,

Trauma Registry, Implant Registry, etc

Looks at entire patient population and then groups them into specific categories

Register Index

INFORMATION COLLECTED IN A REGISTER

General identifying information Whatever specific information

Example: ER Room Register Name, address, zip code, nature of the injury/illness,

time person enters ER, time patient received triage, time the patient was seen by a physician, disposition of the patient, time of discharge, mode of transportation, support person with patient