Alliyah Evangelista-
What are some of the legal regulatory frameworks that exist in Canada and what do they do?
PIPEDA (Personal Information Protection and Electronic Documents Act): defines how gov. or orgs. may collect, use and disclose personal information.
PHIA (Personal Health Information Act): protects the rights of citizens and how they're information will be shared.
-
What are some things that HIM directors and managers are responsible for?
- ensures the accuracy, completeness and consistency of the info
- guarantees that their practices for collection, storage, access and disposal are in place and are met
- provides appropriate training and tools for their employees
-
The stage for capture and collection is to collect or receive health information. What sort of information might they collect and why?
Clinical and administrative data; for research, education and risk management.
-
List some data types and formats.
- discrete, structured (e-charting of labs and medication orders)
- unstructured data (free text)
- graphic (ECG or fetal monitor strips)
- real audio (digital heart sounds)
- streaming video (streams of surgeries being performed)
-
An organization decides how information is collected and constructed. True or false?
True
-
When collecting data, why must we limit the use of symbols, acronyms and abbreviations?
To prevent misinterpretation in the data.
-
What measures can be taken to protect authorship and integrity of the document as a legal record?
Introducing policies that would limit cut, copy and paste functionalities.
-
What is a data dictionary?
A dictionary that outlines definition, formats and acceptable values for each data element (what should be put in this area).
-
It is acceptable to erase or delete data in a health record. True or false?
False; no deletions should be made.
-
How should you mark a blank space?
They should be crossed out to prevent unneeded information to be added.
-
Should all blanks on forms be completed?
Yes, especially on consent forms.
-
What is SOAP?
It is a guideline for providers on what to document a patient's condition.
-
Define the acronyms of SOAP?
S - subjective: chief complaint, history, symptoms (not observed by the physician)
O - objective: vitals, measurements
A - assessment: diagnosis
P -plan: treatment plan, and additional tests
-
What is included in a Master Patient Index (MPI)?
- demographics
- visit dates
- specific identifiers for patients (PHIN, address)
-
What is the difference between serial numbering and serial unit numbering?
Serial numbering: patient receives a new medical record # each time they visit but each record is placed in different areas. However, with serial unit numbering, it moves to a different spot along with each of its previous records each time the patient is assigned a new number.
-
What is the difference between a qualitative analysis and a quantitative analysis?
Qualitative: if all the information included is accurate; consistency, mistakes (checks for the quality).
Quantitative: checks if all the documents are complete and present; consents are signed and present, reports all signed, etc.
-
What is a retrospective view?
Process during quality and quantity audits.
-
Who is primarily responsible for documenting information in the patient record?
Doctors, physicians
-
Why is it important to ensure that data collection and analysis about
patient medical information complete and accurate?
For overall patient care (primary) and for secondary purposes.
-
Name 2 advantages of terminal digit filing over straight numerical filing.
- easy to locate
- latest charts are going to be in one shelf
-
What are the 3 primary steps in a record retention program?
- length of maintenance
- whether its centralized or decentralized storage
- paper or electronic
-
Explain the difference between a centralized and decentralized storage.
Centralized: in the facility
Decentralized: outside the facility
-
What do check for in the stage of preservation?
- data integrity
- data quality
- data quality audits
-
What does disposition refer to?
The destruction of the data and record.
