Primary Data Source - Patient specific/identifiable data
Related to a specific individual
ex. The Health Record
Secondary Data Source - Information on groups of people or patients without identifying any particular
patient individually.
Also called "Aggregate Data"
Compiled from multiple health records
Ex. Data taken from the health record and entered into registries and databases are considered
secondary data.
Confidentiality - ...
Security - ...
Privacy - ...
Quantitative Analysis - Checking for the presence or absence of necessary reports or signatures. Ex.
progress notes, orders
Completeness and Accuracy
Making sure a document is there and authenticated
Focuses on physician documentation
Qualitative Analysis - Ex. Checking documentation consistency, such as contraindications in
entries,progress note dated prior to admission etc
Quality of records
Does documentation reflect the quality of patient care provided
, Incident Report - Written accounts of unusual events that have an adverse effect on a patient,
employee, or facility visitor.
Never filed in patient health record.
Used by risk management and or attorney to investigate incidents that have the potential to become
claims against the organization or individual provider.
Incident - An event considered to be inconsistent with accepted standards of care.
Ex.
res ipsa loquitor - "the thing speaks for itself"
The injury would not ordinarily occur without someones negligence Ex. Surgical instrument left in
patient after surgery
Currency - ...
Data Accessibility - data is available to those authorized to use it
Relevancy - ...
Consistency - ...
Benchmarking - Process of comparing an organization to a standard, a peer group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS for all hospitals
nationwide.
Continuum Of Care - Various types of healthcare services provided in diverse settings from basic primary
care to complex tertiary settings.
Primary Care - Services provided by physicians working in private offices, group practices, private clinics
or community based clinics.
Ex Family practice, pediatrics