VERIFIED GRADED A+
◍ Secondary Data Source. Answer: 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. Answer: ...
◍ Security. Answer: ...
◍ Privacy. Answer: ...
◍ Quantitative Analysis. Answer: 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. Answer: 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. Answer: 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. Answer: An event considered to be inconsistent with
accepted standards of care.
Ex.
◍ res ipsa loquitor. Answer: "the thing speaks for itself"
The injury would not ordinarily occur without someones negligence
Ex. Surgical instrument left in patient after surgery
◍ Currency. Answer: ...
◍ Data Accessibility. Answer: data is available to those authorized to
use it
◍ Relevancy. Answer: ...
, ◍ Consistency. Answer: ...
◍ Benchmarking. Answer: 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. Answer: Various types of healthcare services
provided in diverse settings from basic primary care to complex
tertiary settings.
◍ Primary Care. Answer: Services provided by physicians working in
private offices, group practices, private clinics or community based
clinics.
Ex Family practice, pediatrics
Ex of primary care services: preventative,routine screening,physical
exams
◍ Secondary Care. Answer: Diagnostic and theraputic services
provided by medical specialists.
◍ Tertiary Care. Answer: The provision of highly specialized and
advanced diagnostic and therapeutic services in inpatient hospital
settings.
◍ The medical record is the property of the ......... Answer:
facility/institution