1. Chapter 7 Data Access and Retention

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

3. Specific uses: Patient care Clinical coding Billing Statistical analysis Other operational processes

4. 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

5. Filing Equipment and Space Management Open shelf Motorized units Compressed units Space Retrieval issues Centralized vs. decentralized filing system

6. 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

7. Master Patient Index (MPI) Permanent database including every patient ever admitted to or treated by the facility Kept permanently

8. 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

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

10. Chapter 14 Data Analysis & Use

11. Data Sets Defined by the government Required to be collected Used to provide comparative data across the country, state, healthcare community, etc

12. 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

13. 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

14. 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

15. 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