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					Health Care Delivery Systems

Feipei Lai
National Taiwan University


                               1
Health Care Delivery Systems
   History of Medicine and Health care
    Delivery
   Continuum of Care
   Health Care Facility Ownership
   Health Care Facility Organizational
    Structure
   Licensure, Regulation, and Accreditation

                                           2
Introduction
   Health care delivery has been greatly
    impacted by escalating costs, resulting
    in medical necessity requirements,
    review of appropriateness of admissions,
    and requirement for administration of
    quality and effective treatments.



                                          3
History of Medicine & Health
Care Delivery
   History of medicine
   Evolution of health care delivery in the
    United States




                                               4
History of medicine
   In 1994, scientists discovered the genes
    responsible for many cases of
    hereditary colon cancer, inherited
    breast cancer, and the most common
    type of kidney cancer.




                                           5
Evolution of health care
delivery in the United States
   1991 The Workgroup on Electronic Data
    Interchange (WEDI) was created to
    reduce health care administrative costs
    through implementation of the
    electronic data interchange (EDI),
    which uses national standards to
    transmit data for reimbursement
    purposes.
                                          6
Evolution of health care
delivery in the United States
   1996 The Health Insurance Portability
    and Accountability Act (HIPAA) was
    passed.
   It mandates administrative
    simplification regulations that govern
    privacy, security, and electronic
    transaction standards for health care
    information.
                                             7
Evolution of health care
delivery in the United States
   1996 The Healthcare Integrity and
    Protection Data Bank (HIPDB) was
    created which combats fraud and abuse
    in health insurance and health care
    delivery by alerting users to conduct a
    comprehensive review of a
    practitioner’s, provider’s, or supplier’s
    past actions.
                                            8
Healthcare Integrity and
Protection Data Bank
   Access to information in the HIPDB is
    available to entities that meet the eligibility
    requirements defined in Section 1128E of the
    Social Security Act and the HIPDB regulations.
    In order to access information, eligible
    entities must first register with the Data Bank.
   HIPDB information is not available to the
    general public. However, information in a
    form that does not identify any particular
    entity or practitioner is available.
                                                   9
Healthcare Integrity and
Protection Data Bank
   http://www.npdb-hipdb.hrsa.gov/
   Estimates of annual losses due to health
    care fraud range from 3 to 10 percent
    of all health care expenditures--
    between $30 billion and $100 billion
    based on estimated 1997 expenditures
    of over $1 trillion and 2.5 trillion for
    2009.
                                          10
Continuum of Care
   A complete range of programs and
    services is called a continuum of care,
    with the type of health care indicating
    the health care services provided.
   Primary care
   Secondary care
   Tertiary care

                                              11
Primary care services
   Include preventive and acute care, are
    referred to as the point of first care,
    and are provided by a general
    practitioner or other health professional
    who has the first contact with a patient
    seeking medical treatment, including
    general dental, ophthalmic 眼科的, and
    pharmaceutical services.
                                            12
Primary care services
   Annual physical examinations
   Early detection of disease
   Family planning
   Health education
   Immunizations
   Treatment of minor illnesses and injuries
   Vision and hearing screening


                                                13
Secondary care services
   Provided by medical specialists or
    hospital staff members to a patient
    whose primary care was provided by a
    general practitioner who first diagnosed
    or treated the patient.




                                           14
Tertiary care services
   Provided by specialized hospitals
    equipped with diagnostic and treatment
    facilities not generally available at
    hospitals other than primary teaching
    hospital or Level I, II, III or IV trauma
    centers.



                                            15
Trauma centers
   Level I: provides the highest level of
    comprehensive care for severely injured
    adult and pediatric patients with
    complex, multi-system trauma.
   Level II: broad range of sub-specialists
    are on-call and promptly available to
    provide consultation or care.

                                           16
Trauma centers
   Level III: physicians are advanced
    trauma life support (ATLS) trained and
    experienced in caring for traumatically
    injured patients; nurses and ancillary
    staff are in-house and immediately
    available to initiate resuscitative
    measures.


                                              17
Trauma centers
   Level IV: critically injured patients who
    require specialty care are transferred to
    a higher level trauma system hospital in
    accordance with pre-established criteria.




                                           18
Tertiary care
   Burn center treatment
   Cardiothoracic and vascular surgery
   Inpatient care for AIDS patients
   Magnetic resonance imaging (MRI)
   Neonatology level III unit services
   Neurosurgery
   Organ transplant
                                          19
Tertiary care
   Pediatric surgery
   Positron emissions tomography (PET)
   Radiation oncology
   Services provided to a person with a high-risk
    pregnancy
   Services provided to a person with cancer
   State-designated trauma centers
   Trauma surgery
                                                 20
Positron emissions
tomography (PET)
   builds images by detecting energy given off
    by decaying radioactive isotopes.
   Isotopes are atoms of an element with the
    same number of protons (positively charged
    particles) in the nucleus, but a different
    number of neutrons (neutral particles).
   Because radioactive isotopes are unstable, as
    they decay, they throw off positrons that
    collide with electrons and produce gamma
    rays that shoot off in nearly opposite
    directions.
                                                21
isotope

    3H    => 3He2 + 0e-1
      1




                           22
PET
   PET systems use the paths of the two
    detected gamma rays to determine the
    originating collision point, a process called
    electronic collimation (瞄準).
   The scanners use a circular series of gamma
    ray-detectors to envelope the patient so both
    gammas can be detected so the instrument
    can use electronic collimation to predict
    where the energy signal originated.
   This signal is then converted into a three-
    dimensional image slice.
                                                23
台灣醫院分類
   台灣醫療院所經由財團法人醫院評鑑暨醫療品質策進
    會分類為「一般醫院」及「精神科醫院」兩大類。
   各有兩項評鑑依據,分別為「醫院評鑑」及「教學醫
    院評鑑」兩項。
   其中醫院評鑑項目,在一般醫院有「特優」、「優等
    」、「合格」三個等級,而精神科醫院則有「優等」
    、「合格」二個等級。
   教學醫院評鑑等級無論一般醫院及精神科醫院,其等
    級皆有「優等」、「合格」、「非教學醫院」三個等
    級。

                              24
台灣醫院分類(舊制)
   診所
   地區醫院 (497/2005)
   區域醫院 (80/2005, 65/2006, 64/2007)
   醫學中心 (23/2005, 18/2006, 19/2007,
    14/2009)



                                       25
醫學中心
   在衛生局登記開放的急性一般病床與急
    性精神病床合計須達五百床以上
   至少應能提供 家庭醫學、內、外、婦產、
    兒、骨、神經外、泌尿、耳鼻喉、眼、
    皮膚、神經、精神、復健、麻醉、放射
    線、病理、核醫、牙 等十九科之診療服
    務。

                     26
醫學中心
   專任主治醫師人數 (包括主任在內) 每八床應有一名。

   專任護理人員每2床至少1名。
   加護病房:每床2.5名。
   手術室:每班每台2.5名。
   手術恢復室:每班每床0.5名。
   產房及待產室:每床2名。
   嬰兒室:每床0.4名。
   急診室:觀察室每床0.5名;
   診療室每12人次1名。
   門診:每班每診療室0.5名。
   血液透析室:每4人次1名。
   行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供應中心等
    護理人員) 另計,應佔總人數百分之六。
   應有受過感染控制訓練之專任護理人員,每300床應設1名。

                                    27
醫學中心
   藥事人員每40床至少1名。
   每60張門診處方至少1名。
   特殊藥品處方每15張至少1名。
   藥事人員總數至少四分之三為藥師。
   藥事人員至少有4名負責藥品管理諮詢及
    臨床等工作。


                     28
區域醫院
   應設置 250 床位以上急性病病床數
   每床所擁有的樓地板面積應在 50 平方公尺以
    上
   每 9 床至少應擁有一名主治醫師
   每 2.5 床至少應擁有一名護理人員等。
   至少應能提供 家庭醫學、內、外、婦產、兒、
    骨、耳鼻喉、眼、精神、復健、麻醉、放射線、
    病理、牙 等十四科之診療服務。

                        29
區域醫院 Nurse
   加護病房:每床 2名。
   手術室:每班每台 2名。
   手術恢復室:每班每床 0.5名。
   產房及待產室:每床 1.2名。
   嬰兒室:每床 0.4名。
   急診室:觀察室每床 0.5名;
   診療室每 12人次 1名。
   門診:每班每診療室 0.5名。
   血液透析室:每 4人次 1名。
   行政、教學、研究及其他護理人員 (如院內感染控制、公衛、供
    應中心等護理人員) 另計,應佔總人數百分之四。
   應有受過感染控制訓練之專任護理人員,每 300床應設 1名。



                                     30
區域醫院
   藥事人員每 50床至少 1名。
   每 70張門診處方至少 1名。
   特殊藥品處方每 15張至少 1名。
   藥事人員總數至少四分之三為藥師。
   藥事人員中,至少有 2名負責藥品管理
    諮詢及臨床等工作。


                         31
地區醫院
   在衛生局登記開放的急性一般病床需 20
    床以上,
   急性一般病床及急性精神病床合計 249
    床(含)以下。




                      32
地區醫院
   專任員工總人數每床應有 1名。
   專任主治醫師人數以及專任護理人員應
    符合醫療機構設置標準。
   藥事人員每 50床至少 1名。
   每 80張門診處方至少 1名。
   每增加 100張處方應增加 1名。
   應有藥師 1人以上。
                        33
評鑑分級
   設施
       總樓地板面積
       病房設施
       安全設備及一般設備
       保險病床比率




                    34
評鑑分級
   人員
       員工總人數   醫師總數
       麻醉科醫師   放射線科醫師
       核醫科醫師   病理科醫師
       復健科醫師   精神科醫師
       護理      藥事
       醫事檢驗    醫用放射線技術
       復健技術    精神科
       社會工作    營養師
       病歷管理

                          35
評鑑分級
   醫療業務及設備
       醫療業務       急性病床數
       診療科別       急診業務
       手術及麻醉作業    產房
       嬰兒室        加護病房
       藥事作業       檢驗作業
       輸血作業       放射線診療作業
       病理作業       復健醫療作業
       精神科         核子醫學
       牙科         特殊醫療服務
       醫務社會服務工作    營養部門
       病歷部門        社區衛生服務
       員工健康檢查

                             36
評鑑分級
   品質保證
       醫療品質審查
       感染控制
       人體試驗
       藥事作業品質
       護理服務品質
       檢驗作業品質管制
       輸血作業品質管制
       病理作業品質管制
       放射線診療品質管制
       核子醫學品質管制
       病歷管理
       醫院管理業務
       醫病關係之促進


                    37
評鑑分級
   指定項目評估
       住院
       診斷
       處置
       用藥
       手術
       病歷寫作


               38
評鑑分級
   教學訓練
       教學師資
       教學訓練與研究設備
       教學訓練活動
       與其他醫院(醫學院)交流合作情形
       研究情形及論文發表
       教學進修研究經費


                           39
新制教學醫院評鑑基準
   教學資源
   教學訓練計畫與成果
   研究執行與成果
   臨床師資培育及繼續教育
   學術交流與社區功能及角色
   管理行政


                   40
Health Care Facility Ownership
   Government (not-for-profit) 25%
   Proprietary (for-profit) 15%
   Voluntary (not-for-profit) 60%




                                      41
Medical Staff
   Intern: a physician in the first year of
    graduate medical education, which ordinarily
    immediately follows completion of the four-
    year medical curriculum.
   Resident: a physician who has completed an
    internship and is engaged in a program of
    training designed to increase his or her
    knowledge of the clinical disciplines of
    medicine, surgery, or any of the other special
    fields that provide advanced training in
    preparation for the practice of a specialty.

                                                 42
Medical Staff
   Chief resident: a physician who is in his
    final year of residency or in the year
    after the residency has been completed.
   Visiting Staff (VS): 主治醫師




                                           43
Health Care Facility
Organizational Structure
   Governing board
   Administration
   Medical staff
   Departments, services, and committees
   Contracted services



                                        44
Governing board
   The governing board (board of trustees,
    board of governors, board of directors)
    serves without pay, and its membership
    is represented by professionals from the
    business community.




                                           45
Administration
   Serves as liaison between the medical staff
    and governing board and is responsible for
    developing a strategic plan for supporting the
    mission and goals of the organization.
   CEO: chief executive office
   CFO: chief financial officer
   CIO: chief information officer
   COO: chief operating officer

                                                 46
Medical staff
   Consists of licensed physicians and
    other licensed providers as permitted by
    law (e.g., nurse practitioners and
    physician assistants) who are granted
    clinical privileges.




                                          47
physician assistants
   Examine, diagnose, and treat patients
    under the direct supervision of a
    physician.




                                            48
Medical staff membership
categories
   Active: delivers most hospital medical services,
    performs significant organizational and
    administrative medical staff duties
   Associate: advancement to active category is
    being considered
   Consulting
   Courtesy: admits an occasional patient to the
    hospital
   Honorary

                                                  49
50
Hospital departments,
Services, and Committees




                           51
Health Information Department
   Department administration
   Cancer registry
   Coding and abstracting
   Image processing
   Incomplete record processing
   Medical transcription
   Record circulation
   Release of information processing
                                        52
53
Coding
   Involves assigning numeric and alphanumeric
    codes to diagnoses, procedures, and services;
    this function is usually performed by
    credentialed individuals.
   Coders assign ICD-9-CM codes to inpatient
    cases and Current Procedural Terminology
    (CPT), Health Care Procedure Coding System
    (HCPCS) Level II (National), and ICD-9-CM
    codes to outpatient, emergency department,
    and physician office cases.
                                               54
Cancer registry
   Performed by individuals who are
    credentialed as certified tumor registrars and
    include using computerized registry software
    to conduct lifetime follow-up on each cancer
    patient, electronically transmit data to state
    and national agencies for use at local,
    regional, state, and national levels, and
    generate reports and information for
    requesting entities.

                                                 55
Current Procedural
Terminology (CPT)
   Published annually by the American
    Medical Association and codes are 5-
    digit numbers assigned to ambulatory
    procedures and services.
   E.g. 90663 Influenza virus vaccine,
    pandemic formulation


                                           56
ICD-9-CM
   The International Classification of
    Diseases, Ninth revision, Clinical
    Modification is used in the United States
    to collect information about diseases
    and injuries and to classify diagnoses
    and procedures.
   National Center for Health Statistics
    (NCHS).
                                            57
http://icd9cm.chrisendres.com/
   1. INFECTIOUS AND PARASITIC DISEASES (001-139)
       TUBERCULOSIS (010-018)
            Includes:
                  infection by Mycobacterium 分枝桿菌 tuberculosis (human) (bovine 牛)
            Excludes:
                 congenital tuberculosis (771.2)
                 late effects of tuberculosis (137.0-137.4)
            The following fifth-digit subclassification is for use with categories 010-018:
                  0 unspecified
                  1 bacteriological or histological 組織學的 examination not done
                  2 bacteriological or histological examination unknown (at present)
                  3 tubercle bacilli 結核桿菌 found (in sputum) by microscopy
                  4 tubercle bacilli not found (in sputum) by microscopy, but found by
                   bacterial culture
                  5 tubercle bacilli not found by bacteriological examination, but tuberculosis
                   confirmed histologically
                  6 tubercle bacilli not found by bacteriological or histological examination,
                   but tuberculosis confirmed by other methods [inoculation 預防接種 of
                   animals]


                                                                                              58
http://icd9cm.chrisendres.com/
   010 Primary tuberculous infection
       Requires fifth digit. See beginning of section 010-018 for codes and
        definitions.
   011 Pulmonary tuberculosis
       Requires fifth digit. See beginning of section 010-018 for codes and
        definitions.
       Use additional code to identify any associated silicosis矽肺病 (502)
   012 Other respiratory tuberculosis
       Requires fifth digit. See beginning of section 010-018 for codes and
        definitions.
       Excludes:
            respiratory tuberculosis, unspecified (011.9)
   013 Tuberculosis of meninges 腦脊膜 and central nervous
    system
       Requires fifth digit. See beginning of section 010-018 for codes and
        definitions.



                                                                               59
http://icd9cm.chrisendres.com/
   014 Tuberculosis of intestines 腸, peritoneum 腹膜, and
    mesenteric glands 腸系膜腺
      Requires fifth digit. See beginning of section 010-018 for
       codes and definitions.
   015 Tuberculosis of bones and joints
      Requires fifth digit. See beginning of section 010-018 for
       codes and definitions.
      Use additional code to identify manifestation, as:
           tuberculous:
                 Arthropathy 關節病(711.4)
                 Necrosis 壞死of bone (730.8)
                 Osteitis 骨炎(730.8)
                 Osteomyelitis 骨髓炎(730.8)
                 Synovitis 滑膜炎(727.01)
                 Tenosynovitis 腱鞘炎(727.01)


                                                                    60
http://icd9cm.chrisendres.com/
   016 Tuberculosis of genitourinary 泌尿生殖器的 system
      Requires fifth digit. See beginning of section 010-018 for
       codes and definitions.
   017 Tuberculosis of other organs
      Requires fifth digit. See beginning of section 010-018 for
       codes and definitions.
   018 Miliary 粟粒狀的 tuberculosis
       Includes:
            tuberculosis:
                  Disseminated 彌散性
                  Generalized 全身性的
                  miliary, whether of a single specified site, multiple sites, or
                   unspecified site
                  Polyserositis 漿膜炎



                                                                                     61
ICD-10
   The International Statistical Classification of Diseases
    and Related Health Problems 10th Revision is a
    coding of diseases and signs, symptoms, abnormal
    findings, complaints, social circumstances and
    external causes of injury or diseases, as classified by
    the WHO.
   The code set allows more than 14,400 different codes and
    permits the tracking of many new diagnoses.
   Using optional subclassifications, the codes can be expanded to
    over 16,000 codes.



                                                                  62
US ICD-10 CM
   The International version of ICD should
    not be confused with national Clinical
    Modifications of ICD that include
    frequently much more detail, and
    sometimes have separate sections for
    procedures, so the new US ICD-10 CM
    has some 155,000 codes.


                                          63
HCPCS
   The Health Care Procedure Coding
    System is comprised of Level I (CPT)
    and Level II (National) codes.
   Level II HCPCS codes are developed by
    the Centers for Medicare & Medicaid
    Services (CMS) and used to classify
    report procedures and services.

                                        64
CPT (Current Procedural
Terminology)
   a numeric coding system maintained by
    the American Medical Association (AMA).
   The CPT is a uniform coding system
    consisting of descriptive terms and
    identifying codes that are used primarily
    to identify medical services and
    procedures furnished by physicians and
    other health care professionals.
                                           65
   Level I of the HCPCS, the CPT codes,
    does not include codes needed to
    separately report medical items or
    services that are regularly billed by
    suppliers other than physicians.




                                            66
Level II HCPCS
   Codes are reported to third-party
    payers (e.g., insurance companies) for
    reimbursement purposes.




                                             67
Level II HCPCS
   Level II of the HCPCS is a standardized
    coding system that is used primarily to
    identify products, supplies, and services
    not included in the CPT codes, such as
    ambulance services and durable
    medical equipment, prosthetics 假體,
    orthotics 矯形器, and supplies (DMEPOS)
    when used outside a physician's office
                                           68
Level II HCPCS
   Level II alphanumeric HCPCS procedure and modifier
    codes, their long and short descriptions, and
    applicable Medicare administrative, coverage, and
    pricing data.
   The Level II HCPCS codes, which are established by
    CMS's Alpha-Numeric Editorial Panel, primarily
    represent items and supplies and non-physician
    services not covered by the American Medical
    Association's Current Procedural Terminology-4 (CPT-
    4) codes;
   Medicare, Medicaid, and private health insurers use
    HCPCS procedure and modifier codes for claims
    processing.

                                                      69
         http://www.cms.gov/MedHCPCSGenInfo/

A1001007DRESSING FOR ONE WOUND      Dressing for one wound   C 2002070120020701 N
A2001007DRESSING FOR TWO WOUNDS Dressing for two wounds C 02002070120020701 N
A3001007DRESSING FOR THREE WOUNDS Dressing for three wounds C 02002070120020701 N




                                                                               70
Abstracting
   Performed to enter codes and other
    pertinent information utilizing computer
    software.
   To generate statistical reports and
    disease/procedure indexes, which are
    used for administrative decision-making
    and quality-management purposes.

                                           71
Incomplete record processing
   Includes the assembly and analysis of
    discharged patient records.
   After a patient is discharged from a
    nursing unit, the record is retrieved and
    reports are assembled according to a
    hospital- and medical staff-approved
    order of assembly.

                                            72
Medical transcription
   Involves the accurate and timely
    transcription of dictated reports.




                                         73
Record circulation
   Includes the retrieval of patient records,
    for the purpose of:
       Inpatient readmission
       Scheduled and unscheduled outpatient
        clinic visits
       Authorized quality-management studies
       Education and research


                                                74
Licensure, Regulation and
Accreditation
   Code of Federal Regulations (CFR)
   Federal Register
       A legal newspaper published every
        business day by the National Archives and
        Records Administration (NARA) in paper
        form, microfiche, and online.
   Accreditation Standards and Surveys

                                                    75
Regulation
   A regulation is an interpretation of a law
    that is written by the responsible regulatory
    agency.
   E.g. the Conditions of Participation (CoP) are
    regulations written by the Centers for
    Medicare & Medicaid Services (CMS).
   Congress writes and passes an act, the
    President signs the act into law, and CMS
    interprets the law creating a regulation.
                                                     76
Accreditation
   A voluntary process that a health care
    facility or organization undergoes to
    demonstrate that it has met standards
    beyond those required by law.




                                             77
Standards
   Accreditation organizations develop
    standards, which are measurements of
    a health care organization’s level of
    performance in specific areas and are
    usually more rigorous than regulations.




                                              78
Survey
   A survey (evaluation) process is
    conducted both off-site and on-site to
    determine whether the facility complies
    with standards.




                                          79
Accrediting Organizations
   Accreditation Association for
    Ambulatory Health Care (AAAHC)
   Commission on Accreditation of
    Rehabilitation Facilities (CARF)
   Community Health Accreditation
    Program (CHAP)


                                       80
Accrediting Organizations
   Joint Commission on Accreditation of
    Health Care Organizations (JCAHO)
   National Committee for Quality
    Assurance (NCQA)
   National Commission on Correctional
    Health Care (NCCHC)


                                           81
Health Care Settings



Feipei Lai
National Taiwan University
Objectives
   Define hospital categories
   Identify types of hospital patients
   Differentiate among freestanding,
    hospital-based, and hospital-owned
    ambulatory care settings
   Distinguish among various types of
    behavioral health care facilities

                                          83
Diagnosis-related groups
(DRGs)
   Classify inpatient hospital cases into
    groups that are expected to consume
    similar hospital resources.




                                             84
Australian National Diagnosis
Related Groups (AN-DRGs)
   To ensure the clinical coherence of AN-
    DRGs, every effort is made to assign
    each episode of care to one of 23 Major
    Diagnostic Categories (MDCs).
   Most MDCs are defined by body system
    or disease type, and correspond with a
    particular specialty.

                                          85
Acute Care Facilities
   An acute care facility is a hospital that
    provides health care services to patients
    who have serious, sudden, or acute
    illnesses or injuries and/or who need
    certain surgeries.




                                           86
Acute Care Facilities (ACFs)
   ACFs provide a full range of health care
    services, including ancillary services,
    emergency and critical care, surgery,
    obstetrics, and so on.




                                           87
Acute Care Facilities
   Single hospitals
   Multi-hospital systems
       Two or more hospitals owned, managed, or leased
        by a single organization
   Ancillary services
       Diagnostic
       Therapeutic
   Acute care/short-term care
   Long-term care

                                                     88
Hospital Categories
   Critical access hospitals (CAH)
       Located more than 35 miles from any other
        hospital or another CAH, or they are state certified
        as being a necessary provider of health care to
        area residents. Mileage criteria is reduced to 15
        miles in areas where only secondary roads are
        available or in mountainous terrain.
   General hospitals
   Specialty hospitals
   Rehabilitation hospitals
   Behavioral health care hospitals

                                                          89
General hospitals
   Provide emergency care, perform
    general surgery, and admit patients for
    a range of problems from fractures to
    heart disease.




                                              90
Specialty hospitals
   Concentrate on a particular population
    of patients or disease category.




                                             91
Rehabilitation hospitals
   Admit patients who are diagnosed with
    trauma (e.g., car accident) or disease
    (e.g., stroke) and need to learn how to
    function.




                                              92
Behavioral health care hospitals

   Specialize in treating individuals with
    mental health diagnoses.




                                              93
Hospital Patients
   Ambulatory patients (outpatients)
   Ambulatory surgery patients (day
    surgery)
   Emergency care patients
   Inpatients
   Newborn patients
   Observation care patients
   Subacute care patients              94
Ambulatory patients
(outpatients)
   Are treated and released the same day
    and do not stay overnight in the
    hospital.




                                            95
Ambulatory surgery patients (day
surgery)

   Undergo certain procedures that can be
    performed on an outpatient basis, with
    the patient treated and released the
    same day.




                                         96
Emergency care patients
   Are treated for urgent problems and are
    either released the same day or
    admitted to the hospital as inpatients.




                                          97
Inpatients
   Are provided with room and board and
    nursing services.




                                           98
Newborn patients
   Receive infant care upon birth and if
    necessary they receive neonatal
    intensive care.




                                            99
Observation patients
   Receive services furnished on a
    hospital’s premises that are ordered by
    a physician or other authorized
    individual, including use of a bed and
    periodic monitoring by nursing or other
    staff, which are reasonable and
    necessary to evaluate an outpatient’s
    condition or determine the need for a
    possible admission as an inpatient.
                                          100
Subacute care
   Is provided in hospitals that provide
    specialized long-term acute care such
    as chemotherapy, injury rehabilitation,
    ventilator (breathing machine) support,
    wound care, and other types of health
    care services provided to seriously ill
    patients.


                                          101
Ambulatory and Outpatient Care

   Allows patients to receive care in one
    day without the need for inpatient
    hospitalization.




                                             102
Ambulatory and Outpatient Care

   Ambulatory surgical centers
    (freestanding)
   Hospital-based outpatient department
   Hospital-based emergency department
   Hospital-based ambulatory surgery
   Hospital-based partial hospitalization
    program (behavior health, geriatric, rehabilitative
    care)
   Hospital-owned satellite clinics                  103
Ambulatory and Outpatient Care
   Industrial health clinics
   Neighborhood health centers
   Physician offices
   Public health departments
   Staff model health maintenance
    organization
   Urgent care centers

                                     104
Freestanding Centers and
Facilities
   Ambulatory Surgical Center (ASC)
   Clinical laboratory
   Heart and vascular center
   Staff model health maintenance
    organization (HMO)
   Imaging center
   Industrial health clinic
                                       105
Freestanding Centers and
Facilities
   Infusion center
   Neighborhood health center
   Pain management center
   Physician office
   Primary care center
   Public health center
   Urgent care center
                                 106
Infusion center
   Freestanding center that dispenses and
    administers prescribed medications by
    continuous or intermittent infusion to
    ambulatory patients.




                                         107
Hospital-owned facilities
   Hospital-own physician practice
       At least partially owned by the hospital,
        and the physician participate in a
        compensation plan provided by the
        hospital.
   Satellite clinics
       Ambulatory care centers that are
        established remotely from the hospital.

                                                    108
Alternate Care Facilities
   Behavioral health care facilities
   Home care and hospice
   Long-term care
   Managed care – to control cost




                                        109
Managed care
   Originally referred to the prepaid health care
    sector (e.g., HMOs), which combined health
    care delivery with the financing of health care
    services.
   Increasingly referred to preferred provider
    organizations (PPOs) and some forms of
    indemnity coverage that incorporate
    utilization management activities.


                                                 110
Behavioral health care
   Chemical dependency program
   Crisis service
   Day treatment program
   Developmentally disabled/mentally
    retarded facilities
   Emergency care facilities
   Family support services
   Home health care
                                        111
Crisis service
   Provides short-term (usually fewer than
    15 days) crisis intervention and
    treatment.
   Patients receive 24-hour-a-day
    supervision.




                                          112
Behavioral Health Care
   Hospital treatment
   Intensive case management
   Outpatient clinic
   Partial hospitalization program
   Residential treatment facility



                                      113
Residential treatment facility
   Seriously disturbed patients receive
    intensive and comprehensive psychiatric
    treatment on a long-term basis.




                                         114
Behavioral Health Care
   Respite care
       Patient care provided in the home or
        institution intermittently in order to provide
        temporary relief to the family home care
        giver.
   Therapeutic group home
       Any group of patients meeting together for
        mutual psychotherapeutic, personal
        development, and life change goals.

                                                    115
Home care and hospice
   Home care allows people who are
    seriously ill or dying to remain at home
    and receive treatment from nurses,
    social workers, therapists, and other
    licensed health care professionals who
    provide skilled care in the home.



                                           116
Skilled care
   Includes services that are ordered by a
    physician and provided under the supervision
    of a registered nurse, or physical,
    occupational, or speech therapist.
   Skilled care service include:
       Assessment/monitoring of illnesses
       Intravenous (IV) and medication administration
       Insertion of catheters 導管
       Tube feedings
       Wound care


                                                         117
Home care and hospice
   Home health care also covers the use of durable
    medical equipment (DME), which includes the
    following:
       Canes
       Crutches (架在腋下的)拐杖
       IV supplies
       Hospital beds
       Ostomy supplies 人工肛門
       Oxygen
       Prostheses 義肢
       Walkers
       Wheelchairs


                                                      118
Personal care and support
services
   Provide assistance in performing daily
    living activities
       Bathing
       Dressing,
       Grooming
       Going to the toilet
       Mealtime assistance
       Travel training
       Accessing recreation services        119
Home infusion care
   Provided by home health care agencies
    when intravenous administration of
    medication is medically appropriate for
    the patient’s condition, and treatment is
    administered in the home instead of on
    an inpatient hospital basis.
   E.g. chemotherapy, drug therapy,
    hydration therapy, pain management,
    total parenteral nutrition (TPN) 非經腸
    的                                      120
hydration therapy
   intravenous administration of fluids,
    electrolytes, and other additives




                                            121
Hospice care
   Provides comprehensive medical and
    supportive social, emotional, and
    spiritual care to terminally ill patients
    and their families.
   The goal of hospice is palliative care
    (comfort management) rather than
    curative care (therapeutic).

                                                122
Long-term care
   Includes a range of nursing, social and
    rehabilitative services for people who
    need on-going assistance.




                                          123
Managed care models
   Exclusive provider organization (EPO)
   Integrated delivery system (IDS)
       Group practice without walls (GPWW)
       Medical foundation
       Integrated provider organization (IPO)
       Management service organization (MSO)
       Physician-hospital organization (PHO)

                                                 124
Exclusive provider
organization (EPO)
   Provides benefits to subscribers who
    receive health care services from the
    network providers, which are physicians
    and health care facilities under contract
    to the managed care plan.




                                           125
Integrated delivery system
(IDS)
   An organization of affiliated provider
    sites that offer joint health care services
    to subscribers.




                                             126
Group practice without walls
(GPWW)
   Managed care contract in which
    physicians maintain their own offices
    and share services to plan members.




                                            127
Medical foundation
   Nonprofit organization that contracts
    with and acquires the clinical and
    business assets of physician practices.




                                              128
Integrated provider
organization (IPO)
   Manages health care services provided
    by hospitals, physicians, and other
    health care organizations.




                                            129
Management service
organization (MSO)
   Provides practice management services,
    including administrative and support
    services, to individual physician
    practices.




                                        130
Physician-hospital organization
(PHO)
   Managed care contracts are negotiated
    by hospital(s) and physician groups.
   Physicians maintain their own practices
    and provide service to plan members.




                                          131
Managed care models
   Health Maintenance Organization (HMO)
       Group model HMO
       Staff model HMO
       Direct contract model HMO
       Individual practice association (IPA)
       Network model HMO



                                                132
Group model HMO
   Participating physicians who are
    members of an independent multi-
    specialty group provide health care
    services.
   Physician groups either contract with
    the HMO or they are owned or
    managed by the HMO.

                                            133
Staff model HMO
   Physicians are employed by the HMO,
    premiums are paid to the HMO, and
    usually all ambulatory care services are
    provided within HMO corporate
    buildings.




                                           134
Direct contract model HMO
   Individual physicians in the community
    deliver contracted health care services
    to subscribers.




                                          135
Individual practice association
(IPA)
   Physicians who remain in their
    independent office settings provide
    contracted health care services to
    subscribers.
   The IPA negotiates the HMO contract
    and manages the capitation payment.


                                          136
Network model HMO
   Two or more physician multi-specialty
    group practices provide contracted
    health care services to subscribers.




                                            137
Managed care models
   Point-of-Service Plan (POS)
   Preferred provider organization (PPO)
       A network of physicians and hospitals join
        together to contract with third-party payers,
        employers, and other organization to provide
        health care to subscribers for a discounted fee.
   Triple option plan
       Provides subscribers and employees with a choice
        of HMO, PPO, or traditional health insurance plan.

                                                           138
Federal, State, and Local Health Care

   Correctional facilities
   Military Health System (MHS)
   Veterans Health Administration (VHA)
   U.S. Public Health Service (PHS)




                                           139
U.S. Public Health Service
(PHS)
   Administration for Children and Families (ACF)
   Administration on Aging (AoA)
   Agency for Healthcare Research and Quality
    (AHRQ)
   Agency for Toxic Substance and Disease
    Registry (ATSDR)
   Centers for Disease Control and Prevention
    (CDC)

                                                140
U.S. Public Health Service
(PHS)
   Food and Drug Administration (FDA)
   Health Resources and Services Administration (HRSA)
   Indian Health Service (IHS)
   National Institutes of Health (NIH)
   Office of Public Health and Service (OPHS)
   Office of the Secretary of Health and Human Services
    (OS)
   Program Support Center (PSC)
   Substance Abuse and Mental Health Services
    Administration (SAMHSA)

                                                      141
Program Support Center (PSC)
   is a service-for-fee organization that utilizes a
    business enterprise approach to provide
    government support services throughout the
    Department of Health and Human Services
    (DHHS) as well as other federal agencies.
   Administrative operations, financial
    management, and human resources are
    solution- and customer-oriented, state-of-the-
    art, and highly responsive to customer needs.


                                                   142
The Patient Record: Hospital,
Physician Office, and
Alternate Care Settings

Feipei Lai
National Taiwan University


                             143
Outline
   Definition and Purpose of the Patient
    Record
   Provider Documentation Responsibilities
   Development of the Patient Record
   Patient Record Formats
   Archived Records
   Patient Record Completion
    Responsibilities
                                         144
Definition of Purpose of the
Patient Record
   Ownership of the patient record
   Hospital inpatient record
   Hospital outpatient record
   Physician office record




                                      145
Patient record
   Serves as the business record for a
    patient encounter, contains
    documentation of all health care
    services provided to a patient, and is a
    repository of information that includes
    demographic data, and documentation
    to support diagnoses, justify treatment,
    and record treatment results.
                                           146
Demographic data
   Patient identification information
    collected according to facility policy and
    includes the patient’s name and other
    information, such as date of birth, place
    of birth, mother’s maiden name, social
    security number, and so on.



                                            147
   Each page of the patient record should
    include the following identification
    information: name of the attending or
    primary care provider, patient’s name,
    patient number, date of admission/visit,
    and name/address/telephone number of
    the facility.


                                          148
Essential Principles of Health
Documentation
   Unique patient identification must be assured
    within and across healthcare documentation
    systems
   Healthcare documentation must be accurate
    and consistent, complete, timely,
    interoperable across types of documentation
    systems, accessible at any time and at any
    place where patient care is needed, and
    auditable
   Confidential and secure authentication and
    accountability must be provided
                                               149
Essential Principles of Health
Documentation
   The primary purpose of the patient
    record is to provide continuity of care,
    which includes documentation of
    patient care services so that others who
    treat the patient have a source of
    information from which to base
    additional care and treatment.


                                          150
Secondary purposes of the
patient record
   Evaluating quality of patient care
   Providing information to third-party payers for
    reimbursement
   Serving the medicolegal interests of the
    patient, facility, and providers of care
   Providing data for use in clinical research,
    epidemiology studies, education, public policy
    making, facilities planning, and health care
    statistics

                                                 151
Ownership of the Patient
Record
   The medical record is the property of
    the provider, and as governed by
    federal and state laws, the patient has
    the right to access its content for
    review and to request that inaccurate
    information be amended.



                                              152
Hospital Inpatient Record
   Documents the care and treatment received
    by a patient admitted to the hospital.
   Administrative data includes demographic,
    socioeconomic, and financial information.
   Clinical data includes all patient health
    information obtained throughout the
    treatment and care of the patient.



                                           153
Hospital Outpatient Record
   Documents services received by a
    patient who has not been admitted to
    the hospital overnight and includes
    ancillary services (e.g., lab. tests, X-
    rays), emergency department services,
    and outpatient surgery.



                                           154
Administrative data
   Demographic
       Patient name
       Patient address
       Gender
       Date of Birth
       Social security number (ID number)
       Telephone number


                                             155
Administrative data
   Socioeconomic
       Marital status
       Race and ethnicity
            ethnic(al) 表示語言、習慣等,
            racial 表示膚色、眼睛顏色、骨骼等人種的區別.
       Occupation
       Place of employment


                                      156
Administrative data
   Financial
       Third-party payer
       Insurance number
       Secondary insurance




                              157
Clinical data
   Consultation report
       Discharge summary
       History
       Physical examination
       Laboratory results
       Operative record
       Progress notes
       Radiology report

                               158
Alternate Care Clinical Data
   Ambulatory care
       Patient history
       Problem list
       Medication list
       Physical examination
       Progress notes
       Flow sheets (e.g., growth chart)


                                           159
growth chart
   is used by pediatricians and other health care
    providers to follow a child's growth over time.
   Growth charts have been constructed by
    observing the growth of large numbers of
    normal children over time.
   The height, weight, and head circumference
    of a child can be compared to the expected
    parameters of children of the same age and
    sex to determine whether the child is growing
    appropriately.
                                                 160
Alternate Care Clinical Data
   Behavioral health
       Behavior health diagnoses
       Psychiatric and medical history
       Patient assessment
       Patient treatment plan
       Documentation of therapy and treatment
       Progress notes
       Case conferences
       Consultation notes
       Discharge summary
       Follow-up care
       Aftercare plan

                                                 161
Alternate Care Clinical Data
   Clinical laboratory
       Physician orders
       Testing results




                               162
Alternate Care Clinical Data
   Home care
       Certification
       Plan of care
       Case conference notes
       Physician orders
       Treatment documentation
       Progress notes
       Discharge summary

                                  163
Alternate Care Clinical Data
   Long-term Care
        History (patient, social, and medical)
        Physical examination
        Nursing assessment
        Care plan
        Physician treatment orders
        Progress notes
        Ancillary reports
        Consultation reports
        Nutritional services
        Activities
        Social work notes
        Occupational therapy notes
        Physical therapy notes
        Speech therapy notes
        Discharge plan of care


                                                  164
Alternate Care Clinical Data
   Surgical Center (stand-alone)
       Patient history
       Problem list
       Medication list
       Physical examination
       Progress notes
       Anesthesia record
       Pre- and post-anesthesia evaluation
       Operative record
       Pathology report
       Recovery room record
       Flow sheets (e.g., growth chart)

                                              165
Provider Documentation
Responsibilities
   Authentication of patient record entries
       Signatures
       Countersignatures
       Initials
       Fax signatures
       Electronic signatures
       Rubber stamp signatures
       Abbreviations used in the patient record
       Legibility of Patient Record Entries
       Timeliness of patient record entries
       Amending the patient record

                                                   166
Countersignature
   Is a form of authentication by an
    individual in addition to the signature by
    the original author of an entry.
   Countersignatures are also required
    when nurses and other authorized
    personnel (e.g., pharmacists) document
    a telephone order taken from a
    physician.
                                            167
Telephone order
   A verbal order taken over the telephone
    by a qualified professional from a
    physician.




                                         168
Voice order
   The physician dictates an order in the
    presence of a responsible person.
   Documented in emergencies only.




                                             169
Electronic signature
   Name typed at the end of an e-mail message by the
    sender
   Digitized image of a handwritten signature that is
    inserted (or attached) to an electronic document
   Secret code or PIN (personal identification number)
    to identify the sender to the recipient
   Unique biometrics-based identifier (e.g., finger-print,
    retinal scan)
   Digital signature, which is created using public key
    cryptography to authenticate a document or message.


                                                        170
Signature stamps
   Medicare does not allow the use of
    signature stamps (or date stamp) on
    Certificates of Medical Necessity (CMN)
    for durable medical equipment.




                                          171
Abbreviations Used in the
Patient Record
   Every health care facility should establish a
    policy as to which abbreviations, acronyms,
    and symbols can be documented in the
    patient record.
   The facility should maintain an official
    abbreviation list, which includes medical
    staff-approved abbreviations, acronyms, and
    symbols (and their meanings) that can be
    documented in patient records.
                                                172
Timeliness of Patient Record
Entries
   Medicare Conditions of Participation (CoP) for
    Hospitals that require a complete physical
    examination to be performed no more than 7
    days prior to admission or within 24 hours
    after admission.
   The report of physical examination must be
    placed in the patient record within 48 hours
    after admission.


                                                173
Delinquent records
   The JCAHO requires patient records to
    be completed 30 days after patient is
    discharged, at which time they become
    delinquent records.




                                        174
Amending the Patient Record
   The only person authorized to correct an entry is the
    author of the original entry.
   To amend an entry in a manual patient record
    system, the provider should:
       Draw a single line through the incorrect information, making
        sure that the original entry remains legible.
       Date, specify time, and sign the correct entry.
       Document a reason for the error in a location as close to the
        original documentation as possible.
       Enter the correct information as close to the original
        information as possible. If the length of information to be
        newly entered prohibits this, enter the correct information in
        the next available space in the record, and reference the
        original entry.

                                                                   175
   The electronic health record system
    should store both the original and
    corrected entry as well as a record of
    who documented each entry.
   The date, time, and authentication of
    the person making the correction
    should be maintained as well as the
    reason for the change.
                                             176
Audit trail
   A technical control created by an
    electronic health record system and
    consists of a listing of all transactions
    and activities that occurred.




                                                177
Addendum
   Document the word “addendum” or “clarification” or
    “late entry,” depending on circumstances, at the
    beginning of the new entry
   Document the current date and time as well as the
    date and time of the original entry as a reference
   Authenticate the addendum
   State the reason for documenting the addendum,
    and provide any supporting information that provides
    clarification
   Enter the current date and time. Do not try to give
    the appearance that the entry was made on a
    previous date or time.

                                                      178
Development of the Patient
Record
   Date order of patient record reports
   Outpatient record: handling repeat
    visits
   Physician office record: continuity of
    care



                                             179
Preadmission testing
   Chest X-ray
   Electrocardiogram (EKG)
   Laboratory testing (e.g., blood typing,
    urinalysis)
   Anesthesia screening and pre-anesthesia
    evaluation
   Coordination of ancillary services
   Discharge planning
   Health history screening
   Patient teaching by a registered nurse
                                              180
Inpatient Record: Admission
to Discharge
   At the time of admission, the patient or
    patient’s representative, the person who has
    legal responsibility for the patient, signs an
    admission consent form to document
    consent to treatment.
   If a patient is unable to sign and no one else
    is designated to sign on behalf of the patient,
    the procedure for obtaining a signature to
    consent should follow state laws (e.g., one
    MD and two witnesses).
                                                 181
Nursing assessment
   Documents the patient’s history, current
    medications, and vital signs on a variety
    of nursing forms, including nurses’
    notes, graphic charts, and so on.




                                           182
Discharge summary
   Document the care provided to the
    patient during the inpatient
    hospitalization
       Reason for hospitalization
       The course of treatment
       The patient’s condition at discharge



                                               183
Date Order of Patient Record
Reports
   Reverse chronological date order means
    that the most current document is filed
    first in a section of the record.
   Chronological date order




                                         184
185
Patient Record Formats
   Primary and secondary sources of
    information
   Source oriented record (SOR)
   Problem oriented record (POR)
   Integrated record



                                       186
Primary and secondary
sources of information
   Records that document patient care provided
    by health care professionals are considered
    primary sources of patient information (e.g.,
    original patient record, X-rays, scans, EKGs,
    and other documents of clinical findings).
   Secondary sources of patient information
    contain data abstracted (selected) from
    primary sources of patient information (e.g.,
    indexes and registers, committee minutes,
    incident reports, and so on).
                                                187
Incident report
   Collects information about a potentially
    compensable event (PCE), which is an
    accident or medical error that results in
    personal injury or loss of property.




                                            188
Incident reports are never
filed in the patient record
   When an incident occurs (e.g., a patient
    falls out of bed and breaks her hip),
    document the facts in the progress
    notes.
   Do not enter a note in the patient
    record that an incident report has been
    completed.

                                          189
PCE
   A nurse administered the wrong
    medication to a patient . The nurse
    documents an incident report of this
    PCE and files it with the facility’s risk
    manager.




                                                190
Patient Record Formats
(Continued)
   Automated record systems
   Computers in health care
   Longitudinal patient record
   Advantages and disadvantages of
    manual and automated record systems



                                      191
Source Oriented Record (SOR)
   Maintains reports according to source of
    documentation.
   All documents generated by the nursing staff
    are located in a nursing section of the record,
    radiology reports in a radiology section, and
    physician-generated documents (e.g.,
    physician orders, progress notes, and so on)
    in the medical section.


                                                 192
Problem Oriented Record
(POR)
   A more systematic method of
    documentation, which consists of four
    components:
       Database
       Problem list
       Initial plan
       Progress notes


                                            193
POR database
   Contains a minimum set of data to be
    collected on every patient,
       such as chief complaint;
       present conditions and diagnoses;
       social data;
       Past, personal, medical, and history;
       Review of systems;
       Physical examination; and baseline laboratory data.


                                                        194
POR problem list
   Acts as a table of contents for the
    patient record because it is filed at the
    beginning of the record and contains a
    list of the patient’s problems.
   Each problem is numbered which helps
    to index documentation throughout the
    record.

                                            195
POR problem list
   Problem include anything that requires
    diagnostic review or health care
    intervention and management, such as
    past and present social, medical,
    psychiatric, economic, financial, and
    demographic issues.



                                         196
POR initial plan
   Describes actions that will be taken to
    learn more about the patient’s condition
    and to treat and educate the patient,
    according to three categories:
       Diagnostic/management plans
       Therapeutic plans
       Patient education plans


                                          197
Progress Notes
   4/15/YYYY 8 a.m. CC: Chest pain. Anxious.
   Exam: BP 130/80. Pulse 85.
   Respirations 20. Temperature 98.6°. Lungs clear. Heart regular.
   Abdomen nontender.
   Current medications: None.
   Possible severe panic attack.
   Rule out myocardial infarction.
   Plan: Chest X-ray. EKG. Total CPK. Total LDH. Consult with Dr. Miller,
    Psychiatrist.

   4/15/YYYY noon. No chest pain. Patient is calmer.
   Feels slightly anxious.
   Exam: BP 130/75. Pulse 80.
   Respirations 20. Temperature 98.6°.
   EKG: negative.

                                                                         198
   4/15/YYYY 7 p.m. Patient resting comfortably. No
   chest pain.
   Exam: BP 130/75. Pulse 80.
   Respirations 20. Temperature 98.6°.

   4/16/YYYY 6:30 a.m. Patient slept well. No chest pain.
   Less anxiety today.
   Exam: BP 120/70. Pulse 75.
   Respirations 20. Temperature 98.6°.
   Discharge home. Follow-up in Dr. Miller’s office in one week.
   Xanax 0.25 mg t.i.d.




                                                                    199
CPK -->
creatine phosphokinase肌酸磷催化酶
   <enzyme> An enzyme that is contained in skeletal
    muscle, smooth muscle and cardiac muscle.
   Creatine phosphokinase is released into the
    bloodstream in increased quantities if muscle in
    injured.
   Creatine phosphokinase can be fractionated so that
    specific measurements can be made for blood levels
    of creatine phosphokinase that comes exclusively
    from damaged heart muscle.
   This makes it an important test for the laboratory
    diagnosis of heart attack.

                                                     200
LDH -->
lactic 乳(汁)的 dehydrogenase 脫氫酵素


   <enzyme> The enzyme that catalyses the
    formation and removal of lactate according to
    the equation:
       pyruvate + NADH = lactate NAD.
   <cell culture> The appearance of lactic
    dehydrogenase in the medium is often used
    as an indication of cell death and the release
    of cytoplasmic 細胞質的 constituents.
                                                 201
POR notes are documented for each
problem using the SOAP structure
   Subjective (S) – patient’s statement about how they
    feel, including symptomatic information (e.g.,
    headache)
   Objective (O) – observations about the patient, such
    as physical findings or lab or X-ray results.
   Assessment (A) – judgment, opinion, or evaluation
    made by the health care provider (e.g., acute
    migraine 偏頭痛)
   Plan (P) – diagnostic, therapeutic and educational
    plans to resolve the problems (e.g., patient to take
    Tylenol as needed for pain)

                                                       202
Integrated Record
   The integrated record format usually
    arranges reports in strict chronological
    date order.
   This format allows for observation of
    how the patient is progressing
    according to tests results and how the
    patient responds to treatment based on
    test results.
                                          203
Automated Record Systems
   Electronic health record (EHR)
       A collection of patient information documented by
        a number of providers at different facilities
        regarding one patient.
   Electronic medical record (EMR)
   Optical disk imaging (or document imaging)
       Patient records are converted to an electronic
        image and saved on storage media.


                                                         204
Longitudinal Patient Record
   Contains records from different
    episodes of care, providers, and
    facilities that are linked to form a view,
    over time, of a patient’s health care
    encounters.




                                             205
Archived Records
   Records placed in storage and rarely
    accessed (inactive records)
   A digital archive is a storage solution
    that consolidates electronic records on a
    computer server for management and
    retrieval.


                                           206
Shadow Records and
Independent Databases
   A shadow record is a paper record that
    contains copies of original records and
    is maintained separately from the
    primary record.
   An independent database contains
    clinical information created by
    researchers, typically in academic
    medical centers.
                                          207
Record Retention Laws
   The Medicare Conditions of Participation
    (CoP) requires hospitals, long-term care
    facilities, specialized providers, and
    home health agencies to retain medical
    records for a period of no less than 5
    years.



                                          208
Alternative storage methods

   Off-site or Remote Storage
   Microfilm




                                 209
Record Destruction Methods
   When records are destroyed, a certificate of
    record destruction is maintained by the
    facility, which documents the date of
    destruction, method of destruction, signature
    of the person supervising the destruction
    process, listing of destroyed records, dates
    records were disposed of, and a statement
    that records were destroyed in the normal
    course of business.

                                                210
Disposition of Patient Records
Following Facility Closure
   When a facility or medical practice is
    sold to another health care entity, the
    patient records are considered part of
    the sale.
   The new owner becomes responsible
    for maintaining the patient records.


                                              211
   When a facility is closed, patients must
    be notified of the following:
       Date of closure
       New locations of records
       How to access records following closure
       Proper procedure for accessing records



                                                  212
Patient Record Completion
Responsibility
   Governing board and facility
    administration
   Attending physicians and other health
    care professionals
   Health information department



                                            213
Role of the HIM Department in
Record Completion
   Record assembly
   Quantitative analysis
   Qualitative analysis
   Concurrent analysis
       Review of patient record during inpatient
        hospitalization to ensure quality of care
        through quality patient documentation
   Statistical analysis

                                                    214
國立台灣大學醫學院附設醫院
出院病歷摘要
   病歷號碼:XXXXXXX    姓名:XXX
   性別:X 身分證字號:XXXXXXXXXX 出
    生日期:民國XX年XX月XX日
   地址:台北市中正區大學路一段七十一
    號
   入院日期:民國XX年XX月XX日 皮膚部:
    15A-XX-XX病床
   轉出日期:民國XX年XX月XX日,住院天
    數X天,第X次住院              215
   入院診斷:蜂窩組織炎
   出院診斷:蜂窩組織炎,治療後
   轉出入加護病房:無
   主訴:右小腿紅腫熱痛病發燒約兩天




                       216
   病史:
   現病史:X先生為45歲男性病人,3天前無明顯誘因出
    現右足背出現紅斑,迅速於一天之內擴散至右小腿前
    側與後側,於兩天前進展至明顯的小腿紅腫熱痛,並
    且有發燒、畏寒等症狀。兩日前於台北長庚醫院皮膚
    科就診,經投與抗生素dicloxacillin治療,病況並無好
    轉,於今日凌晨前來本院急診就醫。急診發現體溫
    39.3℃,白血球18.6 K/μL,Segment 92%,CRP
    20.45。系統回顧發現病人並無呼吸道症狀,亦無腹瀉、
    腹痛、嘔吐等症狀,大小便亦無異常。食慾、睡眠尚
    正常。擬住院給予靜注抗生素治療
                                   217
   既往史:10年前有類似病史,經治療後
    好轉,具體診斷為蜂窩組織炎。否認有
    高血壓病、糖尿病、肝炎、肺結核、血
    友病等病史。否認有外傷史、手術史及
    輸血史。否認有藥物及食物過敏史。預
    防接種史不詳。



                     218
   個人史:原籍出生、長大,近五年在大
    陸工作,從事國際貿易工作多年。未涉
    及疫水及傳染病區。無嗜酒史。吸煙史6
    年,10支/天。
   婚姻生育史:已婚、育有三子。
   家族史:否認家族中有類似疾病患者,
    否認家族中有肝炎、肺結核、高血壓病、
    糖尿病、血友病及腫瘤等疾病。
                     219
   體檢發現
   T 38.9℃ P 100次/分R 22次/分BP
    100/70mmHg 發育正常,營養不良,神智清
    楚,精神稍疲,臥床入院,平臥位,自動體位,
    查體合作。定向力、計算力正常。無貧血貌,
    顏面、口唇無發紺。無黃疸。頭顱、五官無畸
    形,雙側瞳孔等圓等大,直徑約3mm,對光反
    射靈敏,外耳道、鼻腔無異常分泌物。伸舌居
    中,雙側扁桃體未見腫大。
                            220
   頸靜脈無怒張,頸軟,無抵抗,氣管居中,甲
    狀腺無腫大。胸廓無畸形,胸骨無壓痛,雙肺
    呼吸音清,雙肺未聞及乾、濕性囉音。心界正
    常,心率80次/分,律齊,各瓣膜聽診區未聞
    及病理性雜音。腹平軟,未見胃腸型、蠕動波
    及腹壁靜脈曲張,未及包塊,無壓痛、反跳痛,
    肝大小正常,無觸痛,脾肋下未及。肝區輕度
    叩擊痛,雙腎區無叩擊痛,移動性濁音陰性,
    腸鳴音約4-5次/分。外生殖器及肛周未查。

                       221
   脊柱和四肢無畸形,活動度正常,脊柱
    無壓痛和叩擊痛,四肢肌力、肌張力正
    常,生理反射存在,未引出病理徵。皮
    膚檢查發現右足背與右小腿有明顯紅腫
    與壓痛並伴隨明顯水腫。
   手術日期方法與所見:無


                        222
   住院治療經過:住院後,X先生接受靜脈
    注射Augmentin治療,第二天之後退燒,
    白血球計數有由急診時的白血球18.6
    K/μL,Segment 92%,出院前降至
    7.3K/μL,Segment 68%:CRP也由
    20.45降至1.14。右小腿與右足背紅腫熱
    痛逐漸消退。血液培養至出院時仍未發
    現培養出細菌。病人於住院後十日出院。
                           223
   併發症:無
   檢查紀錄(一般檢查):
   民國XX年XX月XX日
   白血球總數18.6 K/μL,分葉形白血球佔92%。
   C型反應性蛋白(CRP):20.5。
   血紅素11.8 g/dL, 紅血球5.25×109/dL , 血小版:
    223 K/dL。


                                     224
   檢查紀錄(特殊檢查):無
   放射線報告:無
   轉出時狀況:病情改善、改門診治療。
   病理報告:無
   其他:無
   出院指示與用藥:Amoxicillin, Clavulanate
    Potassium (Augmentin 1g/顆)每天早晚口服一
    顆,五天份。皮膚科門診追蹤治療。

                                    225
Content of the Patient Record:
Inpatient, Outpatient, and
Physician Office

Feipei Lai
National Taiwan University
outline
   General Documentation Issues
   Hospital Inpatient Record –
    Administrative Data, Clinical Data
   Hospital Outpatient Record
   Physician Office Record
   Forms Control and Design


                                         227
General Documentation Issues
   Patient identification
       Name, medical record number, date of
        birth, or ID number.
   Facility identification
     Including the name of the facility, mailing
      address, and a telephone number.
   Addressograph 姓名住址印刷機
   Dating and timing patient record entries

                                                    228
Patient Record Documentation
Guidelines
   Authentication
   Change in a Patient’s Condition
   Communication with Others
   Completeness
   Consistency
   Continuous Documentation
   Objective Documentation
                                      229
Patient Record Documentation
Guidelines
   Referencing Other Patients
   Permanency
   Physical Characteristics
   Specificity




                                 230
Hospital Inpatient Record –
Administrative Data
   Face sheet (or admission/discharge
    record)
   Advance directives
   Informed consent
   Patient property form
   Birth certificate
   Death certificate
                                         231
Face Sheet
   Identification/demographic data
   Financial data
   Clinical data




                                      232
Identification/demographic
data
   Complete name
   Mailing address
   Phone number
   Date and place of birth, and age
   ID number
   Patient record number
   Patient account number
   Gender
   Race and ethnicity
   Marital status
   Admission and discharge date and time
   Type of admission (e.g., elective, emergency)
   Next-of-kin name and address
   Next-of-kin contact information
   Employer name, address, and phone number
   Admitting and/or referring physician
   Hospital name, address, and phone number        233
Financial data
   Third-party payer
       Name
       Address
       Phone number
       Policy number
       Group name and/or number
   Insured (or guarantor)
       Name
       Date of birth
       Gender
       Relationship to patient (e.g., self, spouse)
       Name and address of employer
   Secondary and/or supplemental payer information.


                                                       234
Clinical data
   Admitting diagnosis
   Principal diagnosis (1)
   Secondary diagnosis (e.g., comorbidities
    and/or complications, up to 8)
   Principal procedure (1)
   Secondary procedure(s), up to 5
   Condition of patient at discharge
   Authentication by attending physician
   ICD-9-CM or CPT/HCPCS codes

                                               235
Face Sheet
   Admitting diagnosis
       The condition or disease for which the
        patient is seeking treatment.
   Final diagnosis
       The diagnosis determined after evaluation
        and documented by the attending
        physician upon discharge of the patient
        from the facility.

                                                 236
Uniform Hospital Discharge
Data Set (UHDDS)
   The minimum core data set collected on
    individual hospital discharges for the
    Medicare and Medicaid programs.
   Personal Identification
   Date of Birth
   Sex
   Race and Ethnicity
   Residence
   Health Care Facility Identification Number
                                                 237
Uniform Hospital Discharge
Data Set (UHDDS)
   Admission Date and Type of Admission
   Discharge Date
   Attending Physician Identification
   Surgeon Identification
   Principal Diagnosis
   Principal Procedure and Dates
   Other Procedures and Dates
   Disposition of Patient at Discharge
   Expected Payer for Most of This Bill
   Total Charges

                                           238
National Committee on Vital
Health and Statistics (NCVHS)
   Recommended for ambulatory and inpatient settings
       Personal/Unique Identifier
       Date of Birth
       Gender
       Race and Ethnicity
       Residence
       Living/Residential Arrangement
       Marital Status
       Self-Reported health Status
       Functional Status
       Years Schooling


                                                    239
National Committee on Vital
Health and Statistics (NCVHS)
   Patient’s Relationship to Subscriber/person
    Eligible for Entitlement
   Current or Most Recent Occupation/Industry
   Type of Encounter
   Admission Date (inpatient)
   Discharge Date (inpatient)
   Date of Encounter (ambulatory and physician
    services)
   Facility Identification
   Type of Facility/Place of Encounter
                                              240
National Committee on Vital
Health and Statistics (NCVHS)
   Provider Identification (ambulatory)
   Provider Location or Address (ambulatory)
   Attending Physician Identification (inpatient)
   Operating Physician Identification (inpatient)
   Provider Specialty
   Principal Diagnosis (inpatient)
   Primary Diagnosis (inpatient)
   Other Diagnosis (inpatient)
   Qualifier for Other Diagnosis (inpatient)
   Patient’s Stated Reason for Visit or Chief Complaint
    (ambulatory)

                                                           241
National Committee on Vital
Health and Statistics (NCVHS)
   Other Diagnosis (ambulatory)
   External Cause of Injury
   Birth Weight of Newborn (inpatient)
   Principal Procedure (inpatient)
   Other Procedures (inpatient)
   Dates of Procedure (inpatient)
   Services (ambulatory)
   Medications prescribed
   Medications Dispensed (pharmacy)
   Disposition of Patient (inpatient)
   Disposition (ambulatory)
   Patient’s Expected Sources of Payment
   Injury Related to Employment
   Total Billed Charges


                                            242
Principal diagnosis
   Condition established after study to be
    chiefly responsible for occasioning the
    admission of the patient to the hospital
    for care




                                           243
Secondary diagnosis
   Additional conditions for which the
    patient received treatment and/or
    impacted the inpatient care, including:
       Comorbidities (pre-existing condition that
        will because of its presence with a specific
        principal diagnosis, cause an increase in
        the patient’s length of stay at least one day
        in 75% of the cases)

                                                   244
Secondary diagnosis
   Complications (additional diagnoses
    that describe conditions arising after the
    beginning of hospital observation and
    treatment and that modify the course of
    the patient’s illness or the medical care
    required; they prolong the patient’s
    length of stay by at least one day in
    75% of the cases)
                                            245
Principal procedure
   Procedure performed for definitive
    therapeutic reasons, rather than
    diagnostic purposes, or to treat a
    complication, or that procedure which is
    most closely related to the principal
    diagnosis



                                          246
Secondary procedures
   Additional procedures performed during
    inpatient admission




                                        247
Additional Patient Record
Forms
   Advance directives
   Informed consents
   Patient property form
   Certificate of Birth
   Certificate of death



                            248
Advance Directives
   Health care proxy
       Allows patients to appoint someone to make
        decisions about CPR (cardiopulmonary
        resuscitation) and other treatments if they are
        unable to decide for themselves
   Living will
   Medical power of attorney
   A legal document in which patients provide
    instructions as to how they want to be
    treated in the event they become very ill and
    there is no reasonable hope for recovery.

                                                          249
Informed consent
   The process of advising a patient about
    treatment options and, depending on state
    laws, the provider may be obligated to
    disclose a patient’s diagnosis, proposed
    treatment/surgery, reason for the
    treatment/surgery, possible complications,
    likelihood of success, alternative treatment
    options, and risks if the patient does not
    undergo treatment/surgery.

                                                   250
Certificate of Birth
   A record of birth information about the new-
    born patient and the parents, and it identifies
    medical information regarding the pregnancy
    and birth of the newborn.
   Include:
       Infant’s and parents’ demographic information
       Parents’ occupation, education, ethnicity, race
       Pregnancy information
       Medical risk factors, complications, and/or
        abnormal conditions of newborn

                                                          251
Certificate of Death
   Contains a record of information regarding the decedent, his or
    her family, cause of death, and the disposition of the body.
   Include:
        Name of deceased
        Deceased’s date and place of birth
        Usual residence of deceased at time of death
        Cause of death
        Deceased’s place of burial
        Names and birth places of both parents
        Name of informant
        Name of doctor
        Method and place of disposition of body
        Signature of funeral director
        Signature of certifying physician


                                                                 252
Hospital Inpatient Records–
Clinical Data
   Emergency record
   Discharge summary/clinical résumé
   History and physical examination
   Consultation report
   Physician orders
   Progress notes
   Anesthesia record
                                        253
Hospital Inpatient Records–
Clinical Data (Continued)
   Operative record
   Pathology report
   Recovery room record
   Ancillary reports
   Nursing documentation
   Special reports
   Autopsy reports
                              254
Clinical data
   Includes all health care information
    obtained about a patient’s care and
    treatment, which is documented on
    numerous forms in the patient record.




                                            255
Emergency Record
   Documents the evaluation and
    treatment of patients seen in the
    facility’s emergency department for
    immediate attention of urgent medical
    conditions or traumatic injuries.
   Patient identification
   Time and means of arrival at the
    emergency department

                                            256
Anti-dumping legislation
   Prevents facilities licensed to provide
    emergency services from transferring
    patients who are unable to pay to other
    institutions, and it requires that a
    patient’s condition must be stablized
    prior to transfer (unless the patient
    requests transfer).


                                         257
Discharge summary (clinical
resume)
   Provides information for continuity of care
    and facilitates medical staff committee review.
   Documents the patient’s hospitalization,
    including
       Reason(s) for hospitalization, course of treatment,
        condition at discharge.
       Patient and facility identification
       Admission and discharge dates


                                                         258
History
   Documents the patient’s chief complaint,
    history of present illness (HPI),
    past/family/social history (PFSH), and
    review of systems (ROS).




                                         259
Physical examination
   Is an assessment of the patient’s body
    systems to assist in determining a
    diagnosis, documenting a provisional
    diagnosis, and which may include
    differential diagnoses.




                                             260
Differential diagnosis
   Indicates that several diagnoses are
    being considered as possible.




                                           261
Review of Systems (ROS)
   Inventory by systems to document subjective symptoms stated
    by the patient.
   General
   Skin
   Head
   Eyes
   Ears
   Nose
   Mouth
   Throat
   Breasts
   Respiratory



                                                             262
Review of Systems (ROS)
   Cardiovascular
   Gastrointestinal 胃腸的
   Genitourinary 泌尿生殖器的
   Musculoskeletal 肌(與)骨胳的
   Neurological
   Endocrine 內分泌腺
   Psychological
   Hematologic/Lymphatic 淋巴(液)的
   Allergic/Immunologic

                                   263
Consultation Report
   A consultation is the provision of health care
    services by a consulting physician whose
    opinion or advice is requested by another
    physician.
   A consultation report is documented by the
    consultant and includes the consultant’s
    opinion and findings based on a physical
    examination and review of patient records.


                                                 264
Consulting physician
   Review the patient’s record
   Examines the patient
   Documents pertinent findings
   Provides recommendations and/or
    opinions



                                      265
Physician orders (or doctor
orders)
   Direct the diagnostic and therapeutic
    patient care activities
   Should be
       Clear and complete
       Legible, if handwritten
       Dated and timed
       Authenticated by the responsible physician

                                                 266
Type of Order
   Discharge order
   Routine order
   Standing order
   Stop order
   Telephone order
   Transfer order
   Verbal order
   Voice order
   Written order

                      267
Progress Notes
   Contains statements related to the
    course of the patient’s illness, response
    to treatment, and status at discharge.
   The frequency of documenting progress
    notes is based on the patient’s
    condition.


                                           268
Integrated progress notes
   All progress notes documented by
    physician, nurses, physical therapists,
    occupational therapists, and other
    professional staff members are
    organized in the same section of the
    record.



                                              269
Type of Progress Note
   Admission note
   Follow-up progress note
   Discharge note
   Case management note
   Dietary progress note
   Rehabilitation therapy progress note
   Respiratory therapy progress note
   Preanesthesia evaluation note
   Postanesthesia note
   Preoperative note
   Postoperative note

                                           270
Anesthesia Record
   Include
       Patient’s name
       Dosage route and time of administration of drugs
        and anesthesia agents
       I.V. fluids
       Blood or blood products
       Oxygen flow rate
       Continuous recordings of patient status noting
        blood pressure, heart and respiration rate.

                                                       271
Operative Record
   Principle participants (e.g., surgeon, assistant
    surgeon, anesthesiologist, and so on)
   Pre- and postoperative diagnoses
   Surgical procedure performed
   Anesthesia administered
   Detailed evidence that surgically acceptable
    techniques were used
   Indications for surgery
   Condition of the patient (pre-, intra-, and
    postoperatively)
                                                  272
Operative Record
   Detailed description of the operative
    procedure performed (e.g., surgical
    techniques), including organs explored
   Description of operative findings,
    unique elements in the course of
    procedures performed, any unusual
    events that occurred during the
    procedure, and specimens removed.
                                         273
Operative Record
   Description of other procedures
    performed during operative episode.
   Document of ligatures 結紮線, sutures 縫
    合(傷口), number of packs, drains, and
    sponges used




                                       274
Pathology Report
   To contain a detailed and authenticated
    notation of all tissues examined,
    including microscopic findings.
   If only a gross examination is warranted,
    the record is to include documentation
    that the tissue was received and a
    report of the gross description of that
    tissue.
                                          275
Pathology Report
   The pathology report (or tissue
    report) assists in the diagnosis and
    treatment of patients by documenting
    the analysis of tissue removed surgically
    or diagnostically (e.g., biopsy), or that
    expelled by the patients.



                                           276
Pathology Report
   Contents of the pathology report include:
       Date of examination
       Clinical diagnosis
       Tissue examined
       Pathologic diagnosis
       Macroscopic (or gross) examination
       Microscopic examination
       Authentication by pathologist


                                                277
Recovery Room Record
   After the completion of surgery,
    patients are taken to the recovery room
    where the anesthesiologist and
    recovery room nurse are responsible for
    documenting a recovery room record,
    which delineates care administered to
    the patient from the time of arrival until
    the patient is moved to a nursing unit.
                                           278
Recovery Room Record
   Elements of the recovery room record include:
       Patient’s general condition upon arrival to recovery room
       Postoperative/postanesthesia care given
       Patient’s level of consciousness upon entering and leaving the
        recovery room
       Description of presence/absence of anesthesia-related
        complications and/or postoperative abnormalities (may be
        documented in progress notes)
       Monitoring of patient vital signs, including blood pressure, pulse,
        and presence/absence of swallowing reflex and cyanosis 青紫
       Documentation of infusions, surgical dressings, tubes, catheters 導
        管 , and drains
       Written order releasing patient from recovery room (authenticated
        by physician responsible for release) documented in the physician
        orders


                                                                         279
Ancillary Reports
   are documented by such departments as
    laboratory, radiology (or X-ray), nuclear
    medicine, and so on;
   they assist physicians in diagnosis and
    treatment of patients. The responsible
    physician must document requests for
    ancillary testing to be performed in the
    physician orders, and the patient record must
    include documentation of ancillary report
    results as well as a treatment plan.
                                               280
Ancillary Reports
   Laboratory
   Radiology
   Electrocardiogram (EKG or ECG)
   Electroencephalogram (EEG) 腦波圖
   Electromyogram (EMG) 肌電圖
   Transfusion Record


                                     281
Nursing Documentation
   include the following:
       initial assessments and reassessments;
       nursing diagnoses and/or patient care needs;
       interventions identified to meet patient’s nursing
        care needs;
       nursing care provided;
       patient’s response to, and outcomes of, care
        provided;
       and abilities of the patient and/or, as appropriate,
        significant other(s) to manage continuing care
        needs after discharge.

                                                          282
Nursing Documentation
   Nursing Care Plan
   Nurses Notes
   Nursing Discharge Summary
   Graphic Sheet
   Medication Administration Record
   Bedside Terminal System


                                       283
Special Reports
   Obstetrical record consists of the following reports:
       Antepartum record (or prenatal record): Started in the
        physician’s office and includes health history of the mother,
        family and social history, pregnancy risk factors, care during
        pregnancy including tests performed, medications
        administered, and so on. A summary of this information is
        also documented in the hospital patient record or a copy is
        filed at the birthing facility by the 36th week of pregnancy.
       Labor and delivery record: Records progress of the
        mother from time of admission through time of delivery.
        Information includes time of onset of contractions, severity
        of contractions, medications administered, patient and fetal
        vital signs, and progression of labor.
       Postpartum record: Documents information concerning
        the mother’s condition after delivery.

                                                                    284
Special Reports
   Contents of neonatal record include:
      Birth history: Documents summary of
       pregnancy, labor and delivery, and
       newborn’s condition at birth.
      Newborn identification: Immediately
       following birth, footprints and fingerprints
       of the newborn are created, and a wrist or
       ankle band is placed on the newborn (with
       an identical band placed on the mother);
       within 12 hours of birth, an identification
       form is also used to document information
       about the newborn and mother.
                                                 285
Special Reports
    Newborn physical examination: An
     assessment of the newborn’s condition
     immediately after birth, including time and
     date of birth, vital signs, birth weight and
     length, head and chest measurements,
     general appearance, and physical findings
     is completed.
    Newborn progress notes: Documents
     information gathered by nurses in the
     nursery and includes vital signs, skin color,
     intake and output, weight, medications and
     treatments, and observations.
                                                286
Autopsy Report
   An autopsy (or necropsy) is an
    examination of a body after death that
    includes the macroscopic and
    microscopic examination of vital organs
    and tissue specimens to assist in
    determining a cause of death and the
    character or extent of changes
    produced by disease.
                                          287
Autopsy Report
   Summary of patient’s clinical history including
    diseases, surgical history, and treatment
   Detailed results of the macroscopic and
    microscopic findings, including external
    appearance of the body and internal
    examination by body system
   Contributing factors that led to death
   Clinical-pathologic correlation (e.g., medical
    conclusion of patient’s disease process)
   Authentication by pathologist

                                                 288
Hospital Outpatient Record
   Short stay record
   Uniform Ambulatory Care Data Set
    (UACDS)
   Outpatient visit
   Encounter
   Ancillary service unit/occasion of service


                                            289
Uniform Ambulatory Care Data
Set (UACDS)
   The minimum core data set collected on
    Medicare and Medicaid outpatients.
   Patient
   Date and time of encounter or ancillary
    service
   Practitioner
   Place of service
   Active problem(s)
   Service or procedure provided
                                              290
Hospital Outpatient Record
   include a patient registration form similar to
    the inpatient face sheet,
   and depending on the complexity of
    outpatient services provided, additional
    reports can include ancillary reports,
   progress notes,
   physician orders,
   operative reports,
   pathology reports,
   nursing documentation, and so on.
                                                     291
Physician Office Record
   Patient registration form
   Problem list
   Medication list
   Progress notes
   Ancillary reports
   Encounter form (superbill, or fee slip)
       Used in physician offices to capture charges
        generated during an office visit and consists of a
        single page that contains a list of common
        services provided in the office.

                                                             292
Forms Control and Design
   Forms committee or patient record
    committee
   Role of committee
       Facilitate efficient use of patient record
       Streamline the forms approval process
       Ensure documentation is compliant
       Enhance quality of documentation

                                                     293
Forms Control and Design
   When designing a form, the following
    functional characteristics must be considered:
   Determine the purpose of the form.
      Prior to designing the form, outline the
       purpose, use, and users of the form.
      Make sure that the new form will not
       duplicate information that is already
       contained on another form.



                                                294
Forms Control and Design
   Keep the form simple.
      The simpler the form design, the easier it
       will be to design and use.
   Include basic information.
      All forms should contain the title of the
       form, form number, original date of form,
       revision date, and patient identification
       section.
   Include preprinted instructions.
      Instructions for completion of the form
       should be printed on the form (e.g.,
       reverse of the form).                      295
Forms Control and Design
   Plan spacing on the form.
      Consider the type size and margins of the
       form.
      If handwritten information is going to be
       entered on the form, make sure that there
       is sufficient space.
   Use color-coding for various sections of the
    record.
      Consider using a different color border on
       forms for each discipline.
      Select a color of ink, usually black, that will
       photocopy easily.                           296
Forms Control and Design
   Allow for uniformity in size, content, and
    appearance.
      All headings on the various forms used
       should have a standard format.
      Be sure to standardize the size and
       appearance of individual forms.
   Consider paper requirements.
      Consider the weight and quality of paper
       used.
      Reports that are accessed frequently (e.g.,
       face sheet) should be a heavier weight of
       paper so they can withstand frequent use. 297
Forms Control and Design
   Prepare a draft of the form for review
    by the forms committee.
   Pilot the form for trial use (e.g., 30 days)
    on one nursing unit.
       Revisions can be made if necessary.
   Consider adopting ready-to-use forms,
    which can be cheaper to purchase.

                                              298
MRXO
   在臨床醫學中,進行手術時同時使用磁振造影
    並整合各種影像技術是目前最熱門的醫療概念。
    新式的「未來手術室」中,安裝有全球首套
    MRXO 解決方案,即完全整合磁振造影 (MR)、
    X光及電腦斷層掃描 (CT) 系統,大幅減少病
    患危險並簡化醫師的手續,可望提高手術成功
    率。
   這項由日本東海大學、飛利浦醫療系統事業部
    合力推動的「未來手術室」,已經由日本東海
    大學的松前教授、津具醫師、山本醫師共同在
    手術室同時使用 MR (磁振造影) 和 X 光影像技
    術,來進行神經外科手術。
                            299
MRXO
   在「未來手術室」中執行手術,可依執
    刀醫師與病患狀況,在數分鐘內將病患
    從手術台搬移到磁振造影、電腦斷層掃
    描或X光診斷系統,增加手術精密度與
    成功率。在磁振造影和電腦斷層掃描區
    域有拉門。



                        300
     Bringing a new drug to market
                                                                     1 compound
      Review and approval by Food & Drug Administration
                                                                       approved

     Phase III: Confirms effectiveness and monitors
     adverse reactions from long term use in
     1000 to 500 patient volunteers.

      Phase II: Assesses effectiveness and
      looks for side effects in 100 to 500
      patient volunteers

Phase I: Evaluate safety and dosage                    Discovery and preclinical
in 20 to 100 healthy human volunteers.5 compounds testing: Compounds are
                                           enter       identified and evaluated in
                                       clinical trials laboratory and animal
      5000 compounds evaluated                         studies for safety, biological
                                                       activity, and formulation.
   2     3     4    5     6    7    8     9    10    11   12    13    14   15   16
 years                                                                               301

				
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