for Documentation Medical
Records
Chapter 4, pp.74-82; Ch. 5, p. 93
Reference to LaTour Ch. 8, pp. 226-227
Indexes & Registries
Lecture notes
1
2007
Value Databases, Reporting
Facility-specific reports
Reveal trends
Contribute to improvement of health for general
public
Support state and national indexes, registries and
databases
2007
Data for Research and Statistics
Aggregate data (HIM function)
Clinical and administrative decision support
Research assistance
Review of selected records
Maintenance of indexes for record sorting
Quality control for statistical accuracy
Clinical trial information
2007
Public Health Reporting
Centers for Disease Control and Prevention
WONDER Database
disease prevention, health promotion
National Center for Health Statistics (NCHS)
information on incidence and prevalence
Department of Health and Human Services Data
Council
policy, health information standards issues
National Health Care Survey
2007
Vital Statistics
Births, deaths, fetal deaths, marriages, divorce
States share information with NCHS
National Committee on Vital and Health
Statistics (NCVHS)
coordination
2007
Facility-Specific Indexes
Meet specific customer needs
for reporting
retrieve records by disease, physician, operation
other purposes
Format: Paper cards, microfilm, electronic
2007
Master Patient Index (MPI)
Identifies by name and number ALL patients
treated in a health facility system
or Typically retained as a permanent record
Data is administrative, demographic (p .93)
Data elements should: (p. 78-81)
Be accurate, match persons treated/registered for care
Have minimal duplicates (e.g., same person under two names)
Link to health records/record system
Have merging capability to an enterprise MPI (EMPI)
2007
Master Patient Index (MPI), cont.
See LaTour, pages 227-228 for more on MPI:
Electronic v. manual format
Challenge of duplicate patient data
List of data elements in an MPI
Movement toward a single national patient
identifier (pro and con)
2007
Physician Index
Patients categorized by primary physician
Guides record retrieval, case finding
Assists in physician credentialing
Data elements include: (see p. 79)
Physician name and/or number
Patient record numbers
Dates of admission
Diagnoses and operations
2007
Disease and operation indexes
Patients categorized by disease and operation
Supports record retrieval for education, for
research, quality improvement studies
Data elements include: (see p. 79)
Principal diagnosis with codes
Procedures with codes
Patients age, gender
Attending physicians name
2007
Registries
Chronological listing of patients with common
characteristics (e.g., birth, trauma, disease such
as cancer)
More detailed than indexes, used for follow-up
and aggregate study
Maintenance involves
Case definition
Case finding
Case abstracting
2007