ESaay paper and ecxel file. Essay should be around 2 pages

 

Learning Outcome: Construct information architectural models

 

Additional Reading:  Data Mapping and Its Impact on Data Integrity.  AHIMA. 2013  http://bok.ahima.org/PdfView?oid=107154

 

1.   Designation

 

Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).    For this assignment, you will access an excel file that contains some of the documents or files that are to be reviewed.  See above link for template.  This is not an exhaustive list.  For each element, you will indicate the primary source of the document.  For example, if your institution has an electronic capture of consent forms, then the source would be the EHR documentation system.  But if consent forms are still done via a paper form, then you would indicate that the source is paper.   Examples of the primary sources are given below.  This is not a complete list, so if your institution has a different source for the information, you are free to use that. 

 

Examples of Primary Sources

 

    Paper

    CPOE

    Nursing documentation system

    EHR documentation system

    PACS (Picture Archiving and Communication System)

    Transcription

    Financial System

    Administration system

    Admitting documentation system

 

 

 

You will also indicate if the document/file is part of the Designated Record Set or the Legal Health Record. Part of the assignment includes formatting the file in a way that is user friendly to the reader.  This may include regrouping some of the items, using shading or borders to help the end user find information, or you may need to add additional columns to capture the information you feel is important (although additional columns are not required).  If your entries do not fit into the template column width, please format so that the entry is wrapped in the cell.

 

The comment section can be utilized for any clarification you may wish to make.

 

 

 

2.   Retention

 

 In addition, you will research the retention requirements for these documents.  In some areas, there are no specific guidelines.  It is up to the institution to determine the retention period.  If you cannot find a specific time period, either check with your institution, or use your best judgement and indicate your reasoning in the comment section.

 

 

 

 Resources

 

State Medical Record Laws.  Table A-7. HealthIT.   https://www.healthit.gov/sites/default/files/appa7-1.pdf

 

 Retention and Destruction of Health Information.  AHIMA.  2013.  (http://library.ahima.org/PB/RetentionDestruction#.V9LcAzW8JsU

 

 

 

3.   Reflection

 

Write a two -three paragraph reflection on how this exercise (identifying the source and type of document) will help when mapping the components and structuring an EHR.

LHR/DSR Matrix (80 points )



 

Grading Rubric: LHR/DSR Matrix (80 points)

 

Excellent

Good

Poor

LHR/DRS Designation (30 points)

30-26 points: Is able to distinguish if an element is LHR, DRS, Both or none. Provides source material to justify decision.

25-21 points: Is able to distinguish if an element is LHR, DRS, Both or none in most cases. .

21-0 points: Does not demonstrate a grasp of the differences between LHR and DRS.

Retention

(25 points)

25-23 points: Retention is noted for every item. The retention is consistent with federal, licensing, state, and accreditation guidelines. Justification is noted in the comment section.

22 -19 points: Most items have a retention date. The majority are consistent with federal, licensing, accreditation or state guidelines. Justification is noted in the comment section.

18-0 points:

Only a few items have a designated retention date. Dates are not based on guidelines. No or little justification is provided.

Reflection (15 points)

15-13 points: Reflection is well written and supports opinion regarding the importance of making these distinctions.

12-10 points: Reflection indicates some depth of thought regarding the importance of making these distinctions.

8-0 points: Reflection is not present, or does not provide any insight as to their opinion regarding the importance of making these distinctions.

Mechanics

(10 points)

10-9 points: No proofreading errors.

Use of shading, borders, etc. Easy to read and navigate

8-7 points: 1-3 proofreading errors. Easy to read. Uses some formatting and borders. Easy to navigate.

6-0 points:

More than 3 errors. There is no use of formatting to make the documents easy to follow.


http://library.ahima.org/PB/RetentionDestruction#.WMGCPo6gRtN

Additional Reading:  Data Mapping and Its Impact on Data Integrity.  AHIMA. 2013  http://bok.ahima.org/PdfView?oid=107154

Rubric 

Due Week 1 Day 7

Submit your Matrix in Assignments via the left

Sheet1

Name of Document/File Primary Source Part of DRS (Y or N) Part of LHR (Y or N) Designation Comments Retention Period Retention Comments
Advance directives
Ancillary notes (PT, OT, Social Service)
Autopsy report
Billing statements Financial System
Coding queries
Consent forms
Consults
Copy of patient insurance card
Discharge summary Transcription Y Y
EKGs
Emails of patients checking on an appointment
Emergency department treatment record Paper Y Y
EOBs for the patient
H & P
Incidence reports
Information brought in by the patient Admitting documentation system
Initial office visit Admitting documentation system
Insurance information Financial System
Lab work Computerized Physician Order Entry (CPOE)
Medications CPOE
Op notes
Op notes
Pathology reports
Pathology slides Y Y
Pop up alerts
Post it notes with vitals that have been entered into the EHR
Progress/office notes
Psychotherapy notes
Quality improvement (peer review) records
Radiology films Y Y
Radiology reports Y Y
Release of information forms
Reports sent from other providers not used for treatment Y Y
Research data
Tumor registries N N
Videos Y Y

Data Mapping and Its
Impact on Data Integrity

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

AUTHORS AND CONTRIBUTORS:
Linda Hyde, RHIA; Theresa Rihanek, MHA, RHIA, CCS; Terry Santana-Johnson, RHIT,
CDIP, CCS, CCS-P; Rita Scichilone, MHSA, RHIA, CCS, CCS-P; Cortnie Simmons, MHA,
RHIA, CCS; Jane Beth Turner, RHIA; Wendy Zumar, MA, RHIA, CCS

ACKNOWLEDGEMENTS:
Sue Bowman, MJ, RHIA, CCS, FAHIMA; June Bronnert, RHIA, CCS, CCS-P;
Marlisa Coloso, RHIA, CCS; Angie Comfort, RHIT, CDIP, CCS; Katherine Downing, MA,
RHIA, CHP, PMP; Lesley Kadlec, MA, RHIA; Cheryll Rogers, RHIA, CDIP, CCS, CTR;
Joanne Romasko, RHIA, CPC, CHDA; Rayna Scott, RHIA, CHDA, MS

EDITOR:
Anne Zender

DESIGN:
Maria Sitelis

Representing more than 71,000 specially educated health information management
professionals in the United States and around the world, the American Health Information
Management Association is committed to promoting and advocating for high quality
research, best practices, and effective standards in health information and to actively
contributing to the development and advancement of health information professionals
worldwide. AHIMA’s enduring goal is quality healthcare through quality information.

© 2013

ahima.org

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

1 | AHIMA

INTRODUCTION

The current rise in data mapping projects is the result of the need to link disparate electronic data
systems in a rapidly changing environment. Mapping projects are valuable in a variety of situations
where data elements from one code or data set are compared to another set and evaluated for
equivalence of meaning to accomplish a defined “use case.” Code sets related to health information
functions include CPT and its modifiers, ICD-9-CM, ICD-10-CM/PCS, and HCPCS level II, as well as
LOINC, Rx NORM, and SNOMED CT®. Additionally, quality measures such as those used by the Agen-
cy for Healthcare Research and Quality and National Quality Forum are frequently linked to these
code sets and may require internal mapping to ensure accurate measurement. Data mapping is not
limited to just these code sets; there are many different types of maps in the healthcare realm.

The increased demands for data sharing and interoperability, especially across different practice
settings and different classification systems, increase reliance on data mapping tools and techniques.
The use of these tools requires frequent integrity checks. Understanding the role and context of
data maps, as well as their strengths and weaknesses, is essential in ensuring the reliability of the
data entries derived from maps. Data mapping tasks may be as simple as matching a provider’s
administrative codes for disposition to an external standard such as UB-04 or taking a more
complex clinical con

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention
Periods for Records Held by Medical Doctors and Hospitals*

Summary of statutory or regulatory provision by entity.

State Medical Doctors Hospitals

Alabama As long as may be necessary to
treat the patient and for medical
legal purposes.
Ala. Admin. Code r. 545-X-4-.08
(2007).(1)

5 years.
Ala. Admin. Code § 420-5-7.10 (adopting
42 C.F.R. § 482.24).

Alaska N/A Adult patients
7 years following the discharge of the
patient.
Minor patients (under 19)
7 years following discharge or until patient
reaches the age of 21, whichever is longer.
Alaska Stat. § 18.20.085(a) (2008).

Arizona Adult patients
6 years after the last date of
services from the provider.
Minor patients
6 years after the last date of
services from the provider, or until
patient reaches the age of 21
whichever is longer.
Ariz. Rev. Stat. § 12-2297 (2008).

Adult patients
6 years after the last date of services from
the provider.
Minor patients
6 years after the last date of services from
the provider, or until patient reaches the
age of 21 whichever is longer.
Ariz. Rev. Stat. § 12-2297 (2008).

Arkansas N/A Adult patients
10 years after the last discharge, but
master patient index data must be kept
permanently.
Minor patients
Complete medical records must be retained
2 years after the age of majority (i.e., until
patient turns 20).
016 24 Code Ark. Rules and Regs. 007 §
14(19) (2008).

California N/A(1) Adult patients
7 years following discharge of the patient.
Minor patients
7 years following discharge or 1 year after
the patient reaches the age of 18 (i.e.,
until patient turns 19) whichever is longer.
Cal. Code Regs. tit. 22, § 70751(c) (2008).

Colorado N/A(1) Adult patients
10 years after the most recent patient care
usage.
Minor patients
10 years after the patient reaches the age
of majority (i.e., until patient turns 28).
6 Colo. Code Regs. § 1011-1, chap. IV,
8.102 (2008).

(continued)

A-68

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention
Periods for Records Held by Medical Doctors and Hospitals*
(continued)

State Medical Doctors Hospitals

Connecticut 7 years from the last date of
treatment, or, upon the death of
the patient, for 3 years.
Conn. Agencies Regs. § 19a-14-42
(2008).

10 years after the patient has been
discharged.
Conn. Agencies Regs. §§ 19-13-D3(d)(6)
(2008).

Delaware 7 years from the last entry date on
the patient’s record.
Del. Code Ann. tit. 24, §§ 1761 and
1702 (2008).

N/A

District of
Columbia

Adult pa