No, building No) Patient Alternate Address, City/Province O 250 IHE PIX Patient Alternate Address, State O 250 IHE PIX Patient Alternate Address, Zip Alternate State O 250 IHE PIX, ISO Ref US Postal Codes Patient Alternate Address, Country O 250 CP to IHE PIX Patient Alternate Address, Country Code Numeric O 4 CP to IHE PIX Patient E-mail Address Text O 250 CP to IHE PIX Emergency Contact Name, First O 250 CP to IHE PIX Emergency Contact Name, Middle O 250 CP to IHE PIX Emergency Contact Numeric O 250 CP to IHE PIX Emergency Contact Phone Numeric O 250 CP to IHE PIX Emergency Contact Number-Cell Numeric O 250 CP to IHE PIX
Address Text O CP to IHE PIX STOP REVIEW HERE Public Health/Population Health Information – RISK MANAGEMENT/INFECTION CONTROL Public Health/ Population Health Information Data Element Name Format/Value Optionality Field Length Standard AHIMA Other AHIMA Other Have you been out of the country in the last three weeks Other public health population health questions? – Risk Management/Infection Control Insurance Information Patient Insurance Information – Get from ASC X12 Data Element Name Format/Value Optionality Field Length Standard AHIMA X12 AHIMA X12 Insurance Provider Name (payer) Text R 250 Standards Insurance Provider Type (payer) Number R XXX PHDSC Payer Typology Insurance ID Number R 250 ADD MORE Payment Information Payment Information – Get from ASC X12 Data Element Name Format/Value Optionality
4. Ability to document that the information governance program includes its information management and information control policies and procedures. 2, 3, 5, 7, 11 Steps 2, 3, 5, 7, 11 5. Ability to: document the principles and processes that govern the information governance program accurately and completely record the activities undertaken to implement the information governance program and respond to authorized interested party in a timely manner. – See Availability #1 Steps 2, 3, 5, 7, 11 Steps 2, 3, 5, 7, 11 6. Ability to have procedures put in place to control access to protected information, whether it relates to the confidentiality of information or the confidentiality of proprietary processes. – See Protection #6, #7 and #8 Steps 2, 3, 4, 7, 8, 9, 11 Steps 2, 3, 4, 5, 7, 8, 9, 11 7. Ability to create and manage the records documenting an organization’s information governance program, to ensure its structure, processes, and practices are transparent, understandable, and available as defined by organizational policies and jurisdictional laws (e.g., in time, appropriate requestors, etc.). – See Accountability #3 and #4 Steps 3, 11 Steps 3, 11 8. Ability of an organization to ensure that stakeholders are made of how health information is created, acquired, collected, maintained, used, shared and disclosed. – See Availability ##1-9, #14 and #16 Steps 3, 11 Steps 3, 11 9. Ability to demonstrate transparency through clear descriptions of the uses and sharing of identified, de-identified and information on an individual, or aggregate healthcare information. – See Availability ##1-9, #14 and #16; Protection #3 Steps 3, 11 3, 11
HIM Practice Checklist: <Name> - TO BE DEVELOPED Business Requirement List of by Actor, by Workflow Step List of Documents/Records/Data by Actor, by Workflow Step Conformity Assessment: <Name> - TO BE DEVELOPED References -- TO BE DEVELOPED Patent Registration Use Cases Use Case Name: Patient Registration – Inpatient Admission Scheduled via Call or in Person & Admit Actors Business Actors: Patient, Referring/Ordering Physician, Scheduler, Insurance Verifier Registrar Technical Actors: EHR system & Registration-Admission, Discharge and Transfer System(R-ADT) # of Step Workflow Steps Record, Documents and Data Scheduling 1 Scheduling includes one or more of the follow activities; pre-admission scheduling, physician referrals, physician ordered, or patient presents at hospital scheduling/admissions department to schedule admission. Pt demographics (name, DoB, address, Insurance ID) Admission demographics (enterprise medical record number, attending physician name, date, time, service, admitting diagnosis, chief complaint, anticipated procedure) 2 Registration Staff - identifies patient and schedules the admission 3 Registration staff queries patient about diagnosis and treatment, assigns codes for diagnosis and procedures ICD-10 CM & PCS codes 4 Registration Staff - validates patient information, verifies medical insurance coverage, requests insurance admission authorization insurance authorization number Patient Admission 5 Patient presents at hospital 6 Registration staff asks patient to sign consents, acknowledgements, and authorizations, patient is given notices and information in accordance with policy. Notice of privacy practices, consent to treatment, admission agreement, consent directive, and advanced directive 7 Registration staff enters updated patient information and scans documents into EHR Updated medical record or encounter record? 8 Registration staff initiates either room assignment or bed assignment Updated medical record or encounter record? Entry Condition EHR - registration Exit Condition EHR - triage Quality requirements Real time patient information verification
Technical Actors: EHR system, Patient Portal, mHealth application # of Step Workflow Steps Record, Documents and Data Scheduling 1 Patient calls/comes to clinic to schedule a visit Pt demographics (name, DoB, address, Insurance ID) Visit demographics (clinic name, provider name, date, time) Reason for visit 2 Registration schedules the visit 3 Registration staff validates patient information and assembles record for the visit Same as above New visit record is open Patient Visit 4 Patient comes to the clinic 5 Registration staff asks patient to complete medical summary information and consents Medical Summary , Consents 6 Registration staff enters updated patient information and assembles record for the visit Updated visit record 7 Registration staff sends visit record to clinician Updated visit record Condition EHR - registration Exit Condition EHR - triage Quality reqs Real time patient information verification Use Case Name: Patient Registration – Outpatient Visit Scheduled Online Actors Business Actors: Patient, Registrar Staff Technical Actors: EHR system, Patient Portal, mHealth application # of Step Workflow Steps Record, Documents and Data 1 Patient schedules visit using patient portal or mHealth application Pt demographics (name, DoB, address, Insurance ID) Visit demographics (clinic name, provider name, date, time) Reason for visit 2 Registration staff is notified about scheduled visit completed via patient portal or mHealth application Notification about scheduled visit 3 Registration validates patient information and send confirmation to patient regarding scheduled visit via patient portal or mHealth application New record is open Confirmation about scheduled visit 4 Patient comes to the clinic 5 Registration staff asks patient to complete medical summary information and consents Medical Summary , Consents 6 Registration enters updated patient information and assembles record for the visit Updated visit record 7 Registration staff sends visit record to clinician Updated visit record Entry Condition Patient Portal, mHealth application and EHR-registration Exit Condition EHR - triage Quality reqs Real time patient information verification References TBD