Description
SCENARIO
You are the manager of HIM and are assisting the director of HIM complete preparatory steps for a new Cancer Registry system. The software company has asked for several items related to the development of the system, and the director needs to prepare to meet all needs of the cancer registry. The director has three incomplete tasks and wants you to finish them for her.
INSTRUCTIONS
First, review the provided resources below:
Patient Visit Form
HIM3360-Deliverable-06-Patient-Visit-Form.pdf
United States Core Data for Interoperability
Data Dictionary Type Table
Data Dictionary Table Type.docx
Next, use the Data Compliance Documentation
and the information in the above provided resources to complete the following:
HIM3360-Deliverable-06-Data-Compliance-Documentation.rtf
Part One – Data Elements
Use the Patient Visit Form, determine if the 44 numbered items correspond to the ONC Data Element List or do not correspond.
Review and record all the missing items from the Patient Visit Form in the table.
Please note: Fourteen of the items on the Patient Visit Form are completed for you. When complete, all numbered items on the Patient Visit Form [1-44] will be listed somewhere in the table – only one time. The bottom row in the table is for items numbered on the Patient Visit Form that do NOT correspond to an ONC Data Element
Part Two – Data Dictionary
Use the Data Dictionary Type Table, complete the green empty fields for the cancer registry data:
Attribute
#Type
Length
Definition
Format
Part Three – Evaluation
Evaluate the interoperability needs of the cancer registry by completing the green empty fields for data sharing and exchange category and purpose.
General Requirements
Uses professional language and tone with correct spelling, grammar, and punctuation in the data compliance documentation.
Unformatted Attachment Preview
New Patient Visit Form-Patient Input
New Hope Rd
Healthy, Montana
1.Name:
3. Address:
5. Today’s Visit Date:
2. DOB/Age:
4. Gender :
6. Telephone #:
M
F
7. Insurance :
General Patient History
8. Have you ever been hospitalized? No Yes → Describe
9. Have you had any serious injuries and/or broken bones No Yes → Describe
____________________________________________________
10. Have you ever received a blood transfusion? Unknown No Yes → Approximate year(s)
___________________________________________
11. Have you ever traveled or lived outside the United States or Canada? No Yes → When and
where ______________________________________________
Past Medical History
Describe Here
Yes
No
Describe Here
Yes
No
12. Abnormal Chest Pain
13. Mental health issues
14. Diabetes
15. Bronchitis, pneumonia, COPD
16. High Blood Pressure
17. Stroke of TIA
18. Heart Disease
Social History
19. Are you disabled?
20. Ever used illegal or street drugs?
21. Consume Alcohol?
22. Smoke cigarettes, pipe or cigars?
23. Use chewing tobacco?
24. Consume Coffee, Tea or Soda?
25. What is your highest level of education?
Page 2, LiveWell New Patient Visit Form, Social History Continued
26. Employment Status and Occupation information.
Family History
Parent
Grandparent
Sibling Children
27. Heart Disease
28. Cancer – specify type
29. Diabetes
30. High Blood Pressure
31. Asthma
32. Alzheimer’s/Dementia
Systems Review
33. Do you have allergies? No Yes → Describe
34. Significant headaches, seizures No Yes → Describe
35. Bothered with cough, sneezing, shortness of breath? No Yes → Describe
36. Chest pain, rapid or irregular heart rate? No Yes → Describe
Questions 37 through 40 are for female patients only
37. Have you ever had an abnormal pap smear? No Yes Unknown
38. When was your last mammogram? (Record ‘Never’ if you’ve not had one)
39. Ever had an abnormal mammogram? No Yes → Describe
40. Indicate the number of
________ Pregnancies ______ Live Births _____ Miscarriages/Abortions
41. Patient Signature (Parent sign for Minors)
Date
42. Record Parent Name and DOB
when signing for minor on line 30
43. New Patient Visit Form Abstracted
by staff member (name and employee #):
44. Date Abstracted:
Deliverable 06 – Data Compliance Documentation
Data Dictionary Type Table
Sources
Deliverable 04 – Medical Record Documentation Tool
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Medical Record Documentation Tool
A.
B.
C.
State
Public
Health Record Regulation
CMS Condition
Health
(Locate and identify generally
of
Department
matching words; not exact
Participation
matching words to those listed
D.
Department
Procedure
Regulation
below.)
Confidentiality of Patient Records
Record entries cannot be back-dated
Medical record for each patient
evaluated, treated
Medical Record Department is
Adequately Staffed
Organized in a fashion that
facilitates location and retrieval of
records
A medical history and physical exam
Integrity of Authentication/signed
by responsible party
Medical Record Retention
Requirements
Addendums should be timely and
bear the current date and reason
A System for Coding and Indexing
Medical Records
Demonstrate a method to prevent
the alteration of an authenticated
record or method to properly
evidence a late entry
“Medical Record” includes written
notes, radiology, lab, etc.
Records compliant with HIPAA
Record contains a unique patient
identifier/number
Contain Notes to Justify Continued
Stay; Continuing Care
Records must be safeguarded against
loss and unauthorized access
Never obliterate entries using black
marker or correction fluid
Records must document any refusal
of services
Entries must be Dated, Signed,
Authenticated and Legible
Document the Course and Results of
Care Provided; Document with
factual data
Use only hospital approved
abbreviations
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Deliverable 04 – Medical Record Documentation Tool
22
23
24
25
Verbal (telephoned) Orders must be
Authenticated
Records of minors must be retained
for a period beyond the age of
majority
System in place to identify
incomplete or deficient records
Yes
Yes
No
Yes
No
Categorize the source regulation
in columns B, C and D as either:
• Internal
(regulation/guideline)
• External
(regulation/guideline)
Analyze Patient Office Record
Regulation
26. State Dept Health Regs: Each
patient has a unique identifier
27. CoP: Records must be
completed within 30 days of
service.
28. Department Procedure: All
General Documentation
Requirements
Yes or No:
Does it meet
the listed
regulation?
Justify the ‘Yes or No’ in previous column with
complete sentence(s) below.
Sources
Deliverable 04 – Medical Record Documentation Tool
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Medical Record Documentation Tool
A.
B.
C.
State
Public
Health Record Regulation
CMS Condition
Health
(Locate and identify generally
of
Department
matching words; not exact
Participation
matching words to those listed
D.
Department
Procedure
Regulation
below.)
Confidentiality of Patient Records
Record entries cannot be back-dated
Medical record for each patient
evaluated, treated
Medical Record Department is
Adequately Staffed
Organized in a fashion that
facilitates location and retrieval of
records
A medical history and physical exam
Integrity of Authentication/signed
by responsible party
Medical Record Retention
Requirements
Addendums should be timely and
bear the current date and reason
A System for Coding and Indexing
Medical Records
Demonstrate a method to prevent
the alteration of an authenticated
record or method to properly
evidence a late entry
“Medical Record” includes written
notes, radiology, lab, etc.
Records compliant with HIPAA
Record contains a unique patient
identifier/number
Contain Notes to Justify Continued
Stay; Continuing Care
Records must be safeguarded against
loss and unauthorized access
Never obliterate entries using black
marker or correction fluid
Records must document any refusal
of services
Entries must be Dated, Signed,
Authenticated and Legible
Document the Course and Results of
Care Provided; Document with
factual data
Use only hospital approved
abbreviations
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Deliverable 04 – Medical Record Documentation Tool
22
23
24
25
Verbal (telephoned) Orders must be
Authenticated
Records of minors must be retained
for a period beyond the age of
majority
System in place to identify
incomplete or deficient records
Yes
Yes
No
Yes
No
Categorize the source regulation
in columns B, C and D as either:
• Internal
(regulation/guideline)
• External
(regulation/guideline)
Analyze Patient Office Record
Regulation
26. State Dept Health Regs: Each
patient has a unique identifier
27. CoP: Records must be
completed within 30 days of
service.
28. Department Procedure: All
General Documentation
Requirements
Yes or No:
Does it meet
the listed
regulation?
Justify the ‘Yes or No’ in previous column with
complete sentence(s) below.
Deliverable 06 – Data Compliance Documentation
Part One – Data Elements
ONC Data Element
List – USCDI V1
Corresponding Numbered (1-44) Item from Patient Visit Form
Allergies and Intolerances
Health Concerns
Provenance
Immunizations
Assessment and Plan of
Treatment
Care Team Members
Laboratory
Smoking Status
Medications
Unique Device Identifiers
Clinical Notes
Patient Demographics
Vital Signs
Problems
Goals
Procedures
NOT part of ONC Data
Element List
8
9
27
35
31
13
44
38
1
6
40
5
42
19
Part Two – Data Dictionary
Complete all the green empty fields below.
Attribute
#Type
Patient_ID
Autonumber
Patient Lname
Text
Patient Mname
Length
Definition
Format
Unique patient identifier
xxxxxxxx
35
Legal last name
Alpha plus
hypens
20
Legal first name
Alpha
Patient’s first visit to cancer
center
Y, N
8
Date of birth, 8 digits
MMDDYYYY
8
Date Cancer Diagnosis, 8 digits
MMDDYYYY
Text
Pick list
DOB
Date/time
Deliverable 06 – Data Compliance Documentation
Cancer Category
Pick list
Major Cancer
Site
Pick list
Carcinoma, Sarcoma, Myeloma,
Leukemia, lymphoma, Mixed.
2
Ca, Sa, My,
Le, Ly, Mx
Skin, Lungs, Female breasts,
Prostate, Colon/rectum, Uterus
Date Initial
Treatment Started
Date
Reoccurrence
Date/Time
Cancer Stage
Pick list
2
Stage Category
Tumor, AJCC staging
T0, T1, T2, T3, T4
Nodes, AJCC staging
Nx, N0, N1, N3, N4
Metastases, AJCC staging
M0, M1
Cancer Category from Staging
0, I, II, III, IV
Part Three – Evaluation
Complete all the green empty fields below.
DATA SHARING AND EXCHANGE CATEGORY
Monthly submission of cancer cases to the state
Annual submission of cancer cases to national
cancer database
PURPOSE
Governance, mandatory reporting requirement
Provide diagnosis and treatment data to patient
Providers-physicians, therapist, Nurse
Practitioners, etc.
Continuum of care, future treatment and
diagnosis centers
Billing/insurance
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