I need some help on documentation keywords...

[todell80]

Last week we were given a worksheet with some documentation key words that will be on a test this Wednesday. I found most of them in our book, however, I am having some trouble with a few. I thought maybe some of you might see more of a relevence than I do. Here are the ones I'm stuck on:

Peer Review

Audit

Referral Summary

Statistics

Discussion (which is seperate from Report)

Thank you all so much in advance, I appriciate any help or ideas anyone might have.

~t

[Daytonite, BSN, RN]

peer review is the evaluation of the professional performance by other people of equal standing within the same profession. what is probably key about peer review is that it was brought to prominence by the social security act of 1975 which created a nationwide review agency called the professional standard review organizations (psros). under psros peer review of medicare cases was to be conducted on the physicians providing care to medicare patients at hospitals to assure that medicare patients were being provided the highest quality of care as well as appropriate and efficient use of each particular facility's health care services. this act was repealed and has been replaced over the years by several different laws. currently, each state, by federal law, is required to have a peer review organization that has agreements with every facility in their state taking on medicare and medicaid patients to hold regular peer review activities of it's physicians. these state peer review organizations have a great deal of power. they still review the care physicians are giving to medicare patients. they can deny a hospital reimbursement for providing substandard care and recommend that a practitioner be suspended from the medicare and medicaid programs as preferred providers as well as levy fines for a pattern of poor performance. don't ever doubt that medicare isn't a strong force in healthcare issues!

audit - i am assuming that this is in referral to the retrospective review of healthcare records (charts) or healthcare data in order to evaluate the quality of care or services that were provided to the patient and compared them against pre-determined standards of care. a peer review is a form of retrospective audit. jcaho (joint commission on accreditation of healthcare organization) also conducts audits of healthcare records during their surveys.

referral summary - this is the bottom or end section of a physician referral where the consulting physician gives his opinion about a patient's condition based on a review of the patient's records, an examination of the patient, and a conference with the attending physician. with referrals, the referring physician may or may not be invited by the attending physician to also become a participant in the patient's care or to merely advise the attending physician.

statistics - not sure what you are looking for here. there are all kinds of healthcare statistics. the ones of most focus today are mortality and morbidity rates, autopsy rates, measures of central tendency and dispersion and determination of the most appropriate use of these statistics in the health information management office. many of the healthcare statistics are derived from the demographic information from patient charts and used to create tables, graphs and figures. this data is used to determine hypotheses and data must be deemed appropriate for certain types of statistics. these are all functions that are carried out by health information management professionals. the demographic data of all medicare and medicaid patients treated at acute hospitals and some other types of facilities receiving federal reimbursements for the care of these patients is transmitted to cms (center for medicare and medicaid services) on a regular basis to form the basis of one of the largest databases of statistical information of healthcare in the world. this data is used to determine rates of reimbursement for services as well as other types of trending.

discussion (which is separate from report) - not sure what you are looking for with this!

[todell80]

Thank you so much for that info. Most of my classmates had not started looking at the words, but I finally got ahold of one who said the same thing (although not w/ so much great info), and had some ideas on what they meant by "statistics." We are still both confused on the "Discussion," but I guess if we know all but one that isn't too bad. Hopefully our instructors will tell us what they want in class Tues., last week they avoided it though. Maybe its a test of our research capabilities!! Thanks again for the great response, I appriciate it a lot!

~t

[Daytonite, BSN, RN]

I was just thinking that in some reports there may be a section called Discussion where they kind of give their rationale on the thinking process of how they came to the final decision they made. This may be a section in research papers, not sure. It's been so long since I took my class in research and I haven't read a research paper in ages. I'd just never seen it in a list of terms before.

[todell80]

Just wanted to follow up on this. Turned out I freaked out for no reason, yesterday during class my instructor went over all the definitions during lecture. But you guys were right on the mark w/ your ideas. Some of them sounded word for word of what she said!! Anyway, the test is today over the keywords, hopefully it will all go good.

~t