Comparative Records for
Health Information
Management,
Delmar Learning
Comparative Health
Information
Management, 2e
Delmar Learning
CHAPTER 1
INTRODUCTION
THE CHANGING FACE OF
HEALTH CARE IN AMERICA
United States Hospitals and
Twentieth Century Health Care
Payment Issues Affecting Health
Care Delivery
Technological and Other issues
Affecting the Delivery of Health Care
IMPACT ON THE ROLE OF THE
HEALTH INFORMATION
MANAGER
CHAPTER 1
INTRODUCTION
THE CHANGING FACE OF
HEALTH CARE IN AMERICA
U.S. Hospitals and TwentiethCentury Health Care
Payment Issues Affecting Health
Care Delivery
Technological and Other Issues
Affecting the Delivery of Health Care
IMPACT ON THE ROLE OF THE
HEALTH INFORMATION
MANAGER
Other Regulatory and Accreditation
Issues Affecting Health Care
CHAPTER 2
HOSPITAL-BASED
AMBULATORY CARE
INTRODUCTION TO SETTING
Types of Settings
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Licensure
Federal Regulations
Accreditation
DOCUMENTATION
JCAHO Documentation
Requirements
Other Factors in Ambulatory Care
Documentation
REIMBURSEMENT
Medicare
CHAPTER 2
HOSPITAL-BASED
AMBULATORY CARE
INTRODUCTION TO SETTING
Types of Settings
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Licensure
Federal Regulations
Accreditation
DOCUMENTATION
JCAHO Documentation
Requirements
Other Factors in Ambulatory Care
Documentation
REIMBURSEMENT
Medicare
Ambulatory Patient Groups
Other Payers
Billing
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement (QI)
Utilization Management (UM)
RISK MANAGEMENT AND
LEGAL ISSUES
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Other Payers
Billing
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement (QI)
Utilization Management (UM)
RISK MANAGEMENT AND
LEGAL ISSUES
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ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Centralized Health Information
Services
Specialized Outpatient Areas
Billing Compliance Director
Chargemaster Coordinator
TRENDS
CHAPTER 3
FREESTANDING
AMBULATORY CARE
INTRODUCTION TO SETTING
Care Settings
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Licensure
Accreditation
DOCUMENTATION
Registration/Demographic
Information
History and Physical
Laboratory and X-ray Reports
Progress Notes
Encounter Form
Copies of Hospital Records
Problem List
Special Requirements
Record Format
Patient Identifier/Filing Methods
REIMBURSEMENT
Fee for Service
Resource-Based Relative Value
System
Ambulatory Surgery Center Groups
Capitation
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Record Linkage to Other
Sites/Facilities
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
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ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Centralized Health Information
Services
Specialized Outpatient Areas
Compliance Officer
Chargemaster Coordinator
TRENDS
Hospital Chargemaster or Charge
Description Master (CDM)
CHAPTER 3
FREESTANDING
AMBULATORY CARE
INTRODUCTION TO SETTING
Care Settings
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Licensure
Accreditation
DOCUMENTATION
Registration/Demographic
Information
History and Physical
Laboratory and X-Ray Reports
Progress Notes
Encounter Form
Copies of Hospital Records
Problem List
Special Requirements
Record Format
Patient Identifier/Filing Methods
REIMBURSEMENT
Fee for Service
46
Ambulatory Surgery Center Groups
Capitation
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Record Linkage to Other
Sites/Facilities
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
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86
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91
PROFESSIONAL
TRENDS
CHAPTER 4
MANAGED CARE
INTRODUCTION TO SETTING
Types of Managed Care
Organizations
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Governmental Regulation
Voluntary Accreditation
DOCUMENTATION
Staff Model
Group Model Through Managed
Indemnity Plans
REVENUE GENERATION
Managed Care Organization Revenue
Reimbursement to the Provider of
Care
Coordination of Benefits
INFORMATION MANAGEMENT
Coding and Classification Systems
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Identifying Unusual Events
Informed Consent for Procedures
Credentialing
Contract Management
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Developing and Implementing
Information Plan Based on
Organizational Needs
Specialized Functions
TRENDS
Integrated Delivery
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PROFESSIONAL
TRENDS
Medicare Certification
Other Regulations: Compliance
Medicare Physician Fee Schedule
Ambulatory Payment Classification
(APCs)
Medicaid-Early and Periodic
Screening, Diagnostic, and
Treatment (EPSDT) Service
Reimbursement Resources
CHAPTER 4
MANAGED CARE
INTRODUCTION TO SETTING
Types of Managed Care
Organizations
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Governmental Regulation
Voluntary Accreditation
DOCUMENTATION
Staff Model
Group Model Through Managed
Indemnity Plans
REVENUE GENERATION
Managed Care Organization Revenue
Reimbursement to the Provider of
Care
Coordination of Benefits
INFORMATION MANAGEMENT
Coding and Classification Systems
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Identifying Unusual Events
Informed Consent for Procedures
Credentialing
Contact Management
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Developing and Implementing
Information Plan Base on
Organizational Needs
Specialized Functions
TRENDS
Integrated Delivery
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Systems/Networks
Possible Dissolution of
fee-for-Service Medicine
CHAPTER 5
DIALYSIS
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Surveys
Federal Regulations
Joint Commission on Accreditation of
Healthcare Organizations
ESRD Networks
DOCUMENTATION
REIMBURSEMENT
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management (UM)
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
CHAPTER 6
CORRECTIONAL FACILITIES
INTRODUCTION TO SETTING
State Departments of Correction
Operation by State versus Contracted
Firms
Prisons
Jails
Juvenile Facilities
Immigration and Naturalization
Service
On-site versus Off-site
Types of Patients
Types of Caregivers
Licensure
REGULATORY ISSUES
National Commission on Correctional
Health Care
American Correctional Association
Joint Commission on the
Accreditation of Healthcare
Organizations
American Public Health Association
Systems/Networks
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112
112
112
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136
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143
144
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145
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The Changing Role of the PCP
CHAPTER 5
DIALYSIS
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Surveys
Federal Regulations
Joint Commission on Accreditation
of Healthcare Organizations
ESRD Networks
DOCUMENTATION
REIMBURSEMENT
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management (UM)
RISK MANAGEMENT, LEGAL,
AND ETHICAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
CHAPTER 6
CORRECTIONAL FACILITIES
INTRODUCTION TO SETTING
State Departments of Correction
Operation by State versus Contracted
Firms
Prisons
Jails
Juvenile Facilities
Bureau of Immigration and Customs
Enforcement
On-site versus Off-site
Types of Patients
Types of Caregivers
Licensure
REGULATORY ISSUES
National Commission of Correctional
Health Care
American Correctional Association
Joint Commission on the
Accreditation of Healthcare
Organizations
American Public Health Association
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152
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155
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166
166
169
169
170
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173
177
177
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DOCUMENTATION
The Correctional Health Record
Administrative Information
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Common Legal Issues
Other Areas of Risk
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 7
DENTAL CARE SETTINGS
INTRODUCTION TO SETTING
Care Settings
Types of Patients
Types of Caregivers
REGULATORY ISSUES
State Licensure
Drug Enforcement Agency
Regulations
Reporting of Adverse Effects of
Medications and Dental Materials
Reporting of Physical Abuse
DOCUMENTATION
Patient Information
Medical and Dental History
Head, Neck, and Intraoral
Examination
Dental Examination & Charting
Periodontal Examination
Dental Radiography and Intraoral
Photography
Treatment Plan
Treatment Notes
Patient Education
Diet Evaluation
REIMBURSEMENT
Dental Insurance
Self-Pay Patients
HMO Plans
Medicare and Medicaid
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DOCUMENTATION
The Correctional Health Record
Administrative Information
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Common Legal Issues
Other Areas of Risk
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
HIPAA
CHAPTER 14
DENTAL CARE SETTINGS
INTRODUCTION TO SETTING
Care Settings
Types of Patients
Types of Providers
REGULATORY ISSUES
State Licensure
Drug Enforcement Agency
Regulations
Reporting of Adverse Effects of
Medications and Dental Materials
Reporting Physical Abuse
DOCUMENTATION
Patient Information
Medical and Dental History
Head, Neck, and Intraoral
Examination
Dental Examination & Charting
Periodontal Examination
Dental Radiography and Intraoral
Photography
Treatment Plan
Treatment Notes
Patient Evaluation
Diet Evaluation
REIMBURSEMENT
Dental Insurance
Self-Pay Patients
HMO Plans
Medicare and Medicaid
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498
498
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499
499
500
500
500
501
Civilian Health and Medical Program
of the Uniformed Services
(CHAMPUS)
Veterans Affairs
INFORMATION MANAGEMENT
Computer Systems
Practice Management Software
Electronic Dental Record Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
AIDS and HIV
Injuries to Caregivers and Patients
Malpractice and Negligence
Adverse Reactions to Medications
and Dental Materials
Dental Records for Identification of
Individuals
Fraud
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
Dental Services
Dental Treatment
CHAPTER 8
VETERINARY SETTINGS
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Standards
Format
Forms of Documentation
REIMBURSEMENT
Out-of-Pocket
Mortality Insurance
Pet Health Insurance
INFORMATION MANAGEMENT
Coding and Classification
Data Sets
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Legal Issues
ROLE OF THE HEALTH
179
TRICARE Dental Program
501
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183
184
Veterans Affairs
INFORMATION MANAGEMENT
Coding and Classification
501
501
501
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
507
Injuries to Caregivers and Patients
Malpractice and Negligence
Adverse Reactions to Medications
and Dental Materials
Dental Records for Identification of
Individuals
508
508
509
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
Dental Services
Dental Treatment
Computers in Dentistry
Technology in Dentistry
Dental Informatics
CHAPTER 15
VETERINARY SETTINGS
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Standards
Format
Forms of Documentation
REIMBURSEMENT
Out-of-Pocket
Mortality Insurance
Pet Health Insurance
INFORMATION MANAGEMENT
Coding and Classification
Data Sets
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Legal Issues
ROLE OF THE HEALTH
510
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520
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525
526
529
529
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530
530
532
535
535
536
536
539
542
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 9
SUBSTANCE ABUSE
INTRODUCTION TO SETTING
Care Settings
Types of Clients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Legal/Administrative Documentation
Clinical Documentation
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Data Sets
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Confidentiality and Release of
Information
Court-Ordered Treatment
Involuntary Commitments
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 10
FACILITIES FOR THE
MENTALLY RETARDED OR
DEVELOPMENTALLY
DISABLED
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
Types of Settings
REGULATORY ISSUES
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
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275
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291
INFORMATIONMANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 8
SUBSTANCE ABUSE
INTRODUCTION TO SETTING
Care Settings
Types of Clients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Legal/Administrative Documentation
Clinical Documentation
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Data Sets
Computer Systems
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Confidentiality and Release of
Information
Court-Ordered Treatment
Involuntary Commitments
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 9
FACILITIES FOR INDIVIDUALS
WITH MENTAL
RETARDATION OR
DEVELOPMENTAL
DISABILITIES
INTRODUCTION TO SETTING
Types of Individuals Served
Types of Caregivers
Types of Settings
REGULATORY ISSUES
DOCUMENATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
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272
272
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275
280
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295
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300
300
301
303
304
316
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Legal Issues
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 11
MENTAL HEALTH: LONGTERM AND ACUTE SERVICES
INTRODUCTION TO SETTING
Types of Clients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Assessment
Treatment Plan
Progress Notes
Special Treatment Procedures
Discharge Summary and Aftercare
Plans
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
Confidentiality
Court-Ordered Treatment
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
291
291
292
292
293
295
296
302
304
312
314
315
315
316
318
319
319
322
323
325
327
328
329
329
330
331
332
CHAPTER 12
LONG-TERM CARE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
State Licensure
JCAHO Accreditation
DOCUMENTATION
Federal Requirements
State Licensure Requirements
JCAHO Long Term-Care
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347
349
349
349
350
355
355
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Legal Issues
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 7
MENTAL HEALTH: LONGTERM AND ACUTE SERVICES
INTRODUCTION TO SETTING
Types of Clients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
Assessment
Treatment Plan
Progress Notes
Special Treatment Procedures
Discharge Summary and Aftercare
Plans
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANGEMENT AND LEGAL
ISSUES
Confidentiality
Court-Ordered Treatment
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
Coding and Classification
CHAPTER 10
LONG-TERM CARE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
State Licensure
JCAHO Accreditation
DOCUMENTATION
Federal Requirements
State Licensure Requirements
JCAHO Long-Term Care
316
316
316
316
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320
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201
209
211
213
213
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216
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222
225
228
229
230
231
232
233
234
228
327
328
330
334
336
336
336
337
342
342
Accreditation Requirements
REIMBURSEMENT AND
FUNDING
Medicaid per Diem Based on Overall
Facility Costs
Medicare Part A
355
356
356
Medicaid per Diem Based on Level
of Care
Resource Utilization Groups III
356
Commercial Insurance
Managed Care Payers
Private Pay
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
External Consultant versus Full-Time
Employee
358
358
359
360
360
361
365
365
365
CHAPTER 13
SUBACUTE CARE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
State Licensure
Federal Long-Term-Care Regulations
Accreditation
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
Medicare
Medicaid Subacute Per Diem
Managed Care
Commercial Insurance
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
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368
377
378
380
382
382
383
383
384
385
386
386
390
390
390
391
391
392
392
393
Accreditation Requirements
REIMBURSEMENT AND
FUNDING
Medicaid per Diem Based on Overall
Facility Costs
Medicare Part A Skilled Nursing
Facility Benefit
Medicaid per Diem Based on Level
of Care
Resource Utilization Groups III in
Medicaid Reimbursement
Commercial Insurance
Managed Care Payers
Private Pay
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
External Consultant versus Full-Time
Employee
Long-Term Care Hospital
Prospective Payment System (LTCH
PPS)
Quality Improvement
Utilization Management
Auditing
343
343
343
345
345
346
346
347
348
348
349
352
353
356
359
360
347
356
356
359
UTILIZATION MANAGEMENT
Quality Improvement Required by
Regulation and Accreditation
Quality Measurements for
Competitive Markets
Quality Management for Legal
Concerns
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
External Consultant Versus FullTime Employee
Compliance Coordinator
Facilitator of Proper Documentation
Practices
Information System Selection and
Design
CHAPTER 14
HOME HEALTH CARE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Joint Commission of Accreditation of
Healthcare Organizations
Community Health Accreditation
Program
Medicare/Medicaid
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
Payer Mix
Financial Stability
Future Reimbursement Trends
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
Outcomes and Assessment
information Set (OASIS)
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Satisfaction Committee
Legal Issues
Policies and Procedures
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399
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399
400
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406
407
408
409
409
410
411
412
413
413
414
415
415
416
418
418
422
422
422
423
423
423
424
424
425
CHAPTER 12
HOME HEALTH CARE
INTRODUCE TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
Joint Commission of Accreditation of
Healthcare Organizations
Community Health Accreditation
Program
Medicare/Medicaid
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
Payer Mix
Financial Stability
420
420
421
422
423
423
424
424
428
430
430
INFORMATION MANAGEMENT
Coding and Classification
Data Information and Flow
Computer Systems
Data Sets
432
432
433
433
433
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
Risk Management
Satisfaction Committee
Legal Issues
Policies and Procedures
433
433
436
437
437
438
438
439
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 15
HOSPICE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
CHAPTER 16
REHABILITATION
INTRODUCTION TO SETTING
Types of Rehabilitation Settings
Types of Caregivers
Types of Patients
Durable Medical Equipment
Commonly Used
REGULATORY ISSUES
Joint Commission of Accreditation of
Healthcare Organizations
Commission for Accreditation of
Rehabilitation Facilities
Health Care Financing
Administration
Medical Directors
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
425
425
436
437
438
438
445
451
455
455
458
459
461
462
462
464
465
466
467
473
474
475
478
480
483
484
484
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
Outcome and Assessment Information
Set (OASIS)
Medicare Prospective Payment
System
CHAPTER 13
HOSPICE
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Data and Information Flow
Coding and Classification
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
Quality Improvement
Utilization Management
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
TRENDS
Licensure and Accreditation
Hospice Medicare Benefit
CHAPTER 11
REHABILITATION
INTRODUCTION TO SETTING
Types of Rehabilitation Settings
Types of Caregivers
Types of Patients
Durable Medical Equipment
Commonly Used
REGULATORY ISSUES
Joint Commission on Accreditation
of Healthcare Organizations
Commission for Accreditation of
Rehabilitation Facilities
439
Medical Directors
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
384
384
392
440
427
429
447
448
449
450
455
460
464
464
465
469
470
472
472
473
474
476
477
450
450
370
370
372
375
377
380
381
381
485
485
492
497
497
397
Information Flow
Coding
National Databases
Classification Systems Used in
Rehabilitation
QUALITY IMPROVEMENT AND
PROGRAM EVALUATION
SYSTEMS
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGER
TRENDS
Acute Rehabilitation Subacute
Rehabilitation
Outpatient Rehabilitation
Independent Living
Reimbursement
Technology
Care Paths
CHAPTER 17
CONSULTING
INTRODUCTION TO SETTING
Types of Patients
Types of Caregivers
REGULATORY ISSUES
DOCUMENTATION
REIMBURSEMENT AND
FUNDING
INFORMATION MANAGEMENT
Coding and Classification
Data and Information Flow
Computer Systems
Data Sets
QUALITY IMPROVEMENT AND
UTILIZATION MANAGEMENT
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Leadership Ability
Time and Money Management
Education and Experience
Working at Home
Negotiating Contracts
TRENDS
497
498
498
498
503
504
505
505
505
505
506
506
506
506
518
519
520
520
522
522
Information Flow
Coding
National Databases
Classification Systems Used in
Rehabilitation
QUALITY IMPROVEMENT AND
PROGRAM EVALUATION
SYSTEMS
RISK MANAGEMENT AND
LEGAL ISSUES
ROLE OF THE HEALTH
INFORMATION MANAGER
TRENDS
Acute Rehabilitation Subacute
Rehabilitation
Outpatient Rehabilitation
Independent Living
397
397
401
401
Technology
Care Paths
Centers for Medicare and Medicaid
Services (CMS)
Computer Systems
CHAPTER 16
CONSULTING
INTRODUCTION TO SETTING
408
409
382
REGULATORY ISSUES
DOCUMENTATION
REIMBURSEMENT AND
COMPLIANCE
554
555
555
ROLE OF THE HEALTH
INFORMATION MANAGEMENT
PROFESSIONAL
Leadership Ability
557
Working at Home
Negotiating Contracts
TRENDS
Who Consultants Work With
Who Fees Do HIM Consultants
Charge?
Seeking Clients
562
566
570
553
561
406
406
407
407
407
408
408
401
553
523
523
524
525
525
525
526
526
529
530
530
532
534
534
558
562
Home Office Equipment
Computer
564
564