Chapter 3 Health Care Delivery Due 10-8-09 Turned in Oct 6

Knowledge based Questions

1. List and describe three types of freestanding ambulatory care

settings. Three types of ambulatory care settings are; Public
Health Departments, University Health Centers, and Birthing
Centers. The Public Health Center is a special kind of clinic, in my
opinion, as they reach more children of all ages, than any other
health facility that I know of. They are designed to serve a
community as a whole. University Health Centers are special
places, also, because they take care of a special population of
college students, and they have special needs, financially,
emotionally and there a many diseases that affect them more
than the rest of the population. Birthing Centers are a new
concept to make birth a more family centered experience by
keeping a more relaxed atmosphere.

2. Define the following terms used in ambulatory care: encounter,

nurse practitioner, reason for visit and superbill. An encounter
is defined as a face-to-face encounter between the patient and
the provider. A nurse practitioner is defined as registered
nurse who has additional training and credentials that allow for a
limited independent practice, sometimes specializing in an area
such as family practice, or geriatrics. Sometimes they are the
only health care worker available in rural settings. Reason for
Visit is defined as the reason the patient is being seen. A
Superbill is also called an encounter form, and it is generated at
the end of the visit. It includes information about the patient’s
diagnosis, treatments, and the disease and procedural codes.
3. Name the two main organizations that accredit ambulatory care.
The two main organizations that accredit ambulatory care are
JCAHO (Joint Commission on Accreditation on Accreditation of
Healthcare Organizations) and Accreditation Association for
Ambulatory Health Care, Inc.
4. List the major types of documentation that are basic to all
ambulatory care encounters and settings. The major types of
documentation that are basic to all ambulatory care encounters
and settings are: 1. History and physical, 2. Laboratory and X-
Rays 3. Progress Notes 4. Encounter Form 5. Problem List
5. What types of patient identifiers are used in ambulatory care? In
ambulatory care the patient identifiers used are: patient name,
patient number, patient social security, and family of numbering,
6. What types of data are included in the uniform ambulatory care
data set and how does this affect the content of the ambulatory
record? According to Chapter 2, pg 42, of our text, there are
 now 42 items that could be used as core elements of either
inpatient or outpatient coding. These would include data items
such as: a problem list, encounter record, the registration form
elements such as; demographic information, history and
physical, lab and x-ray reports, progress notes, a problem list,
maybe a summary list, and discharge instructions and diagnoses.
On page 88, Chapter 3, there are three main types of data in the
ambulatory care set, which are A. Patient Data, B. Provider Data,
and C. Encounter Data. I would think that all of this uniformity of
code elements would be good for the completeness and
accuracy of the ambulatory record. I order to get proper
reimbursement; I don’t see how they could avoid using them.

Case Study Post online page 97

1. What are the main problems that she should identify?

2. Develop a plan to solve each of the problems identified above.

I think the problems Judy should identify are as follows:

1. The patient identifier should not be the patient’s name since
they have a very large practice. They admit to a large number
of misfiles, and there are many patients with duplicate names.
2. Three of the doctors use a POMR format, the other use a
source format, no uniformity, resulting in a lot of confusion for
everyone accessing the record.
3. The code sets are not updated, which will cost them in
reimbursement terms as well as accreditation problems.
4. The encounter form has not been updated for quite some
time.
5. It is ridiculous that all appointments would not be entered
into the computer, and kept on a manual log. And, therefore
the new appointments written on the paper log is not entered
into the computerized log. So how can they expect their
records for appointments to be pulled from the computer-
generated list that does not really exist?

So, as for how to solve the problems, in my opinion:

1. I would survey the projected patient record numbers for the
future and hire a professional HIM expert on how to set up a
good and accurate numbering system that would extend to
old records as well as new ones. That is going to be a tough
job. There are several to think about, such as Patient
Numbering, using unit or serial numbers, Patient Numbering,
 such as social security number, or Family Numbering. Each
has advantages and disadvantages and I would want to make
an informed choice because many patients would be affected
should it not work out well.
2. I would recommend the electronic health record (EHR) since it
would simplify and unify record retrieval for the entire facility,
but if it were not feasible, I would insist that the caregivers
pick one system they all could live with and use it.
3. The code sets are updated regularly, with ICD-9-CM updated
in April and October, and the National Center for Health
Statistics requires that ambulatory facilities update their
coding; especially the preprinted codes on the encounter
forms. So, how have they been legally avoiding this? The
AMA revises the HCPCS every year, also. So, that is where I
would start to fix this. I would also consult AHIMA and JCAHO
for form suggestions
4. The same suggestions for action for number 3 would apply
here, also.
5. I would throw away the manual paper appointment log and
insist only the computer generated appointment list be used.
Obviously, walk-ins will have to be handled as they come in,
but it is just learning new habits to rely on the computer
system.