Question

: Identify manual and automated techniques used in storage and maintenance of health records, and differentiate between the UHDDS,OASIS, HEDIS and UACDS healthcare datasets and identify the types of data collected

Answer 1

A medical record or health record are used to somewhat in the changeable to describe the systemic documentation of single patient medical history and care across time within one particular healthcare providers jurisdiction.

The paper medical record is an impediment to effective delivery of high quality healthcare. the recording is difficult to access, information and must be stored  in single location for single use this increased demand for information how forced healthcare system and provides to search alternative way of deliver information effectively while at the same time control in the cost increased by doing so.over the past three decades significant strides have been made in automating record keeping process. Technology has improved enjoying the design and implementation of electronic record keeping system that are easy to use.caregivers will hear many different variations of name for an automated record keeping system included computer based patient record, electronic medical records,computerized medical record on electronic health record

1.UHDDS data-uniform hospital discharge data set

• Implemented in 1974. UHDDSVasco Sonali and initiative by Predecessor of today's department of health and human services.
• medical billing and coding professionals will recognise the following information as being required on today's UHDDSforms.

-hospital of facility identification number or code

-expected insurance payer number or code

-sex age and race of patient

-principal diagnosis

-significant medical procedures performed

-additional significant diagnosis

Today in addition to hospitals facilities such as following might use UHDDS.

• Rehabilitation facilities
• Nursing and retirement communities
• Home healthcare providers

2.OASIS- outcome and assessment information set -

OASIS is a comprehensive assessment designed to collect information on nearly hundred items related to homecare recipient demographic information clinical status functional status and service needs.

-the oasis is completed upon admission , discharge,transfer,and change in condition for all Medicare and medicaid nonmaternity and non paediatric beneficiarie

-OASIS data collected by home care in Asian via direct observation and the interview of the care recipient and and or caregiver.

-the purpose of OASIS is to providestandardized assessment it told that would support a case mix adjusted GPS and mechanism to monitor the quality of care.

3.HEDIS-healthcare effective data information set

HEDIS is a comprehensive set of standardized performance measures ,designed to provide purchases and consumers with the information they need for reliable comparison of health and plan performance.HEDIS messages related to many significant public health issues such as cancer, heart disease s, asthma, and diabetes.

Special need plants reported the following measures in in HEDIS 2016

• Colorectal cancer screening
• Care for older adults
• use of spirometry testing in the assessment and diagnosis of c o p d
• Controlling high blood pressure
• Annual monitoring for patient on persistent medications
• Antidepressant medication management
• Use of high risk medications in elderly
• Board certification
• Follow up after hospitalization for mental illness

UACDS-Uniform ambulatory care data set

• UACDS set of data elements used to report ambulatory data elements in standardized manner.
• Purpose is to identify data elements for a uniform minimum data set on ambulatory care
• CMS 1500 is main vehicle used to collect us seeds that are elements

Reasons for increase ambulatory care

-technological improvements in diagnostic and therapeutic procedures and development of short acting anesthetics.

-third party payers have extended coverage to include most procedures performed on an outpatient basis.

-murder case accused in patient hospital prospective payment system limit reimbursement for inpatient care.