Intro to HIM Chapter 2
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Which of the following is a secondary purpose of the health record
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Generate a report to be used in performance improvement
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Which of the following is an institutional user of the health record
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Third-party payer Government policy maker
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How do patient care managers and support staff use the data documented in the health record
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Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
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Which of the definitions below best describes the concept of confidentiality
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The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended
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Which of the following statements does not pertain to paper-based health records
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They have a built-in access control mechanism
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Which of the following is an advantage offered by computer-based clinical decision support tools? D is the answer
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They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature b. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives d. All of the above
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The hospital where I work is transitioning to an EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as
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A hybrid record
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Critique this statement: Data and information mean the same thing
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This is a false statement as data is raw facts and figures and information is data converted into a meaningful format
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Which of the following statements does not pertain to electronic health records (EHRs)?
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EHRs are filed in paper folders
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Which of the following is a secondary purpose of the health record
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Support for research
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Use of the health record by a clinician to facilitate quality patient care is considered
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Primary purpose of the health record
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Use of the health record to monitor bioterrorism activity is considered
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Secondary purpose of the health record
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How do accreditation organizations use the health record
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Determine whether standards of care are being met
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How do research organizations use the health record
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To examine results of experimental protocols
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Attorneys for healthcare organizations use the health record to
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Protect the legal interests of the facility and its healthcare providers
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Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using
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Source-oriented health record
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Inaccurate data recorded in the health record could
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All of the above Compromise quality patient care Contribute to incorrect assumptions by policy makers Invalidate research findings
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The term used to describe expected data values is
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Data precision
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Protection of healthcare information from damage, loss, and unauthorized alteration is also known as
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Security
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Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using
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Computerized physician/provider order entry
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The paper-based health record format that organizes all forms in chronological order is known as the
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Integrated health record
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Critique this statement: The health record documents services provided by allied health professionals and a patient's family
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This is a false statement as the health record documents the care provided by healthcare professionals
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An individual's right to control access to his or her personal information is known as
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Privacy
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When all required data elements are included in the health record, the quality characteristic for ______ is met
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Data comprehensiveness
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Critique this statement: Patient care managers are individual users of health records
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This is a true statement
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We had 324 Medicare patients last month. This statement represents which of the following
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Data
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I am a patient. My medical history including info from myself and my physicians is stored on the Internet. This is an example of which of the following
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Personal Health Record
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Which of the following is an example of a primary purpose of the medical record
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Patient care management
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Examples of patients care delivery usage of the medical record includes which of the following uses
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Communication b/w caregivers
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Critique this statement. The PHR and EHR are synonyms
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This is false statement as the PHR is controlled by the patient and the EHR is controlled by the providers
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The health record is the principal repository for data about info about the healthcare services provided to individual patients
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True
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The lab test \"hemoglobin: 14.6 gm/110 ml\" is considered info
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False
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Which of the following users of the health record is an example of an institutional user
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Third-party payer
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Which of the following users would utilize aggregate data
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Patient care managers and support staff
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I work for an organization that utilize health record data to prove or disprove hypotheses related to disease. I must work for what type of organization
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REsearch
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A physician just received notification from an EHR system that a person lab's test had a dangerously high value. This is an example of what kind of clinical tool
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Clinical decision support
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I just told my physician something embarrassing about myself. I told him because I expect to him to use the info for my care only. This concept is called
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Confidentiality
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Someone suggested that we collect a patients eye color. This was not implemented. What quality characteristic would be the justification for not collecting this info
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Relevancy
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According to the AHIMA data qualtiy model, what is the term that is used to describe how dat is translated into info
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Data Analysis
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A characteristic of data whose values are defined at the appropriate level of detail
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Data Granularity
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A program designed to protect patients privacy and to prevent unauthorized access, alteration, or destruction of heath record
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Security
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An individual right to control access to his or her personal info
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Privacy
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A characteristic of data that includes every required data element
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Data Comprehensiveness
