Health Information1&2
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the system in which a healthcare record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the
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Unit numbering system
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the primary guide to locating a record in a numerical filing system in the
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master patient index
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all forms should
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contain a unique identifier
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the health record number is typically assigned by
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patient registration
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which of the following is used to locate an electronic health record?
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health record number
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john smith treated as a patient at amulti-hospeital system, has medical record numbers. the term used to describe multiple health record number is
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Duplicates
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which of the following should be part of a comprehensive MPI maintenance program?
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advanced person search
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which of the following is true about the social security number?
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both AHIMA and the social security administration oppose using the social security number as the health record identifier .
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which of identification system is at a disadvantage when there are tow patient with the same name?
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Alphabetical
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the master patient index is necessary to locate health within the paper based storage system except basic storage system except
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Alphabetical filing
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consider the following sequence of number 12-34-55, 13--34-55, and 14-34-54 and14-34-54 what system is being used it these if number represent the health record number of three record filed together within the filling system
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Terminal -digit filling
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the term used to describe a combination of paper-based and electronic health records is
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Hybrid
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which of the following is an advantage of a centralized unit filing system?
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One location in which to look for records
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which filling system is considered to be the most efficient?
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Terminal-digit
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what type of paper-based storage system conserves floor space by eliminating all but one or two aisles?
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Mobile filing units
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what feature of the filing folder helps locate misfiles within the paper base filling systems?
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color coding
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in paper-based system, the HIM department routinely delivers health records to
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patient registration
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which of the following paper wight would be the most durable for the medical record folder?
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20
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what microfilm format is inefficient when patients have multiple admissions on microfilm?
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Roll
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statements that define the performance expectations and / or structures or processes that must be in place are
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standards
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in a paper-base system individual health records are organized in a per-established order. This process is called.
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Assembly
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Reviewing a health record for missing signatures and missing medical reports is called
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Analysis
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Reviewing the record for deficiencies after the patient is discharged from the hospital is and example of what type of review.
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Retrospective
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incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies are called.
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Delinquent record
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In a paper- base record, errors should be completely obliterated.
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false
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Addendums should documents the date the event actually happened not the date if was documented.
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false
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The best practice for forms design is to use white paper with black ink.
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true
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what should be done when HIM department's error of accuracy rate is deemed unaccepted?
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A corrective action should be taken.
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The forms design committee
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provides oversight for the development, review, and control of forms and computer screens.
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Under the false claims act, claims may be brought up to how how many years?
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Generally 7 years, but could go as high as 10
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which of the following is the appropriate method for destroying microfilm?
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shredding
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The tool used to track paper- based health records is
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outguide
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which of the following chart-processing activities is eliminated with and EHR that uses scanned images.
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Assembly
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One of the advantages of EDMS is that it can
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help manage work tasks
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which term indicates that a document has been removed from standard view?
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Retraction
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which term is the procces of checking individual data elements, reports, or files against each other to resolve discrepancies?
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Reconciliation
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which of the following could be used to determine if someone has the right to view a health record?
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photo identification
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version control of documents in the EHR requires
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policies and procedures to control which version displayed
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which of the following is a risk of copying and pasting
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system not recording who entered the date
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when records from other facilities are used in clinical decision making, how is this documented in the EHR?
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they are scanned and filed in the EHR.
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which term verifies claim of identity?
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Authentication
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How are amendments handled in the EHR?
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The amendment must have a separate signature, date, and time.
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EHR data are captured by scanning and direct entry.
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True
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Data validation includes and undo button.
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false
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policies should address how the patient information will be removed from computers at the end of their useful life.
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true
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Data quality begins at the point creation
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true
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authorization is identifying a patient through the use of a use of a user name
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true
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If one needed to know the number of C- section performed by specific obstetrician, which of the following indices would be used to identify the cases?
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Operation
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The computer system that may serve as the MPI function is the.
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Patient registration system
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A chronological listing of data is called a/
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Register
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what department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?
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Billing department
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the function with within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called.
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medical transcription
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Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM department?
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Release of information function
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where does the health record being?
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patient registration
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one of the most sought after accreditation distinction by healthcare facilities is offered by the .
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joint commission
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statements that describe general guidelines that direct behavior or direct or constrain decision making are called.
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policies
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step-by- step instructions on how to complete a specific task are called.
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procedures
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the departmental budget is both an evaluation tool and what type of tool?
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Planing
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employee salaries are part of what type of budget?
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Expense
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the purchase of an EHR system would be planned for in what type of budget?
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Capital
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assigning ICD-9-CM and CPT codes to the diagnose and procedures documented in the medical record is called.
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Clinical coding
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which of the following is an example of how the HIM professional interacts with the medical staff?
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serve on medical staff committees
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removing health records from the storage area to allow space from more current records is called
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purging recorder
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which type of microfilm does not allow for a unit record to be maintained?
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jacket microfilm
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which of the following is true about endowment imaging
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is a paperless system
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which system records the location of health record removed from the filing system and documents the return of the health records
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chart tracking system
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loose report record forms that
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are not received by the HIM department and added to the health record after it has been processed
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in a paper -based system, the completion of the chat is monitored in a special area of the HIM department called the
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incomplete record file
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which of the following is the key to the identification and location of a patients health record
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MPI
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Which of the
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How do patient care managers and support staff use the data documented in the health record?
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Which of the following is a secondary purpose of the health record?
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