Chapter 8 HIM – Flashcards
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Removing health records from the storage area to allow space for more current records is called:
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purging records
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Which type of microfilm does not allow or a unit record to be maintained?
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roll microfilm
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Which is not true about document imaging?
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is a paperless system
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Which system records the location of health records 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' reports are health record forms that....
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are received by the HIM dept. and added to the health record after it has been processed
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In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the....
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incomplete record file
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In which system are all encounters or patient visits kept in one folder?
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unit numbering system
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Which is the key to the identification and location of a patient's health record?
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MPI
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Which numbering systems is best for maintaining encounters for a patient together?
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unit
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In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?
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serial
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Which is not usually a part of quantitative analysis review?
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checking that every word in the record is spelled correctly
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Which is not true about good forms design for paper forms?
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bright colors should be used to identify forms
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Which is not true of good forms design for electronic forms?
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electronic forms should use radio buttons for multiple selections of items
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Which is a disadvantage of alphabetic filing?
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uneven expansion of file shelves or cabinets
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In HC organizations, what is the database that is used to locate the medical record number usually called?
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MPI
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Which is a request from a clinical area to charge out a health record?
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requisition
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What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
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216 inches
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A quantitative review of the health record for missing reports and signatures that occurs when the patient in the hospital is referred to as:
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concurrent review
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A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called:
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delinquent record
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In which department/unit does the health record typically begin?
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patient registration
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When a hospital accredited by the Joint Commission is considered to be in compliance with Medicare's Conditions of Participation, this is called:
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deemed status
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Which of the typical HIM functions assist in monitoring and compliance of the HC facility with Joint Commission standards:
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release of information, record processing and transcription
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What component of the budget would include money for the purchase of an EHR?
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capital budget
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The future role of the HIM professional is expected to change due to:
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advances in technology, implementation of new clinical coding system, and evolution of EHR
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Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called:
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elements of performance
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The system in which the health record number is assigned at the first encounter and then used for subsequent HC 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 is the:
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master patient index (MPI)
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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 is used to locate an electronic health record?
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health record number
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John Smith treated a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:
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duplicates
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Which of the following should be part of the comprehensive MPI maintenance program?
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advanced person search
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Which is true about the Social Security number?
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both AHIMA and the Social Security Admin. oppose using the Social Security number as the health record identifier
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The most common numbering system used in HC is?
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unit numbering
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Which identification system is at a disadvantage when there are two patients with the same name?
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alphabetic
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Consider the following sequence numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
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terminal-digit filing
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The master patient index (MPI) is necessary to locate health records with the paper-based storage system for all types of filing systems except:
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alphabetical filing
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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 is an advantage of a centralized unit filling system?
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one location in which to look for records
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Which filing 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 to locate misfiles which the paper-based filing system?
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color coding
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In a paper-based system, the HIM dept. routinely delivers health records to:
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nursing units
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Which of the following paper 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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Under the False Claims Act, claims may be brought up how many years?
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generally 7 years, but could go as high as 10
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Record retention should be based on:
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State regulations and AHIMA recommendations
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Which of the following is the appropriate method for destroying microfilm?
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pulverizing
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The tool used to track paper-based health records is:
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outguide
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What should be done when the HIM dept's error or accuracy rate is deemed unacceptable?
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a corrective solution 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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Statements that define the performance expectations an/or structures or processes that must be in place are:
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standards
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In a paper-based system, individual health records are organized in a pre-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 an 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 HC facility's policies are called:
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delinquent records
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The best practice for forms design is to use white paper and black ink:
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true
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In a paper-based record, errors should be completely obliterated:
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false
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Addendums should document the date the event actually happened - no the date it was documented
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false
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Which chart-processing activity is eliminated with an EHR that uses scanned images?
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assembly
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One of the advantages of an 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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reassignment
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Which term is the process of checking individual data elements, reports or files against each other to resolve discrepancies?
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reconciliation
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Which 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(s) is displayed
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Which is a risk of copying and pasting?
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system not recording who entered the data
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How are materials from other facilities 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 is captured by scanning and direct entry
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true
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Data validation includes an 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 of creation.
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true
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Authorization is identifying a patient through the use of a user name
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false
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If one needed to know the number of C-sections performed by a specific obstetrician, which indices would be used to identify the cases?
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operation index
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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:
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register
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What dept. within the hospital uses the information abstracted and coded by the HIM dept. to send for payment from third-party payers?
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billing department
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The function within the HIM dept. responsible for listening to dictated reports and typing them into a medial report format is called:
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medical transcription
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Reviewing request 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 begin?
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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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planning
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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 diagnoses and procedures documented in the medical record is called:
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clinical coding
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Which is an example of how the HIM professional interacts with the medical staff?
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serve on medical staff committees
