Health Record Content Chapter 2
Unlock all answers in this set
Unlock answersquestion
The right of individuals to control access to their personal health information
answer
Privacy
question
The expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
answer
Confidentiality
question
The protection of the privacy of individuals and the confidentiality of health records
answer
Security
question
Which of the following best describes the most important function of the health record?
answer
Storing patient care documentation
question
Who are the primary users of the health record?
answer
Clinical professionals who provide direct patient care
question
Which of the following elements is not a component of most patient records?
answer
Financial information
question
Healthcare information systems need to exchange information. This linkage between systems is referred to as:
answer
Connectivity
question
Which of the following is not a characteristic of high-quality healthcare data?
answer
Data Accountability
question
Which of the following represents an example of data granularity?
answer
A numerical measurement carried out to the appropriate decimal place
question
What is the defining characteristic of an integrated health record format?
answer
Integrated health record components are arranged in strict chronological order.
question
Electronic health record systems have the same access control requirements as paper-based record systems.
answer
True
question
Paper-based record systems are not flexible enough to meet all of the needs of every health record user.
answer
True
question
Which of the following best describes data accuracy?
answer
Data are correct
question
Which of the following best describes data completeness?
answer
Data include all required elements
question
Which of the following best describes data accessibility?
answer
Data are easy to obtain
question
Data definition refers to the:
answer
Meaning of data
question
Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
answer
Data currency
question
The admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
answer
Data consistency
question
I need an information system that will provide assist physicians in diagnosing and treating patients. The system that I need is:
answer
Clinical decision support
question
I have been asked to list institutional users of the health record. Which one of the following would I include in my list?
answer
Blue cross and Blue shield
question
Critique this statement: Patient care managers are individual users of health records.
answer
True
question
When all required data elements are included in the health record, the quality characteristic for ______ is met.
answer
Data comprehensiveness
question
An individual's right to control access to his or her personal information is known as:
answer
Privacy
question
Critique this statement: The health record documents services provided by allied health professionals and a patient's family.
answer
This is a false statement as the health record documents the care provided by healthcare professionals.
question
The paper-based health record format that organizes all forms in chronological order is known as the:
answer
Intergrated health record
question
Which of the following is a secondary purpose of the health record?
answer
Generate a report to be used in performance improvement
question
Which of the following is an institutional user of the health record?
answer
Government policy maker
question
How do patient care managers and support staff use the data documented in the health record?
answer
Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
question
Which of the definitions below best describes the concept of confidentiality?
answer
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 purpose
question
Which of the following statements does not pertain to paper-based health records?
answer
They have a built-in access control mechanism
question
Which of the following is an advantage offered by computer-based clinical decision support tools?
answer
- They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature - They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends - 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
question
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:
answer
A hybrid record
question
Critique this statement: Data and information mean the same thing.
answer
This is a false statement as data is raw facts and figures and information is data converted into a meaningful format.
question
Which of the following statements does not pertain to electronic health records (EHRs)?
answer
EHRs are filed in paper folders.
question
Which of the following is a secondary purpose of the health record?
answer
Support for research
question
Use of the health record by a clinician to facilitate quality patient care is considered:
answer
Primary purpose of a health record
question
Use of the health record to monitor bioterrorism activity is considered:
answer
Secondary purpose of a health record
question
How do accreditation organizations use the health record?
answer
Determine whether standards of care are being met
question
How do research organizations use the health record?
answer
To examine results of experimental protocols
question
Attorneys for healthcare organizations use the health record to:
answer
Protect the legal interests of the facility and its healthcare providers
question
Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using?
answer
Source-oriented health record
question
The term used to describe expected data values is:
answer
Data precision
question
Protection of healthcare information from damage, loss, and unauthorized alteration is also known as:
answer
Security
question
Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using?
answer
Computerized physician/provider order entry
