HIT 200 – Ch 8 Q&A
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The system in which the health 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 numerical filing system the:
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Master patient Index
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All forms should contain:
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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 a multi-hospital system, has three 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 SSN:
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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 healthcare is:
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Unit numbering system.
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which identification system is at the disadvantage when there are two patients of the same name?:
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Alphabetic system
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Consider the following sequence for numbers: 12-34-55, 13-34-55, and 14-34-53. 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 system
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The Mater Patient index is necessary to locate health record within the paper based storage for all the 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 record system
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What is the advantage of centralized unit filing 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 filing system
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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-based filing system?
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Color coding
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In paper based system, the HIM department poutinely delivers health records to:
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Nursing Units
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Which is the following paper weights 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 microfilms?
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Roll
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Under the false claims act, claims may be brought up to 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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an appropriate method for destroying microfilms
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Shredding
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An appropriate method for destroying computerized data
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Degaussing
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A 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 department's error or accuracy rate is deemed unacceptable?
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A corrective action should be taken
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Function of form design committee
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provides oversight for the development, review, and control of forms and computer screen.
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statements that define the performance expectations and/or structures that must be in place are:
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Standards
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In 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 policies are called:
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Delinquent records
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(T or F) In paper-based records errors should be completely obliterated.
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False
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(T or F) Addendums should document the date the event actually happened - not the date it was documented.
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False
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(T or F) The best practice for forms design is to use white paper with black ink.
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True
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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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Retraction
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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 of the following could be done 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 the document in the EHR requires:
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polocoes and procedures to control which virsion(s) is 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 data
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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 filled in the EHR.
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Which term verifies claim of identity?
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Authantication
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How are amendments are 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. (T or F)
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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 the specific obstetrician, which of the following 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:
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The patient registration system
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A Chronological listing of data is called a/an:
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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 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 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 constrain decision making are called:
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Polocoes
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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 ---------- 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 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 for more current records is called:
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purging records.
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Which type of microfilm does not allow for a unit record to be maintained?
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roll microfilm
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Which of the following 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 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 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 of the following systems are all encounters or patient visits kept in one folder?
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unit numbering system
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Which of the following is the key to the identification and location of a patient's health record?
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MPI
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Which of the following numbering systems is best for maintaining the encounters of 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 of the following 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 of the following 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 of the following 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 of the following is a disadvantage of alphabetic filing?
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uneven expansion of file shelves or cabinets
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In healthcare 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 of the following 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 is in the hospital is referred to as a ___.
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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 a(n )___.
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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 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 health care facility with Joint Commission standards?
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a. release of information b. record processing c. 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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a. advances in technology b. implementation of new clinical coding system c. evolution of the 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.
