Ch 3 Health Information functions, purpose, users Flashcards
Identify an example of a primary purpose of the health record.
Patient care
Identify the institutional user that utilizes health record data to make decisions regarding healthcare programs.
Policy making body
The entire health record at our healthcare organization is accessible online. We utilize a
EHR
Identify a type of individual user
Patient
Deidentified data are used for
Public health and research
Identify the microfilm format that is inefficient when retrieving multiple admissions for a patient
Roll
The decision was made to choose a filing system that distributes health records evenly throughout the filing system. This is known as
Terminal digit
____ is used to assign weights to potential duplicate health records
Rules based algorithm
Form design standards should include
Assigning a unique identifier
Differentiate between qualitative analysis and quantitative analysis
Qualitative analysis looks at the quality of documentation and quantitative analysis looks for the presence of documents or signatures
The forms design committee
provides oversight for the development, review and control of forms and computer screens
In a paper based system, individual health records are organized in a standardized order in which of the following
assembly
Extracting data from a health record and entering it into an information system is known as
Abstracting
Two patients were given the same health record number. This is an example of a
Overlay
The physician did not complete the health record in the time frame required by the medical staff rules and regulations, these records are known as
Delinquent
Identify the type of health record that is controlled by patients
Personal health record
Explain how amendments to the EHR are handled
The amendment must have a separate signature, date, and time.
Version control of documents in the EHR requires
Policies and procedures to control which versions are displayed
The decision was made to not allow copying and pasting. Justification for this decision includes
Copying outdated information
When I key 10101963, the computer displays it as 10/10/1963. What enables this?
Input mask
Analyze the statement: information and data mean the same thing
False, because data is raw facts and figures and information is data converted into a meaningful format
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called an ———record
Delinquent
How many linear filing inches can a shelving unit hold based on the following data: shelving unit shelf width =36 inches number of shelves per unit = 9 shelves average record thickness: 1/2 inches
324
Calculate the linear filing inches, the width of the shelving unit is multiplied by the number of shelves
36 * 9= 324
Which of the following is a secondary purpose of the health record
Educate medical students
A new employee has been hired to link patient information such as patient name to a scanned document. This employee will be ——-
Indexing
The healthcare organized assigned the same patient 3 different health record numbers but the content is filed under the most recent health record number. This is known as ——-
Serial unit number
Identify the screen design concept that assists with data validation
Checking to ensure that the data is in an appropriate range
Deficiencies in a health record include
Missing a document
Identify the most efficient filing system
Unit numbering system
Determine the number of shelving units required the shelve 2,000 pt health records if the average health record is 0.75 inches. The shelving unit is 36 inches wide and has 8 shelves
6 units
36 * 8 =288 inches
Linear filing inches needed 2000 * 0.75= 1.500
Shelving units needed: 1,500/ 288= 5.2 units = 6 units
Shelving units should always be rounded up to the next full unit
The pt registration department assists the HIM department by _____
Assigning the health record number
Identify the index that is key to locate a health record
Master patient index
The numbering system that assigns one health record number per visit is ______
Serial
The master patient index _____
Contains basic demographics information about the patient
Identifying the filing system that is well suited far a small healthcare organization such as a one physician practice
Alphabetic filing system
Identify the element that is typically found in the paper health record
Patient identification
Writing the word error is appropriate for _____
Corrections
Identify an example of information
The HIM committee will meet to discuss the problem with the delinquent chart count
Identify the task that is preformed during qualitative analysis
Checking that only approved abbreviations are used
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of 3 records filed sequentially within the filing system?
36-45-99
37-45-99
38-45-99
Terminal digit
The annual volume stats for General Hospital are noted below. Determine the name of shelving units that will be required to store this year’s inpatient discharge records
Avg inpatient discharges = 15,000
Avg inpatient record thickness = 3/4 inch
Shelving unit shelf widths = 36 inches
Number of shelves per units = 6
52
15,000 discharges * .75 inches = 11.250 linear filing inches
36 inches width * 6 shelves = 216 linear filing inches per shelving unit
11.250 linear filing inches required / 216 linear filing inches per shelving unit = 52.08
= 52 shelving units
The health record typically begins in the _____
Patient registration department
Identify the component of the EHR that assists physicians in making medical decisions
Clinical decision support
Identify the software that is used for voice recognition
Natural language processing
Critique the following statement. Patient care management are individual users of health records
True
Which of the following statements justifies the need for versioning
To ensure there is no confusion on the correct document
Identify the appropriate description of alphabetical filing
Smith, Carl J.
Smith, Mary A.
Smith, Paul M
Smith, thomas
The use of the health record by a clinician to facilitate quality pt care is considered a ______
A primary purpose of the health record
Determine the sequence of health record numbers that is in terminal digit order
12-56-36, 13-58-39, 14-75-87, 15-85-98
Terminal digit order, the last numbers of the health record number are in ascending order
Which of the following is a way that pt care managers and support staff use the data documented in the health record
Evaluate the performance of the employees
The use of the health record by a clinician to facilitate quality pt care is considered a ____
Patient care support
Identify the HIM task that is eliminated by the electronic health record
Assembly
Dr Smith wants to use a lot of free text in his EHR. What should be your response?
Dr we recommend that you use little if any free text in the EHR
Using information understanding and experience that give individual the power to make informed decisions is known as
Knowledge
Determine the appropriate form design principle
Data fields should be labeled
Identify the filing system that is well suited for a small healthcare org such as a one physician practice
Alphabetic filing system
Identify the component of the EHR that assists physicians in making medical decisions.
Clinical decision support
Justify a rule that prohibits use of the copy and paste function in the electronic health record
The content may contain outdated information
Identify an appropriate standard for forms design.
An appropriate field type such as radio buttons should be selected
Which of the following that pt care managers & support staff use the data documented in the health record?
Communicate vital information among dept and across disciplines and settings
The employee notified the supervisor that she found a problem when reviewing the MPI. She found the 2 pt’s information were merged together inappropriately. The employee found a ___
duplicate
An addendum to the health record should be dated
The day the addendum was created
The health record typically begins in the
Pt registration department
The key to the identification and located of a patient’s health record is the
MPI
How many linear filing inches can a shelving unit hold based on the following data?
Shelving unit shelf width = 36 inches
# of shelves per unit= 9 shelves
Average record record thickness = 1/2 inch
162
Identify the screen design concept that assists with data validation
Selecting from a predefined list such as in check boxes and radio buttons
Which of the following is a secondary purpose of the health record
Assist caregivers in patient care management
