Ch 3 Health Information functions, purpose, users

Question 1

Identify an example of a primary purpose of the health record.

Answer 1

Patient care

Question 2

Identify the institutional user that utilizes health record data to make decisions regarding healthcare programs.

Answer 2

Policy making body

Question 3

The entire health record at our healthcare organization is accessible online. We utilize a

Answer 3

EHR

Question 4

Identify a type of individual user

Answer 4

Patient

Question 5

Deidentified data are used for

Answer 5

Public health and research

Question 6

Identify the microfilm format that is inefficient when retrieving multiple admissions for a patient

Answer 6

Roll

Question 7

The decision was made to choose a filing system that distributes health records evenly throughout the filing system. This is known as

Answer 7

Terminal digit

Question 8

____ is used to assign weights to potential duplicate health records

Answer 8

Rules based algorithm

Question 9

Form design standards should include

Answer 9

Assigning a unique identifier

Question 10

Differentiate between qualitative analysis and quantitative analysis

Answer 10

Qualitative analysis looks at the quality of documentation and quantitative analysis looks for the presence of documents or signatures

Question 11

The forms design committee

Answer 11

provides oversight for the development, review and control of forms and computer screens

Question 12

In a paper based system, individual health records are organized in a standardized order in which of the following

Answer 12

assembly

Question 13

Extracting data from a health record and entering it into an information system is known as

Answer 13

Abstracting

Question 14

Two patients were given the same health record number. This is an example of a

Answer 14

Overlay

Question 15

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

Answer 15

Delinquent

Question 16

Identify the type of health record that is controlled by patients

Answer 16

Personal health record

Question 17

Explain how amendments to the EHR are handled

Answer 17

The amendment must have a separate signature, date, and time.

Question 18

Version control of documents in the EHR requires

Answer 18

Policies and procedures to control which versions are displayed

Question 19

The decision was made to not allow copying and pasting. Justification for this decision includes

Answer 19

Copying outdated information

Question 20

When I key 10101963, the computer displays it as 10/10/1963. What enables this?

Answer 20

Input mask

Question 21

Analyze the statement: information and data mean the same thing

Answer 21

False, because data is raw facts and figures and information is data converted into a meaningful format

Question 22

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called an ———record

Answer 22

Delinquent

Question 23

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

Answer 23

324
Calculate the linear filing inches, the width of the shelving unit is multiplied by the number of shelves
36 * 9= 324

Question 24

Which of the following is a secondary purpose of the health record

Answer 24

Educate medical students

Question 25

A new employee has been hired to link patient information such as patient name to a scanned document. This employee will be ——-

Answer 25

Indexing

Question 26

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 ——-

Answer 26

Serial unit number

Question 27

Identify the screen design concept that assists with data validation

Answer 27

Checking to ensure that the data is in an appropriate range

Question 28

Deficiencies in a health record include

Answer 28

Missing a document

Question 29

Identify the most efficient filing system

Answer 29

Unit numbering system

Question 30

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

Answer 30

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

Question 31

The pt registration department assists the HIM department by _____

Answer 31

Assigning the health record number

Question 32

Identify the index that is key to locate a health record

Answer 32

Master patient index

Question 33

The numbering system that assigns one health record number per visit is ______

Answer 33

Serial

Question 34

The master patient index _____

Answer 34

Contains basic demographics information about the patient

Question 35

Identifying the filing system that is well suited far a small healthcare organization such as a one physician practice

Answer 35

Alphabetic filing system

Question 36

Identify the element that is typically found in the paper health record

Answer 36

Patient identification

Question 37

Writing the word error is appropriate for _____

Answer 37

Corrections

Question 38

Identify an example of information

Answer 38

The HIM committee will meet to discuss the problem with the delinquent chart count

Question 39

Identify the task that is preformed during qualitative analysis

Answer 39

Checking that only approved abbreviations are used

Question 40

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

Answer 40

Terminal digit

Question 41

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

Answer 41

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

Question 42

The health record typically begins in the _____

Answer 42

Patient registration department

Question 43

Identify the component of the EHR that assists physicians in making medical decisions

Answer 43

Clinical decision support

Question 44

Identify the software that is used for voice recognition

Answer 44

Natural language processing

Question 45

Critique the following statement. Patient care management are individual users of health records

Answer 45

True

Question 46

Which of the following statements justifies the need for versioning

Answer 46

To ensure there is no confusion on the correct document

Question 47

Identify the appropriate description of alphabetical filing

Answer 47

Smith, Carl J. Smith, Mary A. Smith, Paul M Smith, thomas

Question 48

The use of the health record by a clinician to facilitate quality pt care is considered a ______

Answer 48

A primary purpose of the health record

Question 49

Determine the sequence of health record numbers that is in terminal digit order

Answer 49

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

Question 50

Which of the following is a way that pt care managers and support staff use the data documented in the health record

Answer 50

Evaluate the performance of the employees

Question 51

The use of the health record by a clinician to facilitate quality pt care is considered a ____

Answer 51

Patient care support

Question 52

Identify the HIM task that is eliminated by the electronic health record

Answer 52

Assembly

Question 53

Dr Smith wants to use a lot of free text in his EHR. What should be your response?

Answer 53

Dr we recommend that you use little if any free text in the EHR

Question 54

Using information understanding and experience that give individual the power to make informed decisions is known as

Answer 54

Knowledge

Question 55

Determine the appropriate form design principle

Answer 55

Data fields should be labeled

Question 56

Identify the filing system that is well suited for a small healthcare org such as a one physician practice

Answer 56

Alphabetic filing system

Question 57

Identify the component of the EHR that assists physicians in making medical decisions.

Answer 57

Clinical decision support

Question 58

Justify a rule that prohibits use of the copy and paste function in the electronic health record

Answer 58

The content may contain outdated information

Question 59

Identify an appropriate standard for forms design.

Answer 59

An appropriate field type such as radio buttons should be selected

Question 60

Which of the following that pt care managers & support staff use the data documented in the health record?

Answer 60

Communicate vital information among dept and across disciplines and settings

Question 61

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 ___

Answer 61

duplicate

Question 62

An addendum to the health record should be dated

Answer 62

The day the addendum was created

Question 63

The health record typically begins in the

Answer 63

Pt registration department

Question 64

The key to the identification and located of a patient's health record is the

Answer 64

MPI

Question 65

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

Answer 65

162

Question 66

Identify the screen design concept that assists with data validation

Answer 66

Selecting from a predefined list such as in check boxes and radio buttons

Question 67

Which of the following is a secondary purpose of the health record

Answer 67

Assist caregivers in patient care management