Chapter 4

Question 1

centralized registration

Answer 1

type of hospital registration in which all patients presenting for nay type of care are registered through one central area, regardless of the type of care being sought

Question 2

decentralized registration

Answer 2

type of hospital registration in which there are multiple points of patient access, depending on the type of care being sought-inpatient admission, emergency department, out patient diagnostics, ambulatory surgery, and so on

Question 3

administrative data

Answer 3

nonmedical data, such as a patients identifiers, insurance-related data, authorizations, and business correspondence

Question 4

demographic data

Answer 4

administrative data that identify the patient- name, date of birth, address, and gender

Question 5

clinical data

Answer 5

data found in a health record that are of a medical nature-past medical or surgical history, vital signs, test results, physician progress notes, nurses’ notes and so on

Question 6

master patient (person) index (MPI)

Answer 6

a permanent listing of all patients who have been admitted to or received care in a healthcare facility’ it is the key to locating patient records in a facility and is maintained permanently

Question 7

medical record number

Answer 7

a unique numeric identifier for each patient seen in a health facility’ sometimes referred to as a health record number

Question 8

hybrid record

Answer 8

health record maintained in paper, electronic format, and or in the form of recordings or tracing derived from diagnostic tests

Question 9

legal health record

Answer 9

the health record, identified by facility policy, that is considered the official business record and that would be presented if subpoenaed

Question 10

electronic signature (e signature)

Answer 10

a digitized signature placed on a chart entry through the use of a personal identification number (PIN)

Question 11

clinical documentation improvement (CDI)

Answer 11

the review of health records, usually concurrently, to ensure that the documentation in the health record is at the level of specificity that allows for code assignment that accurately depicts the patient’s diagnoses and procedures performed

Question 12

reimbursement cycle

Answer 12

the processes that take place from the time a patient is registered for care to the time the services are paid, whither paid by the patient or through insurance

Question 13

straight numeric (sequential) filing

Answer 13

records are filed in sequential numeric order

Question 14

terminal digit filing

Answer 14

breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then the first segment

Question 15

WORM Technology

Answer 15

WORM is an acronym for “write once, read many” meaning that records may be read numerous times, but nothing on the disk can be altered in any way

Question 16

client/server

Answer 16

the use of computers in a network where functions are split between server talks and client tasks; the client computer makes requests of the more powerful server computer in order undertake local processes

Question 17

cloud-based solution

Answer 17

service in which software and data are stored on remote computers and accessed by a local computer through the internet, typically using a browser

Question 18

record retention plan

Answer 18

a written policy that documents the length of time a health care facility retains its health records, the form (medium) in which the records will be kept, and the location(s) of the records

Question 19

jukebox

Answer 19

a means of storing multiple optical discs using a robotic arm that loads and unloads optical disks for delivery of requested health records

Question 20

disaster recovery planning

Answer 20

consists of having a back up infrastructure to support business continuity after a disruptive event. in healthcare, minimal recovery service levels are defined, such as access to patient records within a targeted time frame

Question 21

Enterprise-wide MPI

Answer 21

health system

• may include one hospital and several ambulatory facilities, or it may include three or four hospitals and a hundred or more ambulatory facilities.
• the larger the enterprise the more difficult the task of ensuring the integrity of the MPI database
• MPI links a patient’s administrative data to the patient’s clinical data, found in the EHR

Question 22

concurrent health record

Answer 22

“happening simultaneously”

developing health record that is compiled while the patient is hospitalized or being seen in an ambulatory setting

Question 23

Give an example of EHRs allowing for the concurrent analysis of medical records

Answer 23

dictation and transcription with voice recognition technology