Chapter 4- Maintaining Health Records

Question 1

Centralized registration

P. 90

Answer 1

Type of Hospital registration in which all patients presenting for any type of care are registered through one central area, regardless of the type of care being sought.

Question 2

Decentralized registration

P. 90

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, outpatient Diagnostics, Ambulatory Surgery, and so on.

Question 3

Administrative data

P. 91

Answer 3

Non Medical Data, such as patient identifiers, insurance-related data, authorizations, and business correspondence.

Question 4

Demographic data

P. 91

Answer 4

Administrative data that identify the patient– name, date of birth, address, and gender.

Question 5

Clinical data

P. 91

Answer 5

Data found in an 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)

P. 91

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

P. 91

Answer 7

A unique number identifier for each patient seen in a health facility, sometimes referred to as a health record number.

Question 8

Hybrid record

P. 96

Answer 8

Health record maintained in paper, electronic format, and/or in the form of recordings or tracings derived from diagnostic tests.

Question 9

Legal health record

P. 96

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

Concurrent means

P. 100

Answer 10

Happening simultaneously

Question 11

Electronic Signature (e-Signature)

P. 101

Answer 11

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

Question 12

Clinical documentation Improvement (CDI)

P. 104

Answer 12

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

Question 13

Reimbursement cycle

P. 104

Answer 13

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

Question 14

Straight numeric (sequential) filing

P. 107

Answer 14

Records are filed in sequential numerical order.

Question 14

Straight numeric (sequential) filing

P. 107

Answer 14

Records are filed in sequential numerical order.

Question 15

Terminal digit filing

P. 107

Answer 15

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 16

WORM technology

P. 110

Answer 16

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 17

Client/server

P. 112

Answer 17

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

Question 18

Cloud-based solution

P. 112

Answer 18

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 19

Record retention plan

P. 113

Answer 19

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

Question 20

Jukebox

P. 114

Answer 20

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

Question 21

there are three ways that digital health records can be stored for the purposes of retention or archiving:

(P. 117)

Answer 21

1. Server storage
2. Magnetic Tape storage
3. Optical storage

• with these methods, records can be stored on site, off site, or in the cloud. Cloud storage is initially less expensive, because a provider doesn’t have to purchase servers, storage media, or recording devices, but monthly charges and mounting fees for strong Rising volumes of data can increase cost rapidly.

Question 22

Disaster Recovery planning

P. 118

Answer 22

Consists of having a backup infrastructure to support business continuity after a disruptive event. In healthcare, minimal recovery service levels are defined, such as access to the patient records within a targeted time frame.