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National Exam > Chapter 8: Health Information Functions > Flashcards

Chapter 8: Health Information Functions Flashcards

1
Q

What is a Steering Committee?

A

A body within an enterprise that supports the steering of its actions. Its main concern is making strategic decisions concerning future realization of the enterprise’s investment projects.

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2
Q

What basic information is included in a Master Patient Index (MPI)?

A

Patient’s name, health record number(s), date of birth, gender, dates of encounter.

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3
Q

What is a Serial Numbering System?

A

A type of health record identification and filing system in which patients are assigned a different but unique numerical identifier for every admission.

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4
Q

What is a Serial-Unit Numbering System?

A

A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned.

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5
Q

What is a Unit Numbering System?

A

A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters.

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6
Q

What is an Alphabetic Filing System?

A

A system of health record identification and storage that uses the patient’s last name as the first component of identification and his or her first name and middle name or initial for further definition.

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7
Q

What is a Numeric Filing System?

A

A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number.

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8
Q

What is a Straight Numeric Filing System?

A

A health record filing system in which health records are arranged in ascending numerical order.

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9
Q

What is a Terminal-Digit Filing System?

A

A system of health record identification and filing in which the last digit or group of digits in the health record number determines file placement.

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10
Q

What is a Middle-Digit Filing System?

A

A numeric filing system in which the middle digits are used as the finding aid to organize the filing system.

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11
Q

What is an Alphanumeric Filing System?

A

A system of health record identification and storage that uses a combination of alphabetic letters and numbers to identify individual records.

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12
Q

What is Roll Microfilm?

A

Stores each document page sequentially in a long roll. Can hold thousands of images.

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13
Q

What is Jacket Microfilm?

A

A roll of microfilm is cut and placed into special four-by-six inch jackets with several sleeves to hold the images.

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14
Q

What is Microfiche?

A

A flat piece of film containing microphotographs of the pages of a newspaper, catalog, or other document.

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15
Q

What is an off-site storage system?

A

A contracted service that stores health records.

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16
Q

What is an Outguide?

A

A device used in paper-based health record systems to track the location of records removed from the file storage area.

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17
Q

What is a requisition?

A

A request from an authorized health record user to gain access to a medical record.

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18
Q

What is Retention?

A

The process whereby inactive health records are stored and made available for future use in compliance with state and federal requirements.

19
Q

What is Destruction?

A

The act of breaking down the components of a health record into pieces that can no longer be recognized as parts of the original record.

20
Q

What is a Certificate of Destruction?

A

A document that constitutes proof that a health record was destroyed and that includes the method of destruction, the signature of the person responsible for destruction, and inclusive dates of destruction.

21
Q

What is Record Reconciliation?

A

The process of assuring that all the records of discharged patients have been received by the HIM department for processing.

22
Q

What is Concurrent Review?

A

A review of the health record while the patient is still hospitalized or under treatment.

23
Q

What is Retrospective Review?

A

The part of the utilization review process that concentrates on a review of clinical information following patient discharge.

24
Q

What is a Deficiency Slip?

A

A device for tracking information missing from a paper-based health record.

25
Q

What is a Delinquent Record?

A

An incomplete record not finished or made complete within the time frame determined by the medical staff or facility.

26
Q

How is a correction made in a paper record?

A

By drawing a single line through the original entry, writing “error” above the entry, and then the practitioner signs, dates and times the correction.

27
Q

What is an Addendum?

A

A supplement to a signed report that provides additional health information within the health record?

28
Q

What is an Amendment?

A

A clarification made to the health information after the original documentation has been final signed by the provider.

29
Q

What is Access Control?

A

A computer software program designed to prevent unauthorized use of an information source.

30
Q

What are Standards (in terms of form control)?

A

Fixed rules that must be followed for every form.

31
Q

What are Electronic Document Management Systems (EDMS)?

A

An EDMS encompasses a wide range of technologies used to provide portions of an electronic Health Record and does more than manage documents after they are scanned into the computer.

32
Q

What is Nonrepudiation?

A

Limits an EHR’s user’s ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user.

33
Q

What is Record Reconciliation?

A

The process of assuring that all the records of discharged patients have been received by the HIM department for processing.

34
Q

What is Version Control?

A

The process whereby a healthcare facility ensures that only the most current version of a patient’s health record is available for viewing, updating and so forth.

35
Q

What is Free-text Data?

A

Data that are narrative in nature.

36
Q

What is Authentication?

A

The process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature.

37
Q

What are the three different types of information that can be used for authentication?

A

Something you know, something you have, or something you are.

38
Q

What is Authorization?

A

The granting of permission to disclose confidential information.

39
Q

What is Medical Transcription?

A

The conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients’ health records.

40
Q

What is the Legal Health Record?

A

Documents and data elements that a healthcare provider may include in a response to a legally permissible request for patient information.

41
Q

What is Abstracting?

A

The process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome.

42
Q

What is an Encoder?

A

Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.

43
Q

What are DRG Groupers?

A

A computer program that assigns inpatient cases to DRG’s and determines the Medicare Reimbursement rate.

44
Q

What are APC Groupers?

A

Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter.

National Exam (9 decks)

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