HIM Final Exam

Question 1

How long must records be retained?

Answer 1

In NYS: 6 years from date of visit (for minors under 18, keep an additional 4 years).

Question 2

What is the difference between a numbering system and a filing system?

Answer 2

For numbering system:
– The technique can be used to assign unique medical record numbers to patients. (Unit, Serial, Serial Unit)

For filing system:
– The technique used to place records on the shelving unit in a paper record system (alphabetic by patient name; numeric by patient number; terminal digit by patient number)

Question 3

What is a terminal digit filing system?

Answer 3

The medical record number is split into three sections. For example, in a six-digit number, the sections would be xx-xx-xx. 9 would be xxx-xxx-xxx etc.

Question 4

How do you file by a terminal digit filing system?

Answer 4

1. First, look at primary digits and go to that section of file (the last set)
2. Second, look at secondary digits and go to that subsection. (middle set)
3. File by tertiary digits. (first set)

Question 5

In a medical record number split into three sections, which section is the primary set?

Answer 5

the last set (xx-xx-XX)

Question 6

In a medical record number split into three sections, which section is the tertiary set?

Answer 6

the first set (XX-xx-xx)

Question 7

What are some Terminal Digit advantages?

Answer 7

– Fewer errors
– Spreads newer records throughout the file room. The new records don’t bunch up one place as they would with straight numeric filing. An even distribution of the records.

Question 8

What is an image?

Answer 8

– A picture of one side of a piece of paper.

– If a piece of paper has writing on both sides, both the front and the back of the paper will be photographed for microfilming or scanning.

– The number of images in a record are used to determine costs charged by microfilming & scanning companies.

Question 9

Which set of numbers would be used to calculate the occupancy rate? Inpatient Service Days or Discharge Days

Answer 9

Inpatient Service Days

Question 10

How are inpatient service days computed?

Answer 10

– Total all the midnight censuses

– Patients who were both admitted and discharged on the same day

– Inpatient Service Days

Question 11

How are Discharge Days computed?

Answer 11

Total the lengths of stay for all the patients discharged.

Question 12

In which formula are discharge days used?

Answer 12

Average length of stay

Question 13

If a patient is admitted in November and discharged in December, how is the length of stay (LOS) computed?

Answer 13

– Use subtraction to determine the days in the first
month (November).

– Add the days in the following month (December).

Question 14

Must know the number of days in the month:

Answer 14

September, April, June, November = 30 days
All the rest have 31 days
Except February which has 28 (an 29 in a leap year)

Leap year = any year evenly divisible by 4
Example: 2016/4 = 504 so it was a leap year

Example: 2017/4 = 504.25 so it was not a leap year

Question 15

What four months have 30 days?

Answer 15

September, April, June, and November

Question 16

What is a nosocomial infection?

Answer 16

– Acquired in the health care facility.

– Was not present at the time of admission.

Question 17

When calculating the postoperative infection rate, we only use the infections that occurred in which type of cases?

Answer 17

Clean cases
(not already infected before surgery)

Question 18

What are the definitions of Mean, Median, and Mode?

Answer 18

– Mean = average
Example: 5 + 8 + 11 = 24. 24/3 = 8

– Median = middle number of ordered list
Example: 5, 8, 11. Median is 8

Example: 5, 8, 9, 11. Median is half way between the two middle numbers = 8.5.

– Mode = most commonly occurring number
Example: 5, 6, 8, 8, 9, 9, 9, 11. Mode is 9.

Question 19

A leap year is any number evenly divisible by what number?

Answer 19

4

Question 20

What is the GENERAL RATE FORMULA?

Answer 20

(The number of times something happened x 100) / (The number of times it could have happened)

Question 21

What is the OCCUPANCY RATE?

Answer 21

(Inpatient service days x 100) / (Number of Beds x Number of Days in the Time Period)