Midterm Prep Flashcards
Lecture Slides 1-7
1
Q
What is the role of HIM professionals?
A
Provide leadership in clinical record management, including collection, use, access, disclosure, retention, and destruction of health information.
HIM professionals are essential in ensuring the integrity and confidentiality of health records.
2
Q
What does HIM stand for?
A
Health Information Management
HIM focuses on maintaining, analyzing, and protecting confidential patient information.
3
Q
Define the term ‘health record’.
A
The place where a provider records the patient’s medical information, also known as a medical record.
Health records are crucial for patient care and documentation.
4
Q
What are the responsibilities of HIM professionals?
A
- Review patient records for timeliness and completeness
- Collect and maintain data for clinical databases
- Analyze patient information for quality assessments
- Assign clinical codes for reimbursement
- Manage health information systems
- Protect confidentiality of patient information
These responsibilities ensure proper management of health information.
5
Q
Who started hospital standardization in 1912?
A
Initiated by the American College of Surgeons to raise standards of surgery and establish minimum quality standards.
This was a significant step towards improving healthcare documentation.
6
Q
What is the Canadian Health Information Management Association (CHIMA)?
A
An organization representing HIM professionals in Canada, providing leadership and support in the field.
CHIMA plays a critical role in the development of health information management practices.
7
Q
What is the evolution of the HIM profession in Canada?
Dates, Names
A
- 1912: Recognition of need for clinical documentation improvements
- 1928: Association of Record Librarians of North America (ARLNA)
- 1942: Establishment of Canadian Association of Medical Record Librarians (CAMRL) chartered in 1949
- 1972: Canadian College of Health Record Administrators
- 1976: Canadian Health Records Association
- 2001: Transition to Canadian Health Information Management Association to reflect modern practices
The profession has evolved significantly over the years to adapt to changes in healthcare.
8
Q
What are the four domains of practice for HIM in Canada?
A
- Ethics
- e-HIM
- Data Quality
- Privacy
These domains guide the professional practice of HIM in Canada.
9
Q
What is required for HIM professionals to maintain certification?
A
Abide by the Code of Ethics and demonstrate continuing professional education (CPE).
Maintaining certification ensures that HIM professionals stay current in their field.
10
Q
Fill in the blank: HIM professionals must earn _______ credits over a three-year period.
A
36
A minimum of 80% of these credits must be relevant to the HIM profession.
11
Q
What are examples of HIM job opportunities?
A
- Health Records Clerk
- Hospital Coder
- Clinical Documentation Improvement Specialist
- Cancer Registrar
- Privacy Officer
- EHR Implementation Project Manager
- Performance Improvement Coordinator
The HIM field offers a variety of career paths with diverse responsibilities.
12
Q
What essential skills should HIM professionals possess?
A
- Critical Thinking
- Communication (written and verbal)
- Problem Solving
These skills are crucial for effective management of health information.
13
Q
True or False: HIM professionals primarily focus on the physical management of records.
A
False
HIM professionals also focus on data governance, quality assurance, and the use of technology in healthcare.
14
Q
What is the importance of effective note-taking in HIM?
A
It is crucial for creating study sheets and ensuring organized and legible information for exams.
Good note-taking enhances learning and retention.
15
Q
What is the mission of CHIMA?
A
To elevate health information professionals to be more recognized and impactful.
The mission emphasizes the importance of HIM professionals in healthcare.
16
Q
What is the vision of CHIMA?
A
To envision an equitable country where quality health information empowers people to make better decisions.
This vision reflects the goals of HIM in improving healthcare delivery.
17
Q
What are the three ways to meet eligibility criteria for HIM certification exams?
A
- Graduation from a recognized CCHIM accredited program
- Graduation from an international program approved by CCHIM
- Holding an international credential (e.g., RHIT/RHIA)
These pathways ensure that candidates possess the necessary knowledge and skills.
18
Q
What does e-HIM stand for?
A
Electronic Health Information Management
e-HIM represents the integration of technology in health information management.
19
Q
What is the primary purpose of the Patient Record?
A
To support patient care
It helps determine the course of treatment and provides continuity of care over time and between clinicians and providers.
20
Q
What are the three formats in which patient records may be maintained?
A
- Paper format
- Electronic format
- Hybrid (a combination of both formats)
21
Q
What is the difference between clinical documentation and clinical information?
A
- Clinical information: Patient information such as medical history, physical exams, and labs
- Clinical documentation: The capture and recording of clinical information
22
Q
Define Information Governance.
A
The structures, principles, and practices needed to standardize, manage, protect, access, and communicate data in a business environment.
23
Q
What are some functions of the Health Record?
A
- Ongoing care and treatment of individual patients
- Clinical decision making and communication
- Reimbursement
- Evaluation of the quality and efficacy of care
- Medical research and education
- Operational management
- Legal purposes
24
Q
True or False: The patient record serves as a legal document.
A
TRUE
25
What must the patient record conform to?
* Legal standards
* Regulatory standards
* Accreditation Canada
* Provincial and Federal Regulations
26
Who has the authority to document in the patient record?
Physician, who may delegate authority to document to someone else.
27
What must be included in the patient record to ensure quality documentation?
* Identification of the individual documenting
* Authentication of the report
* Physician review of documentation
28
What is the secondary purpose of the Patient Record?
* Serve as a legal document
* Education
* Substantiate claims for insurance payment
* Support quality improvement activities
* Monitor facility operations
* Monitor public health and other external reports
* Aid in strategic planning
* Plan activities for facility evaluation
29
What is required for proper patient identification in the demographics section?
* Name
* Address
* Health Insurance
* Date of Birth
* Employer
* Family Doctor
30
Fill in the blank: Data that has been organized to make it useful is called _______.
[Information]
31
What is the role of HIM professionals in health records?
Responsibility for quality documentation.
32
What are the challenges of managing hybrid records?
* Locating specific data elements in scanned documents is not possible
* Scanned documents cannot be automatically updated with changes
33
What is Clinical Documentation Improvement (CDI)?
A program to improve the quality of documentation to ensure that it is complete, legible, timely, concise, clear, patient-centered, and accurate.
34
True or False: A hybrid patient record is only two or more types of electronic formats.
FALSE
35
What are some examples of clinical data recorded about a patient's health?
* Diagnosis
* Temperature
* Blood pressure
* Laboratory reports
* Radiographs and other types of imaging
* Medications
* Surgical procedures
36
What happens if records are not completed within the specified timeframe?
They are considered delinquent.
37
What does the term 'signed' refer to in medical documentation?
The author of an order is the person who wrote it.
38
What should be done to ensure authentication of records?
* Record must be dated
* Author identified
* When required, authenticated
39
What is the significance of the Duty to Document?
The physician must review documentation, document any changes, cosign, and accept responsibility for the information.
40
What can lead to an incomplete record?
Missing required documentation and signatures.
41
Fill in the blank: The more complex a patient is, the more _______ is required.
[documentation]
42
What are the two main components of data?
* Items
* Observations
43
What is the importance of accurate documentation for reimbursement?
Complete and accurate documentation more easily translates into medical and procedural codes used for billing.
44
What must be on every page of a patient record?
Patient Identification
## Footnote
Ensures data is attached to the correct patient, making the record easy to check and preventing misfiling.
45
What are the key components that should identify a particular form?
* Name of facility
* Title of form
* Any special instructions
46
What is the purpose of using separate forms for different types of orders?
To categorize orders for specific patient types like newborns, surgical patients, and the general patient population
47
What considerations are important when designing a form?
* Size of the fields included
* Size of printing on the page
* Proximity to the edge of the form
* Whether holes will be punched in the form
48
Who is responsible for creating and maintaining the master forms file?
Director of the HIM department
49
What is the role of the forms committee?
Ensures forms are not duplicated and conform to the institution’s needs
50
What is the purpose of standard formats designed by the facility?
To remind users of what needs to be collected and how to collect it, ensuring complete capture of data as per clinical guidelines
51
What types of forms are included in the patient record?
* Medical
* Surgical
* Obstetrical
* Newborn Admission Forms
* Registration
* Preadmit Checklist
* Demographics
* Consents
* Insurance
* Advance Directives
52
What is included in patient care documentation?
* H&P
* Assessment
* Plan
* Diagnosis
* Physician Orders
* Diagnostic findings
* Fluid Intake-Output
* Medication Records
* Restraint Logs
53
What does the forms committee monitor?
Use of paper forms and electronic data capture screens (EDC)
54
What are the responsibilities of the forms committee?
* Support patient care
* Quality improvement
* Risk management
* Financial activities
* Teaching
* Research
55
What are the essential EHR forms documentation requirements?
* Identify the patient
* Justify diagnosis and treatment
* Document results of care
* Describe condition of patient at discharge
* Document discharge instructions
56
True or False: Notes in a patient record must be reviewed and signed in a timely manner.
True
57
Fill in the blank: Changes and updates to patient records are _______.
[systematic and planned]
58
What must authentication of notes include?
* Identity and credentials of author
* Date and time signed
59
What are addendum notes used for in patient records?
To clarify or provide additional information and cannot be backdated
60
What are the three formats of health records?
Problem-oriented health records, Source-oriented health records, Integrated health records
## Footnote
Each format serves a different purpose in organizing patient information.
61
How is a Problem-oriented medical record (POMR) organized?
Organized by medical problems
## Footnote
Problems addressed at each encounter are listed beside each dated entry.
62
What is a Source-oriented medical record organized by?
Organized by source or category such as progress notes, diagnostics, operative documentation, therapist documentation
## Footnote
This format groups information based on where it comes from.
63
What information is included in Ambulatory (Outpatient) Records?
* Patient identification information
* Health history and onset of illness
* Problem list
* Physical exam results
* Test results
* Medication list
* Record of educational materials provided
* Follow-up instructions
## Footnote
These components are essential for outpatient care.
64
What information is typically found in Hospital (Inpatient) Records?
* Admission and consent forms
* Physician orders
* Test results
* Medications and treatment provided
* Log of vital signs
* Procedures
* Nurses notes
* Provider notes
* Discharge summary
## Footnote
Inpatient records are comprehensive due to the complexity of hospital care.
65
What are the types of inpatient admission?
* Emergency
* Urgent
* Elective
* Other
## Footnote
Each type of admission has specific characteristics and protocols.
66
What is required for a patient to be admitted to a hospital?
Physician must write an order for the patient to be placed in a bed in the hospital
## Footnote
This order defines the patient's status as inpatient or outpatient.
67
What is the role of Patient Registration?
Ensures timely and accurate registration of patients
## Footnote
They may also be referred to as admitting clerks or patient access clerks.
68
What information is obtained during the registration process?
* Proof of identity and insurance
* Demographic data
* Socioeconomic data
* Financial data
## Footnote
This information is crucial for patient management and billing.
69
What is the purpose of a wristband in patient identification?
Labels the patient and includes a barcode for identification
## Footnote
It is difficult to remove and helps ensure accurate patient identification.
70
True or False: Consent for invasive procedures requires additional forms.
True
## Footnote
This ensures that patients are informed and agree to the procedures being performed.
71
What is the purpose of a Discharge Summary?
* History of presenting problem
* Discharge diagnoses
* Other significant findings
* Treatments and procedures performed
* Patient’s condition at discharge
* Medications given during stay and those prescribed at discharge
* Follow-up care or appointments
* Instructions for patient or patient’s caregiver
## Footnote
It provides a comprehensive overview of the patient's hospital stay.
72
What does the acronym SOAP stand for in medical documentation?
Subjective, Objective, Assessment, Plan
## Footnote
This format is used to structure clinical notes.
73
What must be included in a patient's medication administration record?
* Name of medication
* Dosage
* Date and time of administration
* Method of administration
* Name of nurse who administered it
## Footnote
This information is critical for preventing medication errors.
74
What is the purpose of Computerized Physician Order Entry (CPOE)?
Allows a physician to enter orders for medications, tests, treatments, or procedures directly into a system
## Footnote
It enhances efficiency and reduces errors in medication delivery.
75
Fill in the blank: A patient’s medical history and physical exam are documented in the ____ and ____.
History and Physical (H&P) documentation
76
What is an Autopsy Report?
A report that investigates deaths occurring under special circumstances, determining cause of death and other comorbidities
## Footnote
Conducted by medical examiners or pathologists.
77
What is the role of the Admitting Physician?
Physician who issues the order to observe or admit
## Footnote
This physician is responsible for the patient's initial care decisions.
78
What does a Nursing Note evaluate upon patient admission?
* Patient’s care needs
* Condition of patient’s skin
* Patient’s understanding of condition
* Learning needs
* Ability to perform self-care
## Footnote
This assessment helps tailor nursing care to individual needs.
79
What types of data are included in Neonatal Records?
* Progress of the fetus
* Delivery data
* Number of previous births
* Types of deliveries
* Conditions of the newborns
## Footnote
These records focus on the health and care of newborns.
80
What is the purpose of an Anesthesia Record?
Document evaluations and anesthesia administration of the anesthesiologist
## Footnote
It includes preoperative and postoperative evaluations and continuous monitoring during the procedure.
81
What are the levels of care included in data collection in Canada?
* Acute
* Rehabilitation
* Cancer care
* Chronic disease management
* Primary care
* Mental health
* Community residential and ambulatory levels of care
* Continuing and long-term care
## Footnote
These levels highlight the comprehensive approach to health care data collection across various settings.
82
What do professional practice guidelines and requirements pertain to in health care settings?
Documentation standards
## Footnote
These guidelines ensure that documentation is consistent and meets regulatory requirements.
83
What is the focus of documentation standards in health care?
* Patient care quality
* Appropriate reimbursement
* Prevention of fraud and abuse
## Footnote
These focuses are crucial for maintaining integrity within health care documentation.
84
What are some sources of documentation standards?
* Payers
* Insurance companies
* Government regulatory agencies
* Accrediting bodies
* Organization policies
* Medical staff by-laws
## Footnote
These sources contribute to the complexity of documentation standards.
85
Why is quality documentation important in health care?
* Patient safety
* Quality of care
* Appropriate reimbursement
## Footnote
Quality documentation ensures that patient care is effective and accountable.
86
What are the goals of documentation standards?
To ensure accurate and comprehensive health records
## Footnote
This helps in delivering better patient care and supports clinical decision-making.
87
What is the significance of standardization in medical practice?
* Standardization of medical practice
* Standardization of medical documentation
* Standardization of nursing practice
* Standardization of nursing documentation
* Standardization of the allied health professions
## Footnote
Standardization is essential for maintaining consistency and quality across health care services.
88
Name some types of secondary data sources.
* Indices
* Trauma registries
* Birth defect registries
* Diabetes registries
* Implant registry
* Transplant registry
* Immunization registries
## Footnote
These sources are crucial for public health research and monitoring.
89
When was the British North America Act established?
1867
## Footnote
This act is a foundational document of Canada’s constitution.
90
What organization recognized the need for clinical documentation accountability in 1912?
American Medical Association (AMA)
## Footnote
Also ACS (American College of Surgeons) The AMA played a pivotal role in advocating for improved documentation practices.
91
What is the current name of the Association of Record Librarians of North America (ARLNA)?
American Health Information Management Association (AHIMA)
## Footnote
This organization focuses on standardizing medical records.
92
What does the Canadian Health Information Management Association (CHIMA) advocate for?
* Continuing education
* Professional practice of HIM professionals
* Strategic partnerships for electronic HIM development
* Strengthening the HIM role in health care settings
## Footnote
CHIMA plays a vital role in advancing health information management in Canada.
93
What is required to become a certified member of a health information management organization?
Graduation from an accredited HIM program and successfully challenging the national certification exam
## Footnote
Certification ensures that professionals meet the required standards in health information management.
94
What are some benefits of being a member of a health information management association?
* Professional practice benefits (PPB)
* Educational sessions
* Networking opportunities
## Footnote
Membership in these associations provides resources for professional growth.
95
What are the three types of numbering systems in health records?
Serial, Unit, Serial-Unit
## Footnote
Each system has its own method of organizing patient records.
96
What are the benefits of electronic health record systems?
* Improved accessibility
* Enhanced data sharing
* Reduced physical storage needs
* Direct documentation by providers
* Compliance with regulations
## Footnote
Electronic health records facilitate better patient care and operational efficiency.
97
What must the information in a health record outline and justify?
* Treatment
* Diagnosis
* Progress
* Outcomes of care provided
## Footnote
This ensures comprehensive documentation of patient care.
98
What is a longitudinal health record?
Every piece of information about a patient since birth until death
## Footnote
This type of record provides a complete view of a patient's medical history.
99
What is the purpose of a discharge register?
Contains a list of patients based on discharge date
## Footnote
It helps manage patient flow and room availability.
100
True or False: Discharge dates must be entered in a timely manner to avoid process errors.
True
## Footnote
Failing to do so can lead to incorrect discharge registers and delays in room turnover.
101
What happens to a patient record after discharge in a paper-based environment?
Aimed at retention of an accurate and complete record culminating in storage
## Footnote
This process ensures that all necessary documentation is preserved.
102
How are paper records processed post-discharge?
* Remain on the unit until the next morning
* Physicians sign off on orders
* Nurses complete documentation
* Move to HIM department
## Footnote
This allows thorough review and ensures accuracy before storage.
103
What is the primary organization method used in patient care for record assembly?
Reverse chronological order
## Footnote
This method helps in quickly accessing the most recent records.
104
Fill in the blank: The primary number in terminal digit filing is read from _______.
RIGHT to LEFT
## Footnote
This method categorizes records based on the last digits of the medical record number.
105
What are the advantages of digital imaging for health records?
* Multiple user access
* Reduced labor costs
* Fewer filing errors
* Less need for physical storage
* Easier data retrieval
## Footnote
Digital imaging streamlines record management and enhances efficiency.
106
What is unit numbering in health records?
A single number is assigned for the initial visit and kept for all subsequent visits
## Footnote
This method links all records for a patient, simplifying retrieval.
107
What are the security measures for record retention?
* Prevent accidental destruction
* Prevent inappropriate viewing or use
* Ensure timely access when needed
## Footnote
These measures protect patient confidentiality and data integrity.
108
What is the role of the HIM department regarding record storage?
Traditionally responsible for storing records appropriately
## Footnote
This includes ensuring security and accessibility of health information.
109
What are the disadvantages of using file cabinets for record storage?
* Limited access to only one drawer at a time
* Requires additional space to open
## Footnote
These limitations can hinder efficiency in record retrieval.
110
What is the significance of a medical record number?
Used for identification and to protect patient confidentiality
## Footnote
This number is crucial for both paper and electronic records.
111
What is the main disadvantage of serial numbering?
Time-consuming to retrieve records
## Footnote
Each visit requires a new number, complicating the filing system.
112
True or False: Terminal digit filing promotes confidentiality and security of health information.
True
## Footnote
This filing method helps organize files effectively, reducing the risk of misfiles.
113
What is the purpose of form control in record assembly?
Must be closely monitored to ensure data quality
## Footnote
This is critical for both paper and electronic data collection.
114
What is the measure of quality in the record retrieval process?
How quick you can find the record.
115
What filing system organizes files by a patient’s last name followed by their first name?
Alphabetical filing.
116
In straight numeric filing, how are files organized?
Chronological order.
117
What determines the primary location in terminal digit filing?
Last two digits of file number.
118
What determines the primary location in middle digit filing?
Middle two digits of file number.
119
What is the future of paper records in healthcare?
Limited use.
120
After the go-live date for electronic health records (EHR), what type of records will mostly be created?
Electronic records.
121
What is microfilm?
Paper image copied in miniature on film.
122
What equipment is needed to reproduce a paper copy of a patient's record from microfilm?
Printer.
123
What must scanned documents be organized under to indicate the type of documentation?
Tabs.
124
What is the purpose of indexing in record management?
Sorts records by different report types.
125
True or False: In the serial numbering system, individual records from different visits are filed in different locations.
True.
126
True or False: Alphabetical filing systems offer a greater level of privacy than middle and terminal digit filing systems.
False.
127
How do computerized systems improve the record retrieval process?
Eliminate the need for physical outguides and cards.
128
What is the term for patient authorization not required for internal facility review?
Committee Requests for Records.
129
What do PHIPA and PIPEDA privacy rules grant patients the right to do?
Inspect, review, and receive a copy of their health record.
130
Fill in the blank: The process of documenting the release of information to external providers requires _______.
[signed authorization from the patient].
131
What is an outguide in record management?
Physical file or jacket signifying that the record is away from its expected location.
132
What is the role of the HIM department when records are signed out?
Keep track of the location of all records.
133
What is the significance of bar codes in computerized systems?
Facilitates accurate and efficient processing.
134
What should be done if documents have not been incorporated into the patient record during admission?
File them in the chart on the nursing unit as soon as possible.
135
What must be done for records stored off-site?
Need procedures for security and timely retrieval of records.
136
What is the purpose of a log or index card box in record management?
Quick alphabetical reference of all records that are signed out.
137
What is required for the release of information to external providers and third-party payers?
Signed authorization from the patient.
138
What is the process to prepare a release of information?
Locate the information, prepare the release, log and bill.
139
CPOE
Computerized Physician Order Entry
