Purpose And Function Of The Health Record

Question 0

Im a patient. My medical history including information from myself and my physicians is stored on the Internet. This is an example of which of the following: 
A. Health record 
B. EHR
C. PHR
 D. Data

Answer 0

PHR

Question 1

We had 324 Medicare patients last month. This statement represents which of the following: 
A. Information 
B. Data 
C. Content of the PHR
 D. Patient-specific information

Answer 1

Data

Question 2

Which of the following is an example of an primary purpose of the medical record

Answer 2

Patient care management

Question 3

Examples of patient care delivery of the medical record

Answer 3

Communication between caregivers

Question 4

Critique this statement:

The PHR and EHR are synonyms?

Answer 4

False , PHR and EHR are different

Question 5

Who are the primary users of health records

Answer 5

Patient care providers

Question 6

Are lawyers an individual user?

Answer 6

True

Question 7

T/f

Education is a primary purpose of health record

Answer 7

False, it is a secondary purpose

Question 8

Policy health and homeland security are a secondary purpose of a health record

Answer 8

True

Question 9

To verify billing is an secondary purpose ?

Answer 9

False it is a primary purpose

Question 10

Examples of patient care delivery usage of the medical record include which of the following uses?
A. Developing of practice guidelines
B. Communication between caregivers C. Reimbursement for patient care
D. Getting patients involved in their own care

Answer 10

Communication between caregivers

Question 11

T/F
The health record is the principal repository for data and information about the healthcare services provided to individual patients

Answer 11

True

Question 12

T/F The lab test “hemoglobin: 14.6 gm/110 ml” is considered information?

Answer 12

False , this is data

Question 13

T/F Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.

Answer 13

False statement

Question 14

In what year did AHIMA develop the data quality management

Answer 14

1998

Question 15

What are the four domains of the quality management model

Answer 15

Data warehousing
Data application
Data collection
Data analysis

Question 16

Which of the following users of the health record is an example of an institutional user?

A. Third-party payer
B. Patient
C. Physician
D. Employer

Answer 16

A. Third-party payer

Question 17

I work for CMS; how would I use the health record?

A. Make decisions on healthcare reimbursement
B. Medical research
C. Issuing hospital and medical staff licenses
D. Accrediting healthcare organization

Answer 17

A. Make decisions on healthcare reimbursement

Question 18

Which of the following users would utilize aggregate data?

A. Patient care providers
B. Coding and billing staff
C. Law enforcement officers
D. Patient care managers and support staff

Answer 18

. Patient care managers and support staff

Question 19

T/f

A physical therapist documenting in the health record is an institutional health record user.

Answer 19

False, individual user

Question 20

T/f
An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record use

Answer 20

Institutional user

Question 21

T/f

CMS uses data to accredit hospitals

Answer 21

False

Question 22

What is the primary function of the health record ?

Answer 22

Store patient care documentation

Question 23

Define data granularity

Answer 23

attributes and values of data be defined at the correct level of detail for the intended use of the data

Question 24

What is the term for used to describe expected data values

Answer 24

Data precision

Question 25

Define

Confidentiality

Answer 25

refers to the expectation that the personal information shared by an individual

Question 26

What are the three formats for paper based records

Answer 26

Source-orientated
Integrated health
Problem-orientated

Question 27

A physician just received notification from an EHR system that a patient’s lab test had a dangerously high value. This is an example of what kind of clinical tool?

A. Clinical decision support
B. Electronic records
C. Results management
D. Order-entry/order mana

Answer 27

A. Clinical decision support

Question 28

Someone suggested that we collect a patient’s eye color. This was not implemented. What quality characteristic would be the justification for not collecting this information?

A. Accuracy
B. Consistency
C. Granularity
D. Relevancy

Answer 28

Relevancy

Question 29

It was suggested that we enter the patient’s age manually in all of our information systems rather than having it entered once in one system and interfaced to the other systems. What quality characteristic would be the justification for not doing this manual entry into each information system

A. Accuracy
B. Consistency
C. Granularity
D. Relevancy

Answer 29

Consistency

Question 30

According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information? 
A. Data applications 
B. Data collection 
C. Data warehousing
 D. Data analysis

Answer 30

D. Data analysis

Question 31

A characteristic of data that includes every required data element

Answer 31

Data comprehensiveness

Question 32

A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records

Answer 32

Security

Question 33

According to the AHIMA Data quality model, what is the term that is used to describe how data is translated?

Answer 33

Data anaylsis

Question 34

The purposes for which day are collected

Answer 34

Data application