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Intro to HI > Unit 2 Test > Flashcards

Unit 2 Test Flashcards

this one

1
Q

a voluntary process of institutional or organizational review in which a quasi-independent body creates for for this purpose periodically evaluates the quality of the entity’s work against preestablished written criteria

A

Accreditation

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2
Q

a late entry added to a health record to provide additional information in conjunction with a previous entry. Late entry should be timely & bear the current date & reason why; Additional

A

Addendum

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3
Q

a clarification made to healthcare documentation has been signed, it should be dated, timed, & signed; Clarification

A

Amendment

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4
Q

process by which a duly authorized body evaluates & recognizes an individual, institution, or educational program as meeting predetermined requirements

A

Certification

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5
Q

screening for medical necessity & the appropriateness & timeliness of the delivery of medical care from the time of admission until discharge

A

Concurrent review

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6
Q

a patient’s acknowledgement that he or she understands a proposed intervention, including that intervention’s ricks, benefits & alternatives; Document signed by the patient that indicates agreement that protected health information (PHI) can be disclosed

A

Consents

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7
Q

agreement that an individual makes to receive medical treatment, care or services (tests & examinations)

A

Consent to treatment

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8
Q

documentation of the clinical opinion of a physician other than the primary or attending physician

A

Consultation report

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9
Q

History, Physical, Discharge summary, Consultation report, Pathology report, Nursing notes, Progress notes, Physician orders, Consents

A

Contents of the medical record:

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10
Q

an official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation

A

Deemed status

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11
Q

a summary of the patient’s stay at a healthcare organization that is used along with post discharge plan of care to provide continuity of care upon discharge from the facility

A

Discharge summary

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12
Q

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

A

Filing system: Alphabetic filing system

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13
Q

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

A

Filing system: Straight-numeric filing system

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14
Q

a system of health record identification & filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement

A

Filing system: Terminal-digit filing system

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15
Q

How long is the MPI maintained:

A

Permanently

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16
Q

How to correct an error in a paper medical record:

A

should be made by drawing a single line through the erroneous information & writing the word “error” above the mistake

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17
Q

Identification (numbering) system-how the patient is linked to a medical record:

A

the health record number is created by the MPI & the numbers are issued in subsequential numeric order; A system of health record identification & storage in which records are arranged consecutively in ascending numerical order according to the health record number

18
Q

Information contained in the MPI:

A

patient demographics, dates of care, the patient’s health record number

19
Q

A legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed; An individual’s voluntary agreement to participate in research or to undergo a diagnostic, therapeutic or preventive medical procedure

A

Informed consent

20
Q

a system of health record organization in which all the paper forms are arranged in strict chronological order & mixed with forms created by different departments

A

Integrated health record

21
Q

Know how to estimate space needed for shelving:

A

Evaluate volume indicators, such as number of discharges, size of records, & the capacity of the storage units

22
Q

a patient-identifying directory referencing all patients related to an organization, which also serves as a link to the patient record or information, facilitates patient identification, & assists in maintaining a longitudinal patient record from birth to death

A

Master patient index (MPI)

23
Q

portion of clinical data that addresses the patient’s current complaints & symptoms & list his or her past medical, personal, & family history

A

Medical history

24
Q

maintain chronological records of the patient’s initial vital signs & documentation of medications ordered & administered: summary of patient’s problems

A

Nursing notes

25
Q

the legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)

A

License

26
Q

source oriented, universal chart order, problem-oriented, integrated

A

Organization of records

27
Q

identifies where the health record is located & when it was removed; generally made of colored vinyl with 2 plastic pockets

A

Outguide

28
Q

filing patients alphabetically, keeping patient information & identifying patients on the shelf alphabetically

A

Paper based health record: Alphabetic

29
Q

system where a patient is issued a unique numeric identifier for every encounter at the healthcare facility; if a patient is admitted to the healthcare facility 5 times, he or she will have 5 different health record numbers

A

Paper based health record: Serial numbering system

30
Q

a combination of the serial & unit numbering systems; the patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number

A

Paper based health record: Serial-unit numbering system

31
Q

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

A

Paper based health record: Unit numbering system

32
Q

a type of health record or documentation that describes the results of a microscopic & macroscopic evaluation of a specimen

A

Pathology report

33
Q

the physician’s assessment of the patient’s current health status after evaluating the patient’s physical conditions

A

Physical examination

34
Q

a physician’s written or verbal instructions to the other caregivers involved in a patient’s care

A

Physician orders

35
Q

patient record in which clinical problems are defined & documented individually

A

Problem-oriented health record

36
Q

the documentation of a patient’s care, treatment & therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient’s care, including nurses, physicians, therapists & social workers

A

Progress report

37
Q

to remove files of patients who have not been at the healthcare organization for a specified period, from the active filing area

A

Purge

38
Q

Purpose of the MPI

A

a numeric filing system which allows the user to look up the patient health record number so the record can be located

39
Q

a type of research conducted by reviewing records from the past (ex. birth/death certificates or health records) or by obtaining information about past events through surveys or interviews

A

Retrospective review

40
Q

a system of health record organization in which information is arranged accordingly to the patient care department that provided the care

A

Source-oriented health record

41
Q

documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments & plans

A

Subjective Objective Assessment Plan (SOAP) notes

42
Q

a system in which the health record is maintained in the same format while the patient is in the facility & after discharge

A

Universal chart order

Intro to HI (1 decks)

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