Unit 4

Question 1

Steps of record flow

Answer 1

1. Patient registered
2. Previous doc. delivered
3. Doc. Is written by healthcare professional
4. patient is discharged
5. Health record is assembled
6. Health record is analyzed for missing documentation
7. Physicians and other healthcare professionals complete missing doc or signatures
8. Record is permanently filed.

Question 2

Centralized registration

Answer 2

Patients presenting for any type of care are registered through one central area

Question 3

Decentralized registration

Answer 3

Multiple points of patient access depending on the type of care, emergency department, outpatient, diagnostics, ambulatory surgery, and so on

Question 4

Master patient (person) index (mpi)

Answer 4

Permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is permanently maintained.

Question 5

Medical record number

Answer 5

Unique numeric identifier for each patient seen in a health facility

Question 6

Some facilities store pediatric patients records for how long

Answer 6

25 years

Question 7

HIM manger who oversees record security does what

Answer 7

Most input on the final selection of a filing system used to house paper health records

Question 8

Healthcare facilities can increase the efficiency of reimbursement cycles through what?

Answer 8

Performing high-quality, timely coding of diagnoses and treatments

Question 9

Clinical data

Answer 9

Data found in a health record that are of a medical nature

Question 10

WORM tech

Answer 10

Acronym for write once, read many. Records may be read numerous times, but nothing on the disc can be altered in any way.

Question 11

Jukebox

Answer 11

Means of storing multiple optical disks using a robotic arm

Question 12

Clinical data

Answer 12

Collected patient info, such as symptoms and diagnosis

Question 13

Unit record

Answer 13

Master record that houses each individual encounter record

Question 14

Enterprise

Answer 14

System of health providers and facilities that are under the same ownership

Question 15

Outguide

Answer 15

Colored tag that aids kn the filing and organizing of paper records

Question 16

Demographic data

Answer 16

Data that identifies the patient

Question 17

Concurrent documentation takes place

Answer 17

While a patient is being seen or treated

Question 18

Administrative data

Answer 18

Nonmedical data, such as patient idenfiers, insurance related data, etc

Question 19

Hybrid record

Answer 19

Healt record maintained in paper format, electronic format, and or in the form of recordings or tracings derived from diagnostic tests

Question 20

Client/server

Answer 20

Use of pcs in a Bert where functions are split between tasks.

Question 21

Record retention plan

Answer 21

Written policy that documents the length of time a healthcare facility retains its health records, the form in which the records will be kept, and the location of records

Question 22

Reimbursement cycle

Answer 22

Processes that take place from the time a patient is registered for care to the time the services are paid in full

Question 23

Leagal health record

Answer 23

Considered the official business record and would be presented if subpoenaed

Question 24

Clinical doc. Improvement (cdi)

Answer 24

Review of health records to ensure that the doc in the health records is at the level of specificity that allows for code assignment