Chapter 2T: Purpose & Function Of The Record - (Hit) Health Records

Front 1

The principal repository for the documentation of an individual patient’s surgery, medications, and allergies.

Back 1

health record

Front 2

Golden Living, a long term care facility, has a new medical record department. What name is used for a record in this type of setting?

Back 2

resident record

Front 3

The term used for health record in an inpatient hospital is

Back 3

patient record

Front 4

Outside Living is an ambulatory care place. What name is used for a record in this type of setting?

Back 4

client record

Front 5

Today’s date is 9/3/12. This represents which of the following?

Back 5

data

Front 6

Suzy collected and analyzed all the surgery data for last year’s colonoscopies. She would like to use this data to report to the Surgery committee to be used to forecast future growth. This represents which of the following?

Back 6

information

Front 7

Longtown is opening a new medical clinic. They have lots of active paper charts they will be using and they want to start using an EHR once they get in the new building as well. What type of record management system is this?

Back 7

hybrid

Front 8

Luke wants to start keeping a health record of all his health information. He wants to put that record together himself so he can show his new doctor all of his past history. Which term BEST describes this?

Back 8

PHR

Front 9

ABC hospital just initiated a new interactive system at the hospital that will electronically store all of their patient’s information from admission through discharge. It will also provide them decision tools and alerts/reminders. Which term BEST describes this?

Back 9

EHR

Front 10

Which president outlined a plan for EHRs to be in most settings by 2014?

Back 10

George Bush

Front 11

Which governmental office was charged with leading the efforts to get EHRs in many settings?

Back 11

ONC

Front 12

What is the name of the economic stimulus package that provides monies to providers that are meaningful users of EHRs?

Back 12

ARRA

Front 13

Which of the following is not a primary purpose for the health record?

Back 13

education

Front 14

The following people are looking at and working with Tom’s chart. Which would not be considered a primary user?

Back 14

third party payor

Front 15

Which of the following users would be responsible for assigning the appropriate diagnostic code to a health record?

Back 15

coding specialist

Front 16

Dr. Johnson is currently treating Lynn for West Nile Virus. Which of the following best describe Dr. Johnson role as a user?

Back 16

patient care provider

Front 17

What federal legislation granted people the right to privacy, security, as well as the right to access their record?

Back 17

HIPAA

Front 18

How do lawyers use the health record?

Back 18

protect the legal interest of the facility

Front 19

Which of the following health record users is responsible for evaluating the overall health and well-being of the population they serve?

Back 19

government policy makers

Front 20

Blue Cross/Blue Shield needs to review a patient’s record to determine whether the documentation supports Dr. Johns claim for reimbursement. What type of user does Blue Cross represent?

Back 20

third party payers

Front 21

This user works under contract with the federal government to evaluate the adequacy and appropriateness of the care provided by an organization.

Back 21

QIO

Front 22

The participation in accreditation programs is

Back 22

voluntary

Front 23

Which of the following is not an accreditation organization?

Back 23

DMH

Front 24

Accreditation surveys include:

Back 24

-a review the record

-a periodic survey

-a site visit

Front 25

Licensure for health care organizations is

Back 25

mandatory

Front 26

What governmental agency is responsible for administering the federal Medicare and a portion of the federal Medicaid program?

Back 26

CMS

Front 27

Which of the following is not a part of AHIMA’s data quality management?

Back 27

data usefulness

Front 28

The accuracy of patient data in the health record is very important. Which of the following are/is factor(s) when placing data in the record?

Back 28

-providers interviewing skills

- patient's emotional state

- the providers recording skills

Front 29

An emergency room doctor should be able to review the past medical history of a patient prior to an exam. Which data characteristic does this represent?

Back 29

data accessibility

Front 30

Every health record system should allow record access

Back 30

24 hours a day

Front 31

Which of the following characteristics requires the record to be “complete”

Back 31

data comprehensiveness

Front 32

The clinical history for a male patient would not likely include a hysterectomy as a past surgical procedure. Which data characteristic does this represent?

Back 32

data consistency

Front 33

The lab test completed 2 days ago will be available in the record for Dr. Smith to look at during Lynn’s appointment. Which data characteristic does this represent?

Back 33

data timeliness

Front 34

This characteristic requires that attributes and values of data are defined at the correct level of detail.

Back 34

data granularity

Front 35

This characteristic is used to describe expected data values such as the year of birth should be recorded in a 4 digit numerical value “1965”.

Back 35

data precision

Front 36

This characteristic requires that the data in the health record are useful.

Back 36

data relevancy

Front 37

The right of an individual to control access to their personal health information.

Back 37

privacy

Front 38

The expectation that personal information shared by a patient with the doctor during a clinic visit will only be for the intended purpose.

Back 38

confidentiality

Front 39

The protection of privacy of individuals and the confidentiality of health records.

Back 39

security

Front 40

The organization of this record format is according to the department that provided the care.

Back 40

source oriented

Front 41

This record format includes the following: database, problem list, initial plans, etc.

Back 41

POMR

Front 42

All the paper forms are listed in strict chronological order and mix the forms created by different departments.

Back 42

integrated

Front 43

Dr. Smith just got an alert that Suzy’s white blood cell count is too low. This is an example of which kind of clinical tool?

Back 43

clinical decision support

Front 44

What are some advantages to using a CPOE?

Back 44

- eliminate lost orders

- eliminate illegible handwriting

- eliminate duplicate tests

Front 45

Which of the following is a secondary purpose of the health record?

Back 45

to generate a report to be used in performance improvement

Front 46

This provides physicians the ability to place order via computer.

Back 46

CPOE

Front 47

How do accreditation organizations use the health record?

Back 47

to determine whether standards of care are being met

Front 48

Inaccurate data recorded in the health record could:

Back 48

- compromise quality patient care

- contribute to incorrect assumptions by policy makers

- invalidate research findings

Front 49

Healthcare information systems need to exchange information. This linkage between systems is referred to as:

Back 49

connectivity

Front 50

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

Back 50

make decisions about reimbursement

Front 51

List all the data quality characteristics:

Back 51

data accuracy

data appropriateness

data consistency

data currency

data comprehensiveness

data definition

data granularity

data precision

data relevancy

data timeliness