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How do accreditation organizations use the health record?
to determine whether standards of care are being met
How do research organizations use the health record?
to examine results of experimental protocols
Attorneys for healthcare organizations use the health record to
protect the legal interests of the facility and its health care providers
What format files all labs together, all progress notes together, etc.?
Source oriented health record
Inaccurate data recorded in the health record could
*compromise quality patient care
*contribute to incorrect assumptions by policy makers
*invalidate research findings
The term used to describe expected data values is
data precision
Protection of healthcare information from damage, loss, and unauthorized alteration is also known as
security
Which technology eliminates lost orders and problems with legibility?
Computerized physician/provider order entry
The paper-based health record format that organizes all forms in chronological order is known as
the integrated health record
The health record documents services provided by allied health professionals and a patient's family
False.  The health record documents the care provided by healthcare professionals.
An individual's right to control access to his or her personal information is known as
privacy
When all required data elements are included in the health record, the quality characteristic is met for...
data comprehensiveness
Patient care managers are individuals users of health records
True
Fuctions of the Health Record
*planning and managing care
*evaluating the adequacy and appropriateness of care
*substantiating reimbursement claims
*protecting the legal interests of both patient and healthcare provider
Clinical data elements documented in the acute care health record
*clinical observations
*discharge information
*medical history
Functions of the discharge summary
*ensuring the continuity of future care
*providing information to support the activities of the medical staff review committee
*providing concise information that can be used to answer information requests
What way can the patient's consent to undergo treatment be expressed?
*by submission to treatment
*by written agreement
*by verbal agreement
These are considered clinical data
*progress notes
*physician orders
*admission diagnosis

not name of insurance company
Which federal law resulted in the new privacy regulations for healthcare organizations?
The Health Insurance Portability and Accountability Act
Which report includes names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed?
operative report
An example of an advanced directive
living will
Materials documented in an emergency care record
patient's instructions at discharge
time and means of the patient's arrival
emergency care administered before arrival at the facility
Facilities governed by Medicare long-term care documentation standards
subacute care facilities
skilled nursing facilities
intermediate care facilities
Which specialized patient assessment tools must be used by Medicare-certified home care providers?
Outcomes and Assessment Information Set (OASIS)
Which regulations are most commonly applied in end-stage renal disease treatment?
Medicare Conditions for Coverage
What is the process that should be followed in making corrections in paper-based health record entries?
*The correction should be dated adn signed or initialed.
*The reason for the change should be noted.
*The word "error" should be noted on the entry.
Which types of healthcare facilities may seek accreditation from the Join Commission?
*acute care hospitals
*psychiatric hospitals
*home care providres
*ambulatory care organizations
The federal Conditions of Participation apply to which type of healthcare organizations?
any organization that treats Medicare of Medicaid patients
What is a traditional health record format?
process-oriented health record
Which health record format is most commonly used by healthcare settings as they transition to electronic records?
hybrid records
Examples of data capture technology
bar code readers
optical character readers
continuous voice recognition 
Challenges in the implementation of computer-based records
*lack of standardization
*lack of a clear definition
*organizational and behavioral resistance
*difficulty meeting the needs of multiple end users
Factors to be considered when designing a data retrieval system for an EHR
*presentation of data
*quick-search capabilities
*need to know
*analytical capabilities
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?
accreditation
Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological dequence in an ______ paper record
integrated
Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words?
chief complaint
Which creates a chronological report of the patient's condition and response to treatment during a hospital stay?
progress notes
What determines who can receive and transcribe verbal orders?
medical staff by-laws
Removing health records from the storage area to allow space for more current records is called
purging records
Which type of microfilm does not allow for a unit record to be maintained/
roll microfilm
Facts about document imaging
allows random access for retrieval of documents
can be viewed by more than one person at a time
can be viewed from locations remote from the HIM department

not a paperless system
Which system records the location of health records removed from teh filign system and documents the return of the health records?
chart tracking system
"Loose" reports are health record forms that
are received by the HIM department and added to the health record after it has been processed
In a paper-based system, the completion of the chart is monitored in a special area of the HIM deptartment called
the incomplete record file
In which system are all encounters or patient visits kept in one folder?
unit numbering system
What is the key to the identification and location of a patient's health record?
MPI
Which numbering system is best for maintaining the encounters of a patient together?
unit
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?
serial
Which is part of a quantitative analysis review?
*checking that all forms contain the patient's name and health record number
*checking that all forms and reports are present
*checking that reports requiring authentication have signatures

not checking that every word int he record is spelled correctly
What are good forms design for electronic forms?
Keystrokes should be minimized by using pop-up menus
Electronic forms should use completeness checks
Electrnoic forms should use text boxes to enter text.

Electronic forms should NOT used radio buttons for multiple selections of items.
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