Chapter 1-3 Review

To promote the accuracy, confidentialtiy, and accessibility of health records in every healthcare setting.
The primary function of the American Health Information Management Association is
To raise the standards of surgical practice
The primary goal of the Hospital Standardization Program was
Data Administration
Which of the following activities is not a traditional medical recoerds function?
False
The only requirements for professional certification therough the AHIMA are graduating from an accredited two-year or four-year educational program.
Candidates must pass an examination before obtaining any of the credentials
Which of the following is true about AHIMA certification program?
Active membership
Which of the foloowing classes of AHIMA membership requires that individuals hold an AHIMA credential?
Board of Directors
Which of the following entities are at the head of the AHIMA volunteer structure?
Establishing standards for the content of college programs in HIT and HIM
The accreditation program of AHIMA is concerned with
Data resource administrator
The new opportunity for HIM professionals that deals with data repositories and data warehouses is
1928
HIM has been recognized as an allied health professional since
Communities of Practice
The ____________ makes up a virtual network of A?HIMA members who communicate via a Web based program managed by AHIMA
CAHIM
Which of the following accredits academic programs in health information?
Elected by members in state component organizations
Members of the AHIMA House of Delegates are
AHIMA Housse of Delegates
Who is responsible for final approval of the AHIMA Code of Ethics?
AHIMA Foundation
Which of the following actively promotes education and research in health information managment?
storing patient care documentation
Which of the following best describes the most important function of the health record?
the clinical professionals who provide direct patient care
Who are the primary users of the health record?
financial information
Which of the following elements is not a component of most patient records?
Connectivity
Healthcare information systems need to exchange information. This linkage between systems is referred to as:
data accountability
Which of the following is not a characteristic of high- quality healthcare data?
a numerical measurement carried out to the appropriate decimal place
Which of the following represents an example of data granularity?
Integrated health record components are arranged in strict chronological order.
What is the defining characteristic of an integrated health record format?
This is a true statement
Critique this statement: Electronic health record systems have the same access control requirements as paper-based record systems.
This is a true statement
Critique this statement: Paper-based record systems are not flexible enough to meet all of the needs of every health record user.
Confidentiality`
the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
Privacy
the right of individuals to control access to their personal health information
Security
the protection of the privacy of individuals and the confidentiality of health records
Data are correct
Which of the following best describes data accuracy?
Data include all required elements
Which of the following best describes data completeness?
Data are easy to obtain
Which of the following best describes data accessibility?
the meaning of data
Data definition refers to ___________
data currency
Dr. Jones entered a progress note in a patient’s health record 24 hours after he visited the patrient. Which quality element is missing from the progress note?
data consistency
The admitting form of Mrs. Smith’s health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith’s birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith’s health record?
clinical decision support
I need an information system that will provide assist physicians in diagnosing and treating patients. The system that I need is
Blue Cross Blue Shield
I have been asked to list institutional users of the health record. Which one of the following would I include in my list?
problem list
Which of the following is not usually a component of acute care patient records?
discharge summary
The attending physician is responsible for which of the following types of acute care documentation?
medication report
A nurse is rwesponsible for which of the following types of acute care documentation?
admitting diagnosis
Which of the following is an example of clinical data?
operative report
The number of ligatures, sutures, packs, drains and sponges used and specimens removed would be found in the ______________
emergency care report
Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?
all of the above, Joint Commission, American HEalth Information Management Association and National Committee for Quality Assurance
Documentation standards and guidelines are published by a variety of private and public organizations, including the _______________
can be accessed by multiple end users simultaneously
Which of the following is true of computer-based records?
medical history
which of the following represents documentation of the patient’s current and past health?
physical exam
Which of the following contains the physician’s findings based on an examination of the patient?
documents opinions about the patient’s condition from the persepective of a physician not previously involved in the patient’s care
What is the function of a consultation report?
to document the physician’s instructions to other parties involved in providing care to a patient
What is the function of physician’s orders?
living will
Which of the following is an example of an advance directive?
pressent illness
In a medical history, which of the following is a detailed chronological description of the development of the paitent’s illness?
ambulatory care
Patient history questionnaires are most often used in:
physical examination
Which of the following represents the attending physician’s assessment of the patient’s current health stratus?
community mental health centers
Which of the following is not an example of a long-term care setting?
long-term care
An RAI/MDS and care plan are found in records of patients in ___________
correctional facility care
In which setting may treatment records travel with the patient between treatment centers?
personal health record
Documentation of genetic information, immunizations, hopspitalizations, surgeries, medications, and personal, family occupational and environmental histories are maintained over a lifetime in what type of record?
hospice record
Which type of patient care record includes documentation of a family bereavement period?
Use black ink to obliterate the entry
When correcting erroneous information in a health record, which of the following is not appropriate?
Joint Commission
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
home health
documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleanings would be found in which type of specialty record?
Commission on Accreditation of Rehabilitation Facilities
Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?
standardized familiar format
Which of the following is an advantage of paper based records?
electronic record
Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?
document imaging
Which of the following is an example pf data capture technology?
Conditions of Participation
What is the general name for Medicare standards impacting healthcare organizations?
Health Level 7 (HL7)
Which of the following organizations recently drafted functional standards for electronic health records?