Ch.5
49. Sally Smith, RHIT, is designing a screen to collect information on a patient's medical history. List three fields that should be part of the screen.
Patient Name Family History Identification Number Social History • Problem List • Allergies Surgical History Medications
43. A _______ is a collection of related fields.
RECORD
17. Early medical record automation efforts focused on the:
a. Scanning of documents into imaging systems
19. In relation to a hybrid record system, which of the following is false?
b. It totally eliminates paper record storage.
14. Data are defined as:
b. Raw facts
46. List two functions that are included in a pharmacy application. Briefly discuss the advantage of a pharmacy application.
A pharmacy application includes: • Order Entry • Identification of drug interactions Pharmacist review • Medical label printing • Inventory control • Drug usage Advantages include: • Order entry is faster and more accurate • Labeling of medications is more accurate Inventory is automated • Time is saved • Drug usage is monitored
33. In a(n) _____________ system, views of patient records can be customized by users.
AUTOMATED
28. Sally Smith, a pediatric nurse, is collecting the birth weights of children that have a length of stay in the neonatal intensive care unit longer than 60 days. This represents:
C. Health Data
24. Optical disk imaging uses_________ technology to create an image.
C. Laser
31. The term ____________ was used in the period of 1970-1980 to describe the early medical record automation attempt.
COMPUTERIZED MEDICAL
41. Number, letters, images, and symbols that are not interpreted or processed are classified as
DATA
34. Optical disk imaging is also known as
DOCUMENT IMAGING
47. List three nursing application functions.
Development of nursing intake assessments • Documentation of nursing care Ongoing assessments of patients • Medication administration records Charting functions
37. The term _______________ is used currently by the Institute of Medicine (1OM) and HL7 to describe the development of standards that relate to the exchange of clinical health information.
ELECTRONIC HEALTH RECORD
36. The term ____________was used in the late 1990s to describe systems that were based on imaging and merging data from stand-alone systems.
ELECTRONIC MEDICAL RECORD
42. A group of characters forms a
FIELD-
44. A ____________is a collection of related records.
FILE
48. Discuss how the role of HIM professional will change with the implementation of electronic record systems.
HIM professionals will no longer perform manual tasks, but instead will manage and oversee the collection, generation, and retrieval of electronic patient information.
45. Data becomes ___________ after it is given meaning.
INFORMATION
32. A ____________ patient record contains records from different episode of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters.
LONGITUDINAL
38. The content of a legal medical record must be defined in a facility _____________standards for maintaining the security and integrity of the information.
POLICY and
40. A _____________ is an electronic network of patient medical information gathered from multiple health care organizations in a
REGIONAL HEALTH INFORMATION ORGANIZATION (RHIO)
35. Many facilities have ____________ quality reviews of scanned documents
TWO
18. Which of the following is true?
a. Automated record systems can help to prevent drug interactions.
15. Systems that collect and monitor patient physiological data and record the information are known as:
a. Patient Monitoring Systems
27. Which of the following is true in relation to RHIOS?
a. They improve patient care
1. Health information professionals will play a major role in the transformation from a paper patient record environment to a virtual electronic environment.
a. True
3. A computer-based patient record can link patient information at different locations according to a unique patient identifier.
a. True
7. Typically, a patient's medical record number is used as the unique identification number when documents are scanned into automated systems.
a. True
9. HL7 is a standards development organization that develops electronic health record (EHR) standards.
a. True
13. The ultimate goal of a regional health information organization (RHIO) is to:
b. Allow health care providers the opportunity to access patient information that was generated at other locations
22. Which of the following is a disadvantage of a manual record system?
b. Difficult to abstract information
10. A longitudinal patient record is used to describe an electronic medical record maintained and updated by an individual for his or her personal use.
b. False
2. One of the first terms used in the period 1970-1980 to describe early medical record automation attempts was the term electronic medical record.
b. False
4. Low start-up cost is typically an advantage of electronic patient record systems.
b. False
5. Selection and development of manual systems is time consuming.
b. False
6. A scanner is used to capture a patient's vital signs information.
b. False
8. Electronic medical record systems originated in the late 1980s and were based on imaging and the merging of data from various stand-alone systems.
b. False
11. Suzy Supervisor is working to transition the health information management (HIM) department from a paper system to an electronic system. Currently, each patient's record has a paper history and physical, operative report, and discharge summary, while the progress notes and medication administration records are maintained in an electronic system. This is known as a(n):
b. Hybrid Record
25. A(n) ____________ includes the merging of data from different data systems into one centralized database.
c. Clinical Data Repository
30. Nurse Flower is reviewing an electronic report of patient Katie's CBC and urinalysis. This report has most likely been generated as part of a ___________ application.
c. Laboratory
26. Which of the following will occur in an HIM department that has an electronic record system?
c. Notes that are not authenticated
16. Nurse Robin is using a report that records the late dosing of patients' medications. This report is generated from which type of application?
c. Nursing
23. Which of the following is a disadvantage of automated systems?
c. Technical staff is needed to maintain the system
12. Per Joint Commission standards, all inpatient hospital records must be completed within ___________ days after discharge, regardless of the storage media of the record.
d. 30
21. Which of the following is an advantage of an automated system?
d. Eliminates paper record storage
29. A RADT system is defined as a:
d. Registration Admission Discharge Transfer System
20. Which of the following is an advantage of a manual record system?
d. Training of staff is simple.
