Chapter 1-3 Review

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

electronic record

Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

hospice record

Which type of patient care record includes documentation of a family bereavement period?

emergency care report

Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?

the clinical professionals who provide direct patient care

Who are the primary users of the health record?

AHIMA Housse of Delegates

Who is responsible for final approval of the AHIMA Code of Ethics?

Security

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

Privacy

the right of individuals to control access to their personal health information

physical exam

Which of the following contains the physician's findings based on an examination of the patient?

financial information

Which of the following elements is not a component of most patient records?

Board of Directors

Which of the following entities are at the head of the AHIMA volunteer structure?

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.

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?

living will

Which of the following is an example of an advance directive?

admitting diagnosis

Which of the following is an example of clinical data?

document imaging

Which of the following is an example pf data capture technology?

data accountability

Which of the following is not a characteristic of high- quality healthcare data?

community mental health centers

Which of the following is not an example of a long-term care setting?

problem list

Which of the following is not usually a component of acute care patient records?

Candidates must pass an examination before obtaining any of the credentials

Which of the following is true about AHIMA certification program?

can be accessed by multiple end users simultaneously

Which of the following is true of computer-based records?

Health Level 7 (HL7)

Which of the following organizations recently drafted functional standards for electronic health records?

a numerical measurement carried out to the appropriate decimal place

Which of the following represents an example of data granularity?

physical examination

Which of the following represents the attending physician's assessment of the patient's current health stratus?

Active membership

Which of the foloowing classes of AHIMA membership requires that individuals hold an AHIMA credential?

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?

CAHIM

Which of the following accredits academic programs in health information?

AHIMA Foundation

Which of the following actively promotes education and research in health information managment?

Data Administration

Which of the following activities is not a traditional medical recoerds function?

Data are easy to obtain

Which of the following best describes data accessibility?

medication report

A nurse is rwesponsible for which of the following types of acute care documentation?

Data are correct

Which of the following best describes data accuracy?

Data include all required elements

Which of the following best describes data completeness?

storing patient care documentation

Which of the following best describes the most important function of the health record?

long-term care

An RAI/MDS and care plan are found in records of patients in ___________

the meaning of data

Data definition refers to ___________

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?

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 _______________

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?

1928

HIM has been recognized as an allied health professional since

Connectivity

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

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?

clinical decision support

I need an information system that will provide assist physicians in diagnosing and treating patients. The system that I need is

pressent illness

In a medical history, which of the following is a detailed chronological description of the development of the paitent's illness?

correctional facility care

In which setting may treatment records travel with the patient between treatment centers?

Elected by members in state component organizations

Members of the AHIMA House of Delegates are

ambulatory care

Patient history questionnaires are most often used in:

Communities of Practice

The ____________ makes up a virtual network of A?HIMA members who communicate via a Web based program managed by AHIMA

Establishing standards for the content of college programs in HIT and HIM

The accreditation program of AHIMA is concerned with

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?

discharge summary

The attending physician is responsible for which of the following types of acute care documentation?

Data resource administrator

The new opportunity for HIM professionals that deals with data repositories and data warehouses is

operative report

The number of ligatures, sutures, packs, drains and sponges used and specimens removed would be found in the ______________

False

The only requirements for professional certification therough the AHIMA are graduating from an accredited two-year or four-year educational program.

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

Integrated health record components are arranged in strict chronological order.

What is the defining characteristic of an integrated health record format?

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?

Conditions of Participation

What is the general name for Medicare standards impacting healthcare organizations?

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?

medical history

which of the following represents documentation of the patient's current and past health?