Chapter 5

Health information management (HIM) professionals need to develop policies that facilitate a complete and accurate record. a. True b. False

a. True

Health information professionals have skills to assist facilities in the transition to the EHR. a. True b. False

a. True

Images that are stored electronically can enable retrieval of records rapidly. a. True b. False

a. True

The Joint Commission standards state that inpatient hospital records must be completed within 30 days after discharge regardless of the storage system. a. True b. False

a. True

The original record and amendments to a patient record will show in the EHR. a. True b. False

a. True

A lowercase or an uppercase letter, numeric digit, or special character is also known as (a) a. Field b. Character c. Record d. Data

b. Character

A group of characters forms a file. a. True b. False

b. False

A hybrid record is electronic. a. True b. False

b. False

EHR systems are the same for each facility. a. True b. False

b. False

The federal law is the primary basis for the definition of the legal patient record. a. True b. False

b. False

The standards for the exchange of health information are being developed by AHIMA. a. True b. False

b. False

When a page is _____, it means it is identified according to a unique identification number, which is commonly the patient's medical record number. a. Scanned b. Indexed c. Prepped d. Reviewed

b. Indexed

What type of record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters? a. Ancillary Record b. Longitudinal Patient Record c. Hybrid Record d. Series Record

b. Longitudinal Patient Record

This application creates a centralized database of patient demographic information and has replaced the paper master patient index in the virtual world. a. Centralized Ancillary System (CAS) b. Registration-Admission-Discharge-Transfer System (RADT) c. Data Fulfillment Ancillary System (DFAS) d. Enterprise Scheduling System (ESS)

b. Registration-Admission-Discharge-Transfer System (RADT)

Which is an electronic or paper medical record maintained and updated by an individual for his or her own personal use? a. My Individual Record (MIR) b. Personal Historical Capture (PHC) c. Personal Health Record (PHR) d. Sole Record (SR)

c. Personal Health Record (PHR)

Health Level Seven (HL7) is a standards development organization that develops EHR standards under the direction of what department? a. U.S. Department of Defense b. U.S Department of Homeland Security c. U.S. Department of Health and Human Services d. U.S. Department of Natural Resources

c. U.S. Department of Health and Human Services

A ____________ ____________ ____________ is a centralized database which provides easy access to data in electronic of printed form.

clinical data repository

In all electronic health record applications, there are two major components of the system, which are a. Radiology and Patient Monitoring b. Nursing and Medical Documentation c. Pharmacy and Laboratory d. Administrative and Clinical

d. Administrative and Clinical

Which act was passed that will help develop nationwide health information exchange? a. Health Insurance Portability and Accountability Act (HIPAA) b. Health Level Seven (HL7) c. Regional Health Information Organizations (RHIO) d. American Recovery Reinvestment Act of 2009 (ARRA)

d. American Recovery Reinvestment Act of 2009 (ARRA)

What was a 1970 - 1980 term to describe early medical record automation attempts? a. Microfilm b. Optical Imaging c. Microfiche d. Computerized Medical Records

d. Computerized Medical Records

Which system collects and monitors patient physiological data and records the information? a. Financial Monitoring System b. Physician Monitoring System c. Registration Monitoring System d. Patient Monitoring System

d. Patient Monitoring System

Regional Health Information Organizations (RHIOs) focus on what key function? a. Scanning Information b. Prepping Information c. Indexing Information d. Sharing information

d. Sharing information

Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds, are referred to as __________________ .

data

After a document is ______________ saved, the document must not be altered.

finally

____________________ ____________________is comprised of health facts that are collected about a patient or group of patients and that describes a health issue.

health data

__________________ records are considered a transitional state until a true electronic health record can be implemented.

hybrid

Scanned pages are ____________ , which means they are identified according to a unique identification number, which is commonly the patient's medical record number.

indexed

An application system that includes ordering of laboratory tests, the reporting of test results, and report generation is known a(n) ______________ application.

laboratory

A ______________ monitoring system includes systems that allow for the continuous monitoring and collection of vital signs.

patient

An electronic or paper medical record maintained and updated by individuals for their own personal use is known as a(n) __________________ ___________________ record.

personal health

The type of application that includes order entry, identification of drug interactions, medical label printing, and administrative reports such as drug usage is known as a(n) ____________________ application.

pharmacy

A __________________ __________________ template is a document that delineates the various sources of the component parts of the patient's record.

record transitional