Hit 114 final
Patients can review and copy their record but cannot make any corrections.
False
All the users of health records influence patient care in some way.
True
An electronic health record can have multiple versions, different views of displaying the same information, and features that are not present in paper-based records.
True
Ancillary functions of the health record are not associated with specific patients and specific healthcare encounters, but to the environment in which patient care is provided.
True
Healthcare providers in all settings must ensure records remain accessible for legitimate purposes for a reasonable period after the original healthcare episode is complete.
True
Patients have a right to control how information in their health record is used.
True
Personal health records include information provided by the patient.
True
Regardless of the storage format, the functions of the health record remain the same.
True
The health record is used for communication between the patient's caregivers.
True
The health record serves as a basis for discharge planning.
True
The healthcare industry lags behind other industries in the application of information technology in communications and operations usage.
True
True or False? AN HIE moves health information among organizations while adhering to national standards.
True
________ established the right of patients to access and amend their own health records.
HIPAA
There are three steps for HIM professionals to follow in defining the legal record: 1. Determine what legal entities enforce regulations defining the legal record. 2. Determine which records are created in the normal course of business. 3. Create a matrix that defines each element in the legal health record . In what order should the steps be completed?
1,2,3
Match the definition with the type of data using the choices listed. 1. Information relating to payment for healthcare services. 2. Data recorded during the intake process and is the basis of care plans. 3. Factual details about the individual patient. 4. Information about the patient's illness and services provided.
1. Financial data 2. Clinical data 3. Demographic data 4. Patient-care delivery data
Enter the correct response from one of the three choices. Some answers may apply to more than one. 1. Must fulfill the legal and business needs of the organization. 2. Requires a transition plan 3. The official business record 4. Can be stored in any medium 5. Will be disclosed upon request from external parties 6. Created in both paper and electronic media 7. Will be used for interoperability 8. Accessed through a portal
1. Legal health record 2. Hybrid health record 3. Legal health record 4. Legal health record 5. Legal health record 6. Hybrid health record 7. Electronic health record 8. Electronic health record
HIPAA was implemented in what year?
2003
Requirements for content of the medical record come from all the following sources except.
AHIMA best practices
The process of granting formal approval to healthcare organization is called:
Accreditation
Where can you find guidelines for the retention and destruction of healthcare information?
Accreditation standards
___________ are data used for administrative, regulatory, healthcare operations, and payment purposes.
Administrative data
In general, good documentation contains sufficient information to ___________.
All of the answers are correct
Which features will be present in the health record of the future?
All of the answers are correct
Which organization has taken the lead in defining the legal health record?
American Health Information Management Association
Which of the following is not considered a healthcare provider and would not document clinical services in a medical record.
Health information administrator
What is the emphasis of performance improvement programs?
Identification of shortcomings in processes and systems
Documenting consumer and family members' involvement in the consumer's treatment program is an additional medical record purpose in what setting?
Behavioral healthcare
The federal agency that administers the Medicare and Medicaid programs is __________.
CMS
The current healthcare delivery system in the United States can be characterized by which of the following phrases?
Complex and expensive
What has complicated the definition of the legal health record?
Computer technology and the EHR
What is the range of healthcare services provided to a patient, from routine ambulatory care to intensive acute care, with an emphasis on communication among caregivers?
Continuum of care
What has been a challenge of implementation of EHRs?
Cost of electronic clinical documentation systems
Many Americans cannot find affordable health insurance because of the:
Cost of medical-surgical care and pharmaceuticals
_______ involves the review and validation of a physician's qualifications to practice medicine.
Credentialing
A chart showing a series of columns with times, dates, initials, numbers, and symbols is _________.
Data
_______ represents facts and does not convey meaning.
Data
What is the main difference between primary, secondary, and tertiary care?
Degree of specialization
Social Security number is what type of data?
Demographic
What type of information is collected by the patient registration staff?
Demographic data
Accreditation reports, OASIS reports, and quality measure reports are what type of data?
Derived data
________ data consists' of information aggregated or summarized from a group of patient records and there is no means to identify specific patients.
Derived data
HIPAA was designed to accomplish all of the following EXCEPT:
Designate HIM Professionals as privacy officers
The final definition of the legal health record rests with ________.
Each individual facility
What is the primary purpose for documenting and maintaining medical records?
Effective communication among caregivers for continuity of care
What is the preferred term for the health record of the future?
Electronic health record (EHR)
The model to monitor performance and identify areas for improvement developed by Hospital Corporation of America is known as ___________.
FOCUS-PDCA
Accreditation and regulatory standards require healthcare providers to create and maintain medical records only for the inpatient setting. Physician offices and clinics do not have the same requirement.
False
Federal regulations have always been in place to protect the confidentially of health information.
False
Health records should never be destroyed.
False
__________ is the prevention of situations that might put hospital patients, caregivers, or visitors in danger.
Risk management
The name of a patient's insurance company and policy number is what type of data?
Financial
Under HIPAA, when is the patient's written authorization required to release their healthcare information?
For any purpose unrelated to treatment, payment, or healthcare operations
The standards development organization that began work on a functional model for EHRs in 2003 is ________.
HL7
Which professional has the responsibility of determining when an individual or entity has the right to access healthcare information?
Health Information Management Professionals
The acronym HIPAA means __________.
Health Insurance Portability and Accountability Act
Public and private sector stakeholders are focusing efforts on________because there is increasing evidence that health information technology can improve healthcare quality and customer safety by reducing errors and unnecessary expenditures.
Health information exchange (HIE)
What is becoming a factor in an organization's bottom line aside from financial factors?
Healthcare data
Which of the following is not among the principles in an HIE?
Integration with a PHR
When did hospitals begin applying computer processing to operations and management?
In the 1960s
According to definition put forth in the AHIMA Practice Brief, "The Complete Medical Record in a Hybrid EHR Environment" (2003) what must the functional components of a hybrid health record do?
Include both paper and electronic documents and use both manual and electronic processes
Most physicians who provide medical or surgical services in hospitals are ___________.
Independent contractors
Regardless of the healthcare setting, accreditation and regulatory standards require a separate healthcare record for each __________.
Individual patient
Consumer education about the PHR must include which of the following items in order for consumers to embrace the PHR?
Information about security and confidentiality
What is a group of healthcare organizations that collectively provide a full range of coordinated health-related services?
Integrated healthcare network
How has the overall percentage of ,Americans with health insurance coverage changed since the late 1980s?
It has decreased
Which of the following is not true of a PHR?
It will replace the legal records of providers
All the following are factors in the slow adoption of information technologies in healthcare EXCEPT ___________.
Lack of technological capability
________, health records are the property of the healthcare providers who created them; _________, the personal information contained in each record belongs to the patient.
Legally; ethically
_______ is the state's act of granting an organization the right to provide healthcare services.
Licensure
Medical record documentation is guided by Medicare standards in which setting?
Long-term care
Which database collects information on medical malpractice settlements, clinical privilege actions, and medical society actions taken against licensed healthcare providers in the United States?
National Practitioner Data Bank
What is the term for health records maintained by patients and/or their families?
Personal health records
Health records and other documentation related to the patient care are the property of _________.
The provider who created them
Which of the following is not a purpose of healthcare records?
Public education
Which of the following entities is not included in health information exchange?
Public schools
How have recent biomedical advances affected healthcare?
Recent advances have revolutionized healthcare services
What is the meaning of ROI in regards to accessing healthcare information?
Release of information
Which provides a common language for indexing, storing, retrieving, and aggregating clinical data?
SNOMED-CT
What level of care is provided by medical specialists working in private offices, specialty group practices, private clinics, community-based clinics, and general and community hospitals?
Secondary
What is acute care?
Short-term medical and nursing care provided in an inpatient hospital setting to treat the acute phase of a patient's injury or illness
Data from which interpretation, summaries and notes are derived is termed _________.
Source-system data
Radiological films, laboratory values, pathology slides, video recordings, and EKG tracings are all examples of what type of data?
Source-system data
The content and style of clinical documentation is influenced by all the following factors except _______.
Status of the provider's license
All of the following are barriers to healthcare providers adopting EHRs based on the American Recovery and Reinvestment Act (ARRA) except:
Swiftness of adoption
________ serves as a documentation tool that constitutes a permanent account of services the patient received.
The health record
Health records are often called by different names. What factor determines the name that is used.
The healthcare setting
The concept of the continuum of care was initially developed in response to what trend in the healthcare environment?
The increasing cost of healthcare
Patients may participate in biomedical research under what conditions?
They have given informed consent
What has happened to the number of organizations and individuals who have a legitimate need for access to confidential patient information?
The number has increased
The traditional medical record is synonymous with ________.
The patient care record
Guidelines for the style and content of health records depend on what?
The setting in which the healthcare services are provided
Accessing or disclosing health record information without a valid reason is considered violation of the ethical principles of every healthcare profession.
True
Administrative data should have the same level of confidentiality as the legal health record.
True
__________ focuses on how healthcare organizations use their resources.
Utilization management
Consents for treatment are what type of data?
administrative data
Between 2008 and 2009, the percentage of Americans who qualified for employer-based health coverage______and the number of people covered by government-sponsored health insurance programs_________.
decreased, increased
In hospitals, medical records are typically called _________.
health records
The determining factor in whether something is to be considered part of the legal health record is _________.
how the information is used
What type of standards do regulatory and accreditation standards represent?
minimal
Healthcare reimbursement is based on _______.
the documentation contained in the health record