Removing health records from the storage area to allow space for more current records is called:
purging records
Which type of microfilm does not allow or a unit record to be maintained?
roll microfilm
Which is not true about document imaging?
is a paperless system
Which system records the location of health records removed from the filing system and documents the return of the health records?
chart tracking system
“Loose’ reports are health record forms that….
are received by the HIM dept. and added to the health record after it has been processed
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the….
incomplete record file
In which system are all encounters or patient visits kept in one folder?
unit numbering system
Which is the key to the identification and location of a patient’s health record?
MPI
Which numbering systems is best for maintaining encounters for a patient together?
unit
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?
serial
Which is not usually a part of quantitative analysis review?
checking that every word in the record is spelled correctly
Which is not true about good forms design for paper forms?
bright colors should be used to identify forms
Which is not true of good forms design for electronic forms?
electronic forms should use radio buttons for multiple selections of items
Which is a disadvantage of alphabetic filing?
uneven expansion of file shelves or cabinets
In HC organizations, what is the database that is used to locate the medical record number usually called?
MPI
Which is a request from a clinical area to charge out a health record?
requisition
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
216 inches
A quantitative review of the health record for missing reports and signatures that occurs when the patient in the hospital is referred to as:
concurrent review
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called:
delinquent record
In which department/unit does the health record typically begin?
patient registration
When a hospital accredited by the Joint Commission is considered to be in compliance with Medicare’s Conditions of Participation, this is called:
deemed status
Which of the typical HIM functions assist in monitoring and compliance of the HC facility with Joint Commission standards:
release of information, record processing and transcription
What component of the budget would include money for the purchase of an EHR?
capital budget
The future role of the HIM professional is expected to change due to:
advances in technology, implementation of new clinical coding system, and evolution of EHR
Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called:
elements of performance
The system in which the health record number is assigned at the first encounter and then used for subsequent HC encounters is the:
unit numbering system
The primary guide to locating a record in a numerical filing system is the:
master patient index (MPI)
All forms should:
contain a unique identifier
The health record number is typically assigned by:
patient registration
Which is used to locate an electronic health record?
health record number
John Smith treated a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:
duplicates
Which of the following should be part of the comprehensive MPI maintenance program?
advanced person search
Which is true about the Social Security number?
both AHIMA and the Social Security Admin. oppose using the Social Security number as the health record identifier
The most common numbering system used in HC is?
unit numbering
Which identification system is at a disadvantage when there are two patients with the same name?
alphabetic
Consider the following sequence numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
terminal-digit filing
The master patient index (MPI) is necessary to locate health records with the paper-based storage system for all types of filing systems except:
alphabetical filing
The term used to describe a combination of paper-based and electronic health records is:
hybrid
Which is an advantage of a centralized unit filling system?
one location in which to look for records
Which filing system is considered to be the most efficient?
terminal-digit
What type of paper-based storage system conserves floor space by eliminating all but one or two aisles?
mobile filing units
What feature of the filing folder helps to locate misfiles which the paper-based filing system?
color coding
In a paper-based system, the HIM dept. routinely delivers health records to:
nursing units
Which of the following paper would be the most durable for the medical record folder?
20
What microfilm format is inefficient when patients have multiple admissions on microfilm?
Roll
Under the False Claims Act, claims may be brought up how many years?
generally 7 years, but could go as high as 10
Record retention should be based on:
State regulations and AHIMA recommendations
Which of the following is the appropriate method for destroying microfilm?
pulverizing
The tool used to track paper-based health records is:
outguide
What should be done when the HIM dept’s error or accuracy rate is deemed unacceptable?
a corrective solution should be taken
The forms design committee:
provides oversight for the development, review and control of forms and computer screens
Statements that define the performance expectations an/or structures or processes that must be in place are:
standards
In a paper-based system, individual health records are organized in a pre-established order. This process is called:
assembly
Reviewing a health record for missing signatures and missing medical reports is called:
analysis
Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?
retrospective
Incomplete records that are not completed by the physician within the time frame specified in the HC facility’s policies are called:
delinquent records
The best practice for forms design is to use white paper and black ink:
true
In a paper-based record, errors should be completely obliterated:
false
Addendums should document the date the event actually happened – no the date it was documented
false
Which chart-processing activity is eliminated with an EHR that uses scanned images?
assembly
One of the advantages of an EDMS is that it can:
help manage work tasks
Which term indicates that a document has been removed from standard view?
reassignment
Which term is the process of checking individual data elements, reports or files against each other to resolve discrepancies?
reconciliation
Which could be used to determine if someone has the right to view a health record?
photo identification
Version control of documents in the EHR requires:
policies and procedures to control which version(s) is displayed
Which is a risk of copying and pasting?
system not recording who entered the data
How are materials from other facilities documented in the EHR?
they are scanned and filed in the EHR
Which term verifies claim of identity?
authentication
How are amendments handled in the EHR?
the amendment must have a separate signature, date and time
EHR data is captured by scanning and direct entry
true
Data validation includes an undo button
false
Policies should address how the patient information will be removed from computers at the end of their useful life:
true
Data quality begins at the point of creation.
true
Authorization is identifying a patient through the use of a user name
false
If one needed to know the number of C-sections performed by a specific obstetrician, which indices would be used to identify the cases?
operation index
The computer system that may serve as the MPI function is the :
patient registration system
A chronological listing of data is called:
register
What dept. within the hospital uses the information abstracted and coded by the HIM dept. to send for payment from third-party payers?
billing department
The function within the HIM dept. responsible for listening to dictated reports and typing them into a medial report format is called:
medical transcription
Reviewing request for health record copies and determining if they are valid is part of what function within the HIM department?
release of information function
Where does the health record begin?
patient registration
One of the most sought after accreditation distinction by healthcare facilities is offered by the:
joint commission
Statements that describe general guidelines that direct behavior or direct or constrain decision making are called:
policies
Step-by-step instructions on how to complete a specific task are called:
procedures
The departmental budget is both an evaluation tool and what type of tool?
planning
Employee salaries are part of what type of budget?
expense
The purchase of an EHR system would be planned for in what type of budget?
capital
Assigning ICD-9-CM and CPT codes to the diagnoses and procedures documented in the medical record is called:
clinical coding
Which is an example of how the HIM professional interacts with the medical staff?
serve on medical staff committees
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