Chapter 2

25 July 2022
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question
Which of the following is a secondary purpose of the health record? a. to document patient care delivery b. to assist caregivers in patient care management c. to aid in billing and reimbursement functions d. to generate a report to be used in performance improvement
answer
d
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Which of the following is an institutional user of the health record? a. patient care provider b. third-party payer c. coding and billing staff d. government policy maker
answer
d
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How do patient care managers and support staff use the data documented in the health record? a. to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided b. to communicate vital information among departments and across disciplines and settings c. to generate patient bills and/or third-party payer claims for reimbursement d. to determine the extent and effects of occupational hazards
answer
a
question
Which of the definitions below best describes the concept of confidentiality? a. the right of individuals to control access to their personal health information b. the protection of healthcare information from damage, loss, and unauthorized alteration c. the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose d. the expectation that only individuals with the appropriate authority will be allowed to access healthcare information
answer
c
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Which of the following statements does not pertain to paper-based health records? a. They have a built-in access control mechanism. b. They are kept in locked storage areas that are accessible only to authorized staff. c. They are logged out according to the organization's prescribed procedure. d. They are forwarded to the appropriate service area when needed for patient care purposes.
answer
a
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Which of the following is an advantage offered by computer-based clinical decision support tools? a. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature. b. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends. c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives. d. all of the above
answer
d
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The hospital where I work is transitioning to the EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as: a. integrated health record format b. a hybrid record c. a resident record d. integrated health record format
answer
b
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Critique this statement: Data and information mean the same thing. a. This is a true statement. b. This is false as data is used for administrative purposes and information is used for clinical purposes c. This is a false statement as data is raw facts and figures and information is data converted into a meaningful format d. This is a true statement as information is raw facts and figures and data is information converted into a meaningful format.
answer
c
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Which of the following statements does not pertain to electronic health records (EHRs)? a. EHR technologies and systems must not intrude on the patient and provider relationship. b. EHRs are filed in paper folders. c. In the United States, a national health information infrastructure is being designed to support EHRs. d. Clinicians use computer keyboards when documenting in the EHR.
answer
b
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Which of the following is a secondary purpose of the health record? a. support for provider reimbursement b. support for patient self-management activities c. support for research d. support for patient care delivery
answer
c
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Use of the health record by a clinician to facilitate quality patient care is considered a. a primary purpose of the health record b. patient care support c. a secondary purpose of the health record d. patient care effectiveness
answer
b
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Use of the health record to monitor bioterrorism activity is considered a. a primary purpose of the health record b. a secondary purpose of the health record c. a patient use of the health record d. a healthcare licensing agency function
answer
b
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How do accreditation organizations use the health record? a. to serve as a source for case study information b. to determine whether the documentation supports the provider's claim for reimbursement] c. to provide healthcare services d. to determine whether standards of care are being met
answer
d
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How do research organizations use the health record? a. to examine results of experimental protocols b. for reporting of communicable diseases c. to investigate domestic violence d. to manage disability insurance benefits
answer
a
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Attorneys for healthcare organizations use the health record to a. support claims for medical malpractice b. protect the legal interests of the facility and its health care providers c. plan and market services d. locate missing persons
answer
b
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Our record has all of the lab filed together, all of the progress notes file together, and so on. What format are we using? a. Source oriented health record b. Integrated health record c. Patient-oriented health record d. Problem-oriented health record
answer
a
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Inaccurate data recorded in the health record could a. compromise quality patient care b. contribute to incorrect assumptions by policy makers c. invalidate research findings d. all of the above
answer
d
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The term used to describe expected data values is a. data definition b. data currency c. data precision d. data relevancy
answer
c
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Protection of healthcare information from damage, loss, and unauthorized alteration is also known as a. privacy b. results management c. security d. data accuracy
answer
c
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Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using? a. Computerized physician/provider order entry b. Electronic health record c. Results management d. Clinical decision support
answer
a
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The paper-based health record format that organizes all forms in chronological order is known as a. the problem-oriented health record b. the integrated health record c. the patient-oriented health record d. the source-oriented health record
answer
b
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Critique this statement: The health record documents services provided by allied health professionals and a patient's family. a. This is a true statement. b. This is a false statement as the health record only document's physician's care c. This is a false statement as the health record only documents care provided by patient families d. This is a false statement as the health record documents the care provided by healthcare professionals
answer
d
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An individual's right to control access to his or her personal information is known as a. security b. confidentiality c. privacy d. all of the above
answer
c
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When all required data elements are included in the health record, the quality characteristic for is met. a. data security b. data accessibility c. data flexibility d. data comprehensiveness
answer
d
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Critique this statement: Patient care managers are individual users of health records. a. This is a true statement. pg 35 b. This is a false statement as they do not require patient information to do their job. c. This is a false statement as they require patient information to do their job d. This is a false statement as patient care managers are institutional users
answer
a
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1. Which of the following users would utilize aggregate data? a. Patient care providers b. Coding and billing staff c. Law enforcement officers d. Patient care managers and support staff pg 37
answer
d
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2. Which of the following users of the health record is an example of an institutional user: a. Third party payer pg 39 b. Accreditation organization c. Physician d. Employer
answer
a
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3. Critique this statement: A user of health records includes only care providers who document in the health recorder refer it for patient care: a. True, as defined IOM b. False, as the information is used for other purposes such as analysis c. True, as defined by AHIMA d. False, as the information contained in the health record is also used for patients to document in their opwn health record.
answer
b
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Data applications -
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the purpose for which data are collected
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Data collection -
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the processes for which data are collected
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Data warehousing -
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processes by which data are archived
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Data analysis -
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the processes by which data are translated into useful information
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Data accuracy
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data are correct
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Data accessibility -
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data are easily obtainable
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Data consistency -
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data are reliable
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Data currency and data timeliness
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data should be up to date and recorded at or near the time of observation
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Data definition -
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data is defined (meaningful, pertinent)
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requires that the attributes & value of the data be defined at correct level of detail for its intended use.
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data granularity
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Data precision -
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expected data values
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Data relevancy -
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data in the health record are useful
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1. A physical therapist documenting in the health record is an institutional health record user. T or F
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f
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2. CMS uses data to accredit hospitals t or f
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f
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3. A researcher uses data to determine the recommended treatment. t or f
answer
t
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4. Patients do not have the right to add missing information to the health record t or f
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f
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5. An auditor employed by CMS is reviewing a health record for a mortality study. They are an individual health record user. t or f
answer
f