Information relating to the physical or mental health or condition of an individual, collected by a health professional
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Primary purposes of health records
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Patient care, managing patient care, and administrative purposes
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Secondary purposes of health records
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Education; legal, accreditation, and policy development; and public health and research
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Individual users of the health record
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Patient care providers; patient care managers and support staff; coding and billing staff; patients; employers; lawyers; law enforcement officials; healthcare researchers and clinical investigators; and government policy makers
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Institutional uses of the health record
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Healthcare delivery organizations; third party payers; medical review organizations; research organizations; educational organizations; accreditation organizations; government licensing agencies; and policy making bodies
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Hybrid health record
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combination of the paper record and the EHR
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Aggregate data
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data that has been extracted from individual health records and combined to form deidentified information about group of patients that can be compared and analyzed
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HIM functions include...
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record processing; monitoring of record completing; transcription; clinical coding, abstracting, and clinical data analysis; birth and death certificate completion
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Master Patient Index (MPI)
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Permanent record of all patients treated at a healthcare facility
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Enterprise master patient index (EMPI)
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Links the patient's information at different facilities
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MPI Quality Control
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To maintain the MPI, algorithms are used to match patients so patient information can be merged
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Overlay
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where a patient is erroneously assigned another persons health record number
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Overlap
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when a patient has more than one health record number at different locations in an enterprise
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Delinquent record
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A record that remains incomplete longer than the time allowed by medical staff rules and regulations
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Serial numbering system
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a patient is issued a unique numerical identifier for every encounter at the healthcare facility; this method is inefficient and costly
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Unit numbering system
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commonly used in large healthcare facilities; patient is issued a health record number at the first encounter and that number is used for all encounters
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Serial-unit numbering system
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A combination of the serial and unit numbering systems
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Outguide
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identifies where the health record is located and when it was removed
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Requisition
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request for the health record
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Record reconciliation
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process of assuring that all the records of discharged patients have been received by the HIM department for processing
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Addendum
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Additional information provided in the heal record. It should be dated the day it was written
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Amendment
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Clarification made to healthcare documentation after the original document has been signed
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Requisition
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Request for the health record
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Document management system (DMS)
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Scans paper records and stores it digitally. Used during the transition from paper to EHR
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Clinical coding
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Assigning codes to represent diagnoses and procedures
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Abstracting
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The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome, or extracting elements of data from a document and entering them into an automated system
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Which of the following is a secondary purpose of the health record?
a. Document patient care delivery
b. Assist caregivers in patient care management
c. Aid in billing and reimbursement functions
d. Educate medical students
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d. Educate medical students
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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
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b. Third-party payer
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How do patient care managers and support staff use the data documented in the health record?
a. Evaluate the performance of employees
b. Communicate vital information among departments and across disciplines and settings
c. Generate patient bills or third-party payer claims for reimbursement
d. Determine the extent and effects of occupational hazards
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a. Evaluate the performance of employees
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An HIM student asked an HIM director why the hybrid record is so challenging. What is the HIM director's response?
a. It is because we are focusing on the EHR.
b. It is because we have to maintain all of the traditional HIM functions.
c. It is because HIM professionals do not have the skills to manage the EHR.
d. It is because we have to manage both the electronic and paper media.
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d. It is because we have to manage both the electronic and paper media.
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What is the process of ensuring that a record is available for every patient seen at the healthcare facility?
a. Overlap
b. Delinquent chart
c. Abstracting
d. Reconciliation
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d. Reconciliation
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Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used?
a. Back-end
b. Front-end
c. Physician
d. Outsourced
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b. Front-end
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Critique this statement: Data and information mean the same thing.
a. This is a true statement.
b. This is a false statement because data is used for administrative purposes and information is used for clinical purposes.
c. This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.
d. This is a true statement because information is raw facts and figures and data is information converted into a meaningful format.
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c. This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.
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Which information system will track information provided to a requester?
a. Registry
b. Quality improvement
c. Chart tracking
d. Release of information
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d. Release of information
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The 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
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a. A primary purpose of the health record
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Why is only the most current version of a document displayed?
a. All previous versions are deleted
b. To ensure there is no confusion on the correct document
c. Only the physician has access to previous versions of a document
d. The user decides which version to see
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b. To ensure there is no confusion on the correct document
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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 are being met
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d. To determine whether standards are being met
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How long should the MPI be retained?
a. Permanently
b. 25 years
c. 50 years
d. 10 years
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a. Permanently
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Deficiencies in a health record include which of the following?
a. Mistake in the patient's age
b. Missing document
c. Contradictory content
d. Illegible content
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b. Missing document
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Critique this statement: Patient care managers are individual users of health records.
a. This is a true statement.
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.
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a. This is a true statement.
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Removing health records of patients who have not been treated at the facility for a specific period of time from the storage area to allow space for more current records is called:
a. Purging records
b. Assembling records
c. Logging records
d. Cycling records
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a. Purging records
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Which type of microfilm does not allow for a unit record to be maintained?
a. Roll microfilm
b. Jacket microfilm
c. Microfiche
d. Micrographics
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a. Roll microfilm
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Which of the following is true about document imaging?
a. Data in the scanned documents can be manipulated
b. Scanned documents can only be viewed by one person at a time
c. Outguides are required
d. Documents can be indexed
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d. Documents can be indexed
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Which system records the location of health records removed from the filing system and documents the return of the health records?
a. Chart deficiency system
b. Chart tracking system
c. Abstracting system
d. Registry system
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b. Chart tracking system
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"Loose" reports are health record forms that:
a. Are maintained separately from the health record
b. Are not part of the legal health record
c. Are received by the HIM department and added to the health record after it has been processed
d. Are misfiled
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c. Are received by the HIM department and added to the health record after it has been processed
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Which of the following is the most efficient filing system?
a. Serial numbering system
b. Unit numbering system
c. Serial unit numbering system
d. Middle-digit filing system
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b. Unit numbering system
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Which of the following is the key to the identification and location of a patient's health record?
a. Disease index
b. Outguide
c. Deficiency slip
d. MPI
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d. MPI
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Which of the following numbering system assigns multiple health record number, or, one per visit?
a. Unit
b. Serial-unit
c. Serial
d. Alphabetic
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c. Serial
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In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers but the content is filed under the most recent health record number?
a. Unit
b. Serial
c. Serial-unit number
d. Alphabetic
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c. Serial-unit number
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Which of the following is part of qualitative analysis review?
a. Checking that only approved abbreviations are used
b. Checking that all forms and reports are present
c. Checking that documents have patient identification information
d. Checking that reports requiring authentication have signatures
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a. Checking that only approved abbreviations are used
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Which of the following is true of good forms design for paper forms?
a. Every form should have a unique identification number
b. Barcodes are never included
c. Bright color paper should be used to identify forms.
d. Paper size should be 8.5 inches by 14 inches
answer
a. Every form should have a unique identification number
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