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Primary purpose of Continuity of care

Allow health care providers regular access to records about those patients healthcare at any point in time

A special web page that offers secure access to data

portal

An interface is

a special program of exchanged data

Data that describes the data to be entered into the EHR

metadata

When a hospital uses many different vendors to support its information system, the IT strategy being used is

Best of Breed

LOINC is a terminology used for coding

Provides names and codes for laboratory results and other observations

Which of the following encourages patients to take an active role in collecting and storing their health record

Personal health record

Which of the following is NOT a description of a hybrid record?

Includes an equal part of paper and electronically produced record

A medical record that is part paper is called

hybrid

Natural Language Processing does what?

Converts narrative information into descrete data

The primary user of a computerized provider order entry is (CPOE)

the provider (physician)

How will hospitals benefit most from the EHR?

Reduction in errors

The exchange of digitized images such as xrays, CT scans and MRI's is supported by what?

DICOM Digital Imaging Communications in Medicine

The ability to electronically send data from one electronic to a different electronic system and still retain its meaning is what?

Interoperability

Electronic prescribing is a special case of what?

CPOE

The first point of data collection and the area where the health record is most commonly assigned is

patient registration

In a paper based system, the completion of a chart is monitored in a special area

Incomplete record file

Which of the following tools is usually used to track health records that have been removed from their permanent storeage? (paper based)

Outguide

The MPI is necessary to physically locate health records within the paper based storeage systerm for all types of storeage systems EXCEPT.

Alphabetical

In which of the following systems are all encounters of patient visits kept in one folder?

unit numbering

"Loose" reports are health record forms that are what?

Recieved by the HIM department and added to the health record after it has been processed

This is a disadvantage in alphabetical filing.

Uneven expansion.

In which of the following systems does an individual recieve a unique numerical identifier for each encounter at that healthcare facility?

Serial Numbering System

The key data element for linking data about an individual that is seen in a variety of care settings is what?

Unique Patient Identifier.

Which of the following features of the filing folder helps best to locate misfiles? (paper based)

color coding

Which of the following filing methods is considered most efficient?

Terminal Digit

What is an advantage of paper based records?

Standardized, familiar format

Which of the following vocabularies is likely to be used to describe drugs in clinically relevant form?

RxNorm

The tool that allows the internet user to search for and find information

Web Browser

What is the difference between data and information?

Data is fact.
Information is meaning.

Which of the following uniquely identifies each record in a database?

Primary Key

Which of the following dictates how the medical staff operates?

Bylaws

The primary goal of the Hospital Standardization Program, established in 1918 by the American College of Surgeons was to what?

Raise standards

What was the main result of the publication of the Flexner Report?

Medical school standards were set.

Who is responsible for implementing policies and the strategic direction of the hospital or healthcare organization, and for building an effective management team?

CEO

Individuals who recieve acute care services in a hospital are considered

Inpatients

Review of the disease indexes, pathology reports, and radiation therapy reports are part of which function of the cancer registry?

Case finding

Which of the following contains a list maintaining procedure, code number, or a patient's discharge from a faclilty during a different time period?

operation index

Which of the following contains a list maintained in diagnosis code number for a patient discharged from a facility?

Disease index

Vital statistics include data on what?

Births, deaths, and fetal deaths

The most prevelent trend in the collection of secondary databases is what?

The increased use of automated data entry

Case finding is a method used to do what?

Identify those patients who have been seen or treated in a facility for that particular disease for inclusion in the registry.

In a cancer registry, the accession number is what?

Number assigned to each case as it is entered into the registry

A population based registry is what?

Includes information in one facility from one geopolitical area

In designing an electronic health record, one of the most best resources to use in helping define the content of the record as well as to standardize data definition is the E1384 Standard promulgated by the

ASTM American Society for Testing and Measurement.

A record is considered a primary data source when it does what?

Contains information about the patient that has been documented by those providing care

Which of the following is a secondary purpose of the health record?

Support for research

What is the general name for medicare standards?

Conditions of participation

Which accrediting organization has instituted continuous improvement, sentinal event monitoring, and uses tracer methodology.

The joint commision

HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma.
Chest: Good bilateral chest sounds

Physicians Examination Report

Microscopic: Sections are of squamous mucosa with no atypia.

Pathology report

CBC: WBC 12.0H, RBC 4.65
HGB 14.8, HCT 43.3, MCV 93

Diagnostic reports; laboratory tests

PA and Lateral Chest: the lungs are clear. The heart and mediastinum are normal in size and configuration. there are minor degenerative changes of the lower thoracic spine.

Radiological scan

Aide recording of bathing, cooking, and cleaning; nursing and therapy assessments

Home Health Care

Data accuracy means what?

Data are correct

Data completeness means what?

Comprehensiveness

Data accessibility means what?

Data are easily obtainable.

Problem oriented health records are indexed how?

With a unique number.

Integrated records are arranged how?

So that the documentation from various sources is intermingeld and follows strict chronological order.

What is a weakness in paper records?

It can only be viewed by one person at a time. Lack of availability.

The quantitative analysis usually involves checking to ensure what three things?

All forms and reports contain correct patient identification, all reports are present, and reports requiring authentication have signatures.

Quantitative analysis includes reviewing for missing...

signatures

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