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Introduction, Purpose and Function, Content and Structure Of Health Record, Electronic Health Record, Health Information Technology Functions, Secondary Data Sources, Healthcare Delivery Systems, Ethical Issues

HIM has been recognised as an allied healh profession since:


The hospital standardization movement was inaugurated by the

American College of Surgeons

Throughout the years, HIM roles have

Become more focused

The traditioinal model of HIM practice was

Department based

The new model of HIM practice is

Information focused

What evolving role oversees the process that begins at the time of documentation through billing:

Revenue Cycle Management

The organization that accredits HIM Program is:


What evolving role assesses quality in health record banking?

Health Record reviewer

Purpose: to ensure the quality, confidentiality and availability of health information across diverse organizations, settings and disciplines


What is the purpose of the Hosptial Standardization Program?

to raise the standards of surgery by establishing minimum quality standards for hospitals.

What did the ACS realize?

that the most important item in the care of any patient was a complete and accurate report of the care and treatment provided during hospitilization.

Who is responsible for the accredidation of academic and certificate programs for HIT?

CAHIIM (Commission on Accredidation for Health Informatics and Information Management Education

AHIMA was orignially named?


What is the primary focus of AHIMA

To foster the professional development of its members through education, certification and lifelong learning.

Active members of AHIMA include those who:

Hold an AHIMA credential

Who functions as the legislative body of AHIMA

House of Delegates

Who promotes education and research?


The virtual network used by AHIMA members is:

Communities of Practice

How many types of memberships are there in AHIMA


WHat does the volunteer component of AHIMA do:

Establishes the organizations missions and goals, develops policy and provides oversight for the organizations operations.

What does the staff component of AHIMA do?

Carries out the operational task necessary to support the organizations missions and goals

Who leads the volunteer structure of AHIMA and has the responsibility for managing the property, affairs and operations.

Board of Directors

Must be active members, are elected by the membership and serve three year terms.

Board of Directors

Who is responsible for overseeing AHIMA's certification process and for setting policies and procedures?

CCHIIM (Commission on Certification for Health Informatics and Information Management)

Makes up a virtual network of AHIMA memebers who communicate via a Web-based program called

Communities of Practice (CoP)

Functions as AHIMA's legislative body and conducts the official bysiness of the organizations

House of Delegates

Who elects the representatives to the House of Delegates?

Each state HIM Association

The following: Approving Standards, Guide to Interpreting the Code of Ethics, Electing members of AHIMA Nominating Committee, Advising the Board of Directors, Levying Special Assessments, Approving ammendments to AHIMA by laws, Approving resolutions is the responsibility of

House of Delegates

Provide members with local access to professional educationn, networking, and representation, are a forum for communicating information relevant to national issues, informing members of regional affairs that affect health information management

CSA's (Component State Associations)

AHIMA headquarters are located in?


Who can sit for the RHIA and RHIT exams?

People who have graduated from and accredited and aproved program

To achieve certification from AHIMA do what?

Meet eligibilty reguirements and complete the certifcation exam.

A program of earned recognition for AHIMA members who have made signigicant and sustained contributions?

Fellowship Program

We had 324 Medicare patients last month - this statement represents:


I am a patient - Information from myself and my physician on my medical history is stored on the internet. What am I?

EHR (eletronic health record)

The principal repository that documents the who, what, when, where, why and how of patient care.

Health Record

Represents the basic facts about people, processess, measurements,and conditions


What represents meaning


Health Record initiated,maintained and owned by an individual is called

Personal Health Record (PHR)

Healthcare information created and maintained iteractively, used by healthcar providers.

Electronic Health Record (EHR)

What is the primary purpose of a health record

Patient care management

The secondary purpose of a health record is for?

Related to environment where healthcare services are provided

In reference to medical records patient care delivery, patent care management, patient care support processess, financial and other administrative processess, patient self managment are all examples of what purpose?

Primary Purpose

In reference to medical records education (teaching and documentaition), regulation (litigation, assess compliance and comparisons), research (Clinical), Public health and homeland security (monitor public health), policy making and support, industry (research and development) are all examples of what purpose?

Secondary Purpose

Submitting documetation to a third party for substantiating a patients bill is considered what purpose


Using a health record to study effectiveness of a given drug is considered what purpose


Physicians, nurses, clinical personnell, therapists, respiratory, lab and radiology technicians, patients, families, unit clerks, administrators, quality managers, benefit managers, insurers, accreditors, lawyers, researchers represent what type of users of health records?

Individual Users

Healthcare delivery organizations like physician practices, ambulatory clinics, rehab and long term facilities, public health departments, disease registries, research centers, medicare peer review, employers, insurers, edcuational institutions, accredidation, federal, local and governmental agencies represent what type of users of health records?

Institutional User

Details taken from individual health records and then all information is put together in one place is called what type of data?


Who would utilize Aggregate data to identify patterns and trends in patient care facilities?

Patient Care Managers

Individuals who enter, verify, correct, analyze, or obtain information from the record, either inderctly or directly through an intermediary are what?

Users of Health Records

Medical records that are used as a tool to protect the legal interests of facility and for litigation would be used by who?


Health records used in the investigation of gunshot injuries, child abuse, domestic violence and other crimes are used by who?

Law Enforcement Officals

The review of health records for a particular population being studied and extract data, used to evaluate and make decisions about disease procese and treatments would be used by?

Healthcare Researchers and CLinical Investigators

Patient care information aggregated by researchers and investigators to generate consumer reports would be used by?

Healthcare Science Publishers and Journalist

Aggregate information taken from a health record and used for the basis of investigations of health patterns and trends in a given population - used to develp and fund community programs are used by?

Government Policy Makers

Information taken from a medical record and used for the evaluation of adequacy and appropriatenes of care provided, and to determine whether services were medically necessary would be used by?

Medical Review Organizations

Medical records used in healthcare related research and study to prove or disprove hypothesis related to disease processess and treatments would be utilized by?

Research Organizations

Medical records that are used as a source for case studies would be used by?

Educational Organizations

Medical records that are used to review documentation of patient care services to determine whether the standards for care are being met would be utilized by?

Accredidation Organizations

Medical records used to determine whether a facility is complying with the licensing regulation in a geographic area are used by?

Govenrment Licensing Agencies

Data taken from health records and then used to make decisions related to Healthcare reimbursement, effectiveness of healthcare services and the general health of Medicare populations is utilized by?

CMS (centers ofr Medicare and Medicaid Services)

Who develops and test experimental patient care protocols?

Research Organizations

What is the primary function of the health record?

To store patient care documentation

To accomplish the primary and secondary purposes of a health record the data must be?

of the Highest Quality

The HIM professionals most important role is to ensure that the health record contains....

The highest quality data possible

Data applications, data collection, data warehousing and data analysis are the four domains of:

Data Quality Management

The purposes for which data is collected is?

Data Applications

The processes for which data is collected is?

Data collections

Process and system in which data is archived

Data Warehouseing

Process in which data is translated into information that can be used is?

Data Analysis

Accuracy, Accesibility, Comprehensiveness, Consistency, Currency, Definition, Granularity, Precision, Relevancy, and timeliness are characteristics of?

Data Quality Management

Data that is correct and represents what was intender or defined by original source is

Data Accuracy

Data that is easily obtainable

Data Accesibility

All required data elements are included in the health record and is complete.

Data Comprehensiveness

Data that is reliable and values are consistent - data does not change due to storage, process or display and values are the same on any application and system

Data Consistency

Healthcare data is up to date and recorded at time or near time of the event or observations

Data Currency and Data Timeleness

Information and data in the health record is meaningful and pertinent, has clear definition and range of acceptable values

Data definition

That data attributes and values be defined at the correct level of detail for the intended use

Data Granularity

Expected data values - yields accurate data collections

Data Precision

Data in the health record is useful - reason for collecting the data is clear

Data Relevancy

The right of the individual to control acces to their personal information is defined as


The expectation that personal information shared by an individual with a provider during care is used only for its intended purpose defines...


Program designed to protect patient privacy and to prevent unauthroized access, alteration or destruction of health records


The capacity of health record sytems to provide communication linkages and allow the exchange of health record data amoung information system defines...


Source orientated health record format, Problem orientated health record format and Integrated health record format are commonly used in...

Paper based record systems

Organizes the patient information according to the patient care department that provided the care. Are grouped together according to their point of origin. (lab grouped, radiology grouped, etc.)

Source-orientated Health Record Format

Documentation approach where the phsyician defines each clinical problem individually and then organized into database, problem list, initial plans and progress notes. Each problem is indexed with a unique number.

Problem Orientated Health Record Format

Organizes all paper forms in strict chronological order and mixes the forms created by different departments. Easy to follow course of the patients diagnosis and treatment, but is difficult to compare similar types of information due to the format.

Integrated Orientated Health Record Format

Acute Care Hospitals use which paper based format system?

Source Orientated

A combination of paper based records and electronic records.

Hybrid Health Record

In reference to electronic health records - having timely access to all types of results (lab, radiology) represents what clinical tool in the EHR model

Results Management

What system helps providers to eliminate lost orders, illegible handwriting, duplicate orders, medication errors, and reduction in time filling orders

CPOE (Computerized provider order entry)

CPOE were developed to improve quality of care and represent what clinical tool and function of the EHR model

Order-Entry/Order Managment

Is more than a simple repository of patient care data, alert practioners to our-of-range lab values or dangerous trends, access to pharmaceutical formularies, referral databases and reference literature is what clinical tood and function of the EHR model

Clinical Decision Support

A tool for documenting patient care and for patient caregivers to commmunicate with each other

Health Record

Health records has two types of data?

Clinical and Administrative

Patients medical conditions, diagnosis and procedures performed and treatement provided represents what type of data?

Clinical Data

Demographics,financial information, consents and authorizations represent what type of data?

Administrative Data

What content is found in the medical record is determined by?

The needs of the practice and pertinent standards

Standards found in facility policies and procedures, medical staff bylaws, rules and regulations is what type of source?

Facility-Specific Standard

State or County regulation that healthcare facilities must meet to be permitted to provide care?


Facilities that are certified and participate in Medicaid and Medicare

Government Reimbursement Programs

Standards that are applied to facilities participating in Government Reimbursement programs are called

Conditions of participation or Coditions for Coverage

Indication that a facility has voluntarily met the standards of an independnet accredidation organization

Accredidation standards

Documented in the health record are Medical History, Physical Examination, diagnosis, orders, clinical observations, reports, and discharge summary these are also known as?

Clinical Data

Documentation of patients current compliants an symptoms, past medical, personal and family.

Medical History

Assessment of patients current health status is found in the....

Physical Examination Report

Instructions given to healthcare profesionals to perform diagnostic test, treatments, medications and specific services to a particular patient are called...

Physicians orders

Documentation by nurses, physicians and other care givers stating patients condition and response to treatment are found.......

Progress notes

A summary of the patients problems with a detailed plan for interventions is called a

Care Plan

Results for laboratory tests, pathological examinations, radiological scans are documented and called

Diagnostic Reports

Before a procedure is performed whose responsibility is it to make sure the patient understands the nature of a procedure, alternative treatments and risks and complications


Preoperative medication and responses, anesthesia administered with dose and method, duration and vital signs can be found in what type of report

Anesthesia Report

Describes the surgical procedures, diagnosis, normal and abnormal findings, blood loss, medical condition, specimens removed, unusual events, names of surgeons, assistants and date and duration of surgery

Operative Report

Post anesthesia note, nurse note on condition, vital signs, surgical site and any meds or IV are noted in what type of report?

Recovery Room Report

Report that is dictated after examination of tissue received for evaluation, describes tissue and interpretive findings

Pathology Report

The clinical opinion of a physician other than the primary or attending physician

Consultations Report

A concise account of a patients illness, course of treatment, response, includes instructions for follow up care

Discharge Summary

Discharge summary is the responsibility of and must be signed by.....

Attending Physician

Prenatal care summary, admission evaluation, record of labor, info on contractions, fetal heart tones, examination of birth canal, medications and vital signs are all part of what type of records

Obstetric Delivery Record

Financial information maintained in the acute care health record lis limited to ........

Insurance Information

Before providing routine services, diagnostic procedures and medical care what is obtained from the patient

Consent to treatment

What rule requires provides to secure a patient's written acknowledgement that they received notice of providers privacy practices...

Privacy Rule

Permission granted by the patient to release information for reasons other than treatement, payment or healthcare operations is called


Permission for treatment, payment or healthcare operations is called


What allows a facility to verbally disclose or send health information to other oranizations

Authorization to disclose information

A written documnet that names the patients choice of legal representative for healthcare purposes - designated and empowered to make all healthcare decisions on behalf of the patient if they are no longer capable is called

Advance Directive

Living wills and Durable Powers of Attorney for healthcare are examples of...

Advance Directives

What should be consistent advance directives in reference to Physicians orders


What specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment actions steps

Care Plan

Written or spoken permission to proceed with care is

Expressed consent

Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in what type of Record


Who issues specific health information standards for Acute Care Hospitals

Joint Commision

Rehabilitation hospitals use the standards of...

CARF (Commission on the Accredidation of Rehabilitation Facilities)

Care provided in a physicians office, group practices, clinics, outpatient facilities, public health, industrial health and urgent care settings as well as receiving care through HMO's, PPO's, and IPA's all fall under what type of documentation

Ambulatory Care Documentation

What unigue records are found in Ambulatory Documentaion that aren't found in Acute Care

Problem List and Patient History Questionaire

In the ambulatory documentation record any significant current and past illnessess, conditions, surgeries and procedures as well as allergies and drug sensitivity - can be found where?

Problems List

A structured form used to collect past medical history and information from the patient in an Ambulatory setting

Patient History Questionaire

Skilled Nursing Facilities, Subacute care facilities, Nursing facilities, Intermediate Care Facilities, mentally disabled and retarded facilities and assisted living facilities all fall under what type of care classification?

Long Term Care

SNF's and NF's and ICF's are governed by

Federal and State regulations and Medicare Conditions of Participation

Assisted living facilities are goverened by

State Regulations

Care Plan for SNF facilities that is reguired by the federal government, is based on the Minimum Data Set (MDS), includes triggers, utilization guidelines and RAP's, is a critical component of the health record. This care plan format is called?

RAI (Resident Assessment Instrument)

RAP's stands for

Resident Assessment Protocol

Home care agencies that accept Medicare are governed by

Federal Regulations

Medicare certified home healthcare use a standardized patient assessment instrument called?

OASIS (Outcomes and Assessment Information Set)

Hospice programs provide what type of care

Palliative Care

Patient care that focuses on symptom management and patient comfort versus life prolonging measures is

Hospice Care

Standards for facilities that specialize in mental health, mental disabilities and developmental disabilities can be found with what organizations?


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