125 terms

RHIT Chapter IV Information and Access

Which one of the following actions would not be included in the professional obligations of the health information practitioner that lead to responsible handling of patient health information?
Take a compromising position toward optimal interpretation on nonspecifistemc regulations and laws
If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the
date of birth
Which one of the following is NOT a step in developing a record retention schedule?
assigning all records the same retention period
What type of filing system is being used if records are filed in the following order : 12-23-75, 12-34-29, 13-42-14, and 14-32-79?
straight numeric
If there are 150,000 records and the HIM Department receives 3, 545 requests for records within a given period of time, what is the request rate?
Which of the following would not be an advantage of a centralized filing system?
There is less transportation time and effort when a facility operates from several sites
In a terminal digit filing system, what would the record number immediately in front of record number 01-06-26?
The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which one of the following corrective actions would be most effective in reducing the delay in retrieval of requested records?
Review and possibly reengineer the retrieval process to decrease retrieval time
Which one of the following is NOT an advantage of a computerized master patient index?
Duplication of patient registration can never occur
Color coding of record folders is used to assist in the control of
Which of the following would NOT be considered secondary data?
Under the Patient Self-Determination Act of 1990, advance directives
are not required to be included in the health record
A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number?
A 200-bed acute care hospital currently has 15 years of records in hard copy and filing space is limited. What action should be taken?
Destroy inactive records that exceed the statue of limitations
Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital?
straight numeric
What is the chief criterion for determining record inactivity?
amount of space available for storage of newer records
Out of 2, 543 records requested from the HIM Department 2, 375 were located. What is the filing accuracy rate?
Which set of records filed consecutively on a shelf displays terminal digit filing order?
57-78-00, 57-78-01, 56-78-99
In the master patient index, which is filed by last name, Jill Thomas-Jones would be
T-H-O-M-A-S-J-O-N-E-S, J-I-L-L
According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30?
Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least __________ years unless a longer period is required by state or local laws.
Your state regulations require records to be kept for a statue of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in you facility should be
7 years
Which of the following technologies works best with automated record-tracking systems to speed the data entry process?
bar codes
A HIM Department, currently using 2, 540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches would be planned to allow for 5-year expansion needs. How many new file shelving units should be purchased?
Microfilmed records are considered
acceptable as courtroom evidence
A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2013. Which of the following indices would be the best source in locating the needed records?
disease index
When using stationary open shelf files __________ inches are recommended for aisles between the units
In a manual record-tracking system, no record should be removed from the file without being replaced by an
Which of the following should not be included in documentation of record destruction?
dates not covered in destruction
If the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number?
In the event of water damage to a large volume of records, what action should be taken immediately to assist in disaster recovery?
Freeze the records to prevent mold or mildew from forming
Which of the following lists is in correct alphabetical order?
Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip
Mary Schnering was admitted to Community Hospital on 1/3/2012 and assigned a record number of 54-47-53. The patient was later admitted on 2/14/12 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/filing system if being used at Community Hospital?
North Port Health Center is moving to a new facility in 2014. The CEO is projecting a conversion to paperless health records by then. This new facility will not include space for the filing of paper records. Which of the following items would not be considered when planning this conversion?
relationship with the microfilm vendor
What microform should the HIM practitioner select if the records must be unitized and color-coded for filing purposes?
jacket microfilm
In retrieval of optical image files, cache memory
decreases access time for all users on the system
At Community Hospital the average admission will create a file that will take up .25 inch of file space. Each new ER record requires 0.125 inches of file space. Approximately 25,000 new patients are admitted per year and 15,000 ER patients are treated per year. The shelving cost is $1.05 per filing inch. How much money should be allocated for storage space in next year's budget?
On his 5/23/12 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-28. The previous record number assigned to Mr. Robinson during a 4/1/12 admission was 07-10-47. In a serial numbering/filing system, how would these records be filed?
Each admission is filed under its own number
The same patient was admitted on three different occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be using given the following information?
Admitted 5/04/12 Patty Miller 23-33-56
Admitted 6/05/12 P.J. Miller 25-56-88
Admitted 9/27/12 Patricia Miller 27-12-12
Void the last two numbers and file all admissions under 23-33-56
The health care providers in a large teaching hospital require access to health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should
staff the department with personnel 24 hours a day
As a prerequisite to phasing in a new imaging system, what process would facilitate automatic indexing?
redesigning forms to include bar codes
Which of the following is NOT a safety hazard in the file area of the HIM Department?
stepladders that are fully open and locked in place
A HIM Department want to buy new open-shelf filing units for its file expansion. Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average record is 1-inch thick. How many filing units should be purchased?
Which of the following microfilm types is the least expensive to prepare and results in the greatest storage density?
roll microfilm
Brian Hills was discharged from the hospital after a 3-day hospitalization and instructed to return to the outpatient department for follow-up care. On his first visit as an outpatient, a new record was created and he was assigned a new record number. Following completion of the outpatient appointment, his outpatient record is filed permanently in the outpatient department. What is the filing system used in this situation.
The master patient index must, at a minimum, include sufficient information to
uniquely identify the patient
Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medial staff privileges at another hospital?
National Practitioner Data Bank
Which type of patient information does the Joint Commission suggest that hospitals use?
unit record, computer-based patient record, protocol for requesting information, whereby the request is provided to the practitioner in a timely manner
A health information manager develops a formal plan or record retention, schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?
file area staffing
Which of the following is NOT a benefit of the electronic document management system in the HIM Department?
decreased use of computer technology
Which one of the following is an advantage of straight numeric filing over terminal digit filing?
The training period is short
Which one of the following is NOT an electronic document management system component?
the reader-printer
Which of the following items should the Health Information Manager be primarily concerned with when purchasing file guides?
durability and visibility
Palm Beach Healthcare Center has been in operation for 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admission per year from now on. There are 2,500 linear feet of filing space available and half is being used. The facility expects a 30% readmission rate. It a unit numbering/filing system is used, how many file folders will be needed. for the next year?
As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to
install a computerized access panel
What technical security controls do electronic health record systems employ that are different from paper-based health record systems?
audit trails, data encryption protocols, user-based access controls
The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information?
operation index
A major consideration in a hospital or facility closure is to
ensure that authorized parties have access to the information as provided by law
The American College of Surgeons mandates a successful follow-up rate for all cancer cases of at least __________ to meet approval requirements as a cancer program
In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing?
confidentiality policies and liability concerns
Which one of the following master patient index core data elements is optional, not recommended, by AHIMA?
marital status
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for a least how long?
age of majority plus statue of limitations
A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?
overwriting the backup tapes
Which of the following statements would be found in the laboratory report section of the health record?
BUN reported as 20 mg.
Which of the following is a disadvantage or terminal digit filing as compared to straight numeric filing?
The training period is slightly longer
The main advantage of phonetic filing is
names that sound alike are filed together
Technologies that can make data capture easier include all but which one of the following?
direct data capture from a medical device attached to the HIM department employee
If the file clerks are having trouble locating the terminal digit sections quickly, the filing supervisor could add more
file guides
The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should
direct the request to the state's office of vital records
A surgeon request the name of a patient he admitted on January 11, 2013. Which of the following would be used to retrieve this information?
admission register
Which of the following is NOT a consideration in file folder size and design?
vendor location
Where in the health record would the following statement be located? "Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"?
pathology report
The HIM Department is located , in a hospital that provides health record access 24 hours a day, 7 days a week. To secure the file area and continue to maintain accessibility, the department director should
staff the file area with file clerks on all three shifts
A file area has limited space, medium file activity, and two file clerks. The HIM department would benefit from choosing which type of storage equipment?
compressible filing units
When evaluating a microfilm service bureau, all but which of the following are important factors to rate?
cache memory
AHIMA recommends converting all but which one of the following minimum data elements when merging or overwriting demographic information for duplicate and overlap master patient index entries?
attending physician
Which of the following steps would NOT be taken when bringing all patient health information together in a complete record, regardless of the media output form?
Look at the past composition of records in the facility
When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow?
Security training is provided to all levels of staff
When designing a computer view for information capture, all of the following should be considered except for which one?
forms committee membership
When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT for
Communities of Practice requirements
Case finding methods for patients with diabetes include a review of all but which of the following?
CPT diagnostic codes
To protect health information from catastrophes such as fire, flooding, bomb threats, and theft, Joint Commission-accredited facilities are required to maintain a ________ plan.
Which of the following is NOT an alternative storage method for paper-based records?
Which of the following issues would be of LEAST concern when storing health records in off-site storage?
filing order of the records
The HIM Department maintains 500,000 records and responds to 5,000 requests for records in a given period of time. What is the record usage rate?
Which one of the following is NOT a data retrieval technology?
Point and click fields
When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract?
Type of reader or printer needed to view the microfilm
What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital?
Microfilming all 250,000 records for the cost of $195,000
The total number of records filed during the month is 2,500 and upon completion of a filling accuracy study, 90 records were not found. What is the accuracy rate for filing?
A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the
filing of loose materials
According to AHIMA's recommended retention standards, which one of the following types of health information does NOT need to be retained permanently?
Physician index
For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which one of the following elements?
Patient notification
The steps in developing a record retention program include all but which one of the following?
Notifying the courts of the destruction
A heath care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial date would be most easily collected from the
birth defects registry
An example of a primary data source is the
health record
Which one of the following is NOT considered a challenge in the adoption of an electronic health record system?
contribution to the quality of patient care
Fetal monitoring strips are part of the __________ record and should be maintained ___________
mother's ; according to the length of time for a minor's record
Which one of the following would NOT be a strategy when purchasing and electronic health record system?
Broaden the vendor field and select several vendors of choice
Which on of the following describes the electronic health record's impact on the record retrieval function?
This function will be eliminated except for historical files maintained in paper or on microform
What data cannot be retrieved from the MEDPAR?
Non-Medicare patient data
As the filing and retrieval supervisor, you are evaluating storage devices for a new health information management system. Which one of the following would you NOT consider as an option for storing health information?
light pen
General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity?
database management system
The Director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Director's response?
elimination of the need for expensive desktop computers
The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed?
Test the software prior to purchase
Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate
security controls and access privileges of staff, policies and procedures developed to safeguard privacy and security, use of a back-up system
Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database so that is can be used to improve clinical services. Which tool should be used?
The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for?
chart tracking
The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?
executive information system
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interactions or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using?
Clinical information system
The HIM practitioner's duty to retain health information by, archiving and storage of health data includes
strategies that consider accessibility, natural disasters, and innovations in storage technology, strategies ensuring that inactive records are as secure as active records, a retention plan for multiple volumes of records
As Chief Privacy Office, you are evaluating software programs that will support the hospital's policy on security controls for computer terminals. One of the required items you include in the RFP to vendors is
time-out feature
Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a
interfaced system
The function of a ___________ is limited to data retrieval
clinical data repository
The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which one of the following would be the key advantage in using this type of data entry?
Enhanced databases will provide information for improved clinical care
University Hospital, a 900 bed tertiary health care organization, is undergoing an information systems development. The system that would best meet its needs is the
application service provider model
A 16-year old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would
be filed in the mother's record
Which one of the following is a major management challenge in the storage and retention of electronic health record systems?
Following state and federal laws and accreditation requirements when developing retention and destruction policies, keeping technology updated in order to retrieve data, and ensuring that health information can be retrieved in a timely manner
When implementing the electronic health record, what is the technical security standard that requires user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?
access control
Which of the following is NOT a factor to consider when developing a record retention program?
reimbursement guidelines
Of 750 records filed during the week, 75 were not located. What is the filing error rate?
Which one of the following is NOT an example of document capture in the electronic document management system?
Which of the following statements is FALSE when addressing characteristics of the legal health record in an electronic document management system?
Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems
Which of the following is NOT a data retrieval tool?
light pen
Messenger, pneumatic tube, dumbwaiter, and conveyor belt are all examples of
mechanical circulation systems
Which item is collected and maintained in the transplant registry?
histocompatibility information