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Health Information: Midterm

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AHIMA
AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION
CCS
CERTIFIED CODING SPECIALIST
AOA
AMERICAN OSTEOPATHIC ASSOCIATION
NCQA
NATIONAL COMMITTEE FOR QUALITY ASSURANCE
ARLNA
ASSOCIATION OF RECORD LIBRARIANS OF NORTH AMERICA
HIM
HEALTH INFORMATION MANAGEMENT
MDS
MINIMUM DATA SET
MRN
MEDICAL RECORD NUMBER
RHIT
REGISTERED HEALTH INFORMATION TECHNICIAN
MPI
MASTER PATIENT INDEX
TJC
THE JOINT COMMISSION
CMS
CENTERS FOR MEDICARE AND MEDICAID SERVICES
HIT
HEALTH INFORMATION TECHNICIAN
PHR
PERSONAL HEALTH RECORD
RHIA
REGISTERED HEALTH INFORMATION ADMINISTRATOR
CAHIIM
COMMISSION ON ACCREDITATION FOR HEALTH INFORMATICS AND INFORMATION MANAGEMENT EDUCATION
CCHIIM
COMMISSION ON CERTIFICATION FOR HEALTH INFORMATICS AND INFORMATION MANAGEMENT
EHR
ELECTRONIC HEALTH RECORD
POHR
PROBLEM ORIENTED HEALTH RECORD
OASIS
OUTCOMES AND ASSESSMENT INFORMATION SET
CARF
COMMISSION IN ACCREDITATION OF REHABILITATION FACILITIES
RAI
RESIDENT ASSESSMENT INSTRUCTION
PAI
PATIENT ASSESSMENT INSTRUCTION
CPR
COMPUTER BASED PATIENT RECORD
CIO
CHIEF INFORMATION OFFICER
CEO
CHIEF EXECUTIVE OFFICER
LOS
LENGTH OF STAY
IMPLIED CONSENT
ASSUMED
EXPRESSED CONSENT
WRITTEN OR SPOKEN
LICENSED BED COUNT
ACTUAL NUMBER
BED COUNT
ACTUAL STAFFED
PAPER RECORD WEAKNESSES
- SINGLE USER
- DAMAGE
- DOESN'T TRAVEL
- POSSIBLY INCOMPLETE
- PENMANSHIP
- ORGANIZATION
E-RECORD STRENGTHS
- MULTIPLE USERS
- TRAVELS
- COST SAVINGS
- INFO. IMMEDIATELY AVAILABLE
- CLIENT ALERTS
- FLEXIBLE TO USER NEEDS
E- RECORD WEAKNESSES
- IMPLEMENTATION COSTS
- LEARNING CURVE
- STANDARDS?
ADDENDUM
AN ADDITION TO A MEDICAL RECORD THAT DOESN'T CHANGE ANY PRE-EXISTING CONTENT
AMENDMENT
ACTUAL CHANGE TO THE MEDICAL RECORD
AHIMA MEMBERSHIP CATEGORIES
- STUDENT
- ACTIVE
- NEW GRAD.
- SENIOR*
CONCURRENT REVIEW
OCCURS DURING ADMINISTRATION OF SERVICES
RETROSPECTIVE REVIEW
OCCURS AFTER MEDICAL SERVICES HAVE BEEN PROVIDED
HIM HAS BEEN RECOGNIZED AS AN ALLIED HEALTH PROFESSION SINCE:
1928
THE HOSPITAL STANDARDIZATION MOVEMENT WAS INAUGURATED BY THE:
AMERICAN COLLEGE OF SURGEONS
THROUGHOUT THE YEARS, HIM ROLES HAVE:
BROADENED IN SCOPE
THE TRADITIONAL MODEL OF HIM PRACTICE WAS:
DEPARTMENT BASED
THE NEW MODEL OF HIM PRACTICE IS:
INFORMATION BASED
WHAT EVOLVING ROLE OVERSEES THE PROCESS THAT BEGINS AT THE TIME OF DOCUMENTATION THROUGH BILLING?
REVENUE CYCLE MANAGEMENT
THE ORGANIZATION THAT ACCREDITS HIM PROGRAMS IS?
CAHIIM
WHAT EVOLVING ROLE ASSESSES QUALITY IN HEALTH RECORD BANKING
HEALTH RECORD REVIEWER
THE PRIMARY FOCUS OF AHIMA?
FOSTER PROFESSIONAL DEVELOPMENT OF ITS MEMBERS
ACTIVE MEMBERS OF AHIMA INCLUDE THOSE WHO:
ARE SENIOR MEMBERS
WHICH OF THE FOLLOWING FUNCTIONS AS THE LEGISLATIVE BODY OF AHIMA?
HOUSE OF DELEGATES
WHICH OF THE FOLLOWING PROMOTES EDUCATION AND RESEARCH?
AHIMA FOUNDATION
THE VIRTUAL NETWORK USED BY AHIMA MEMBERS IS?
COMMUNITIES OF PRACTICE
WE HAD 324 MEDICARE PATIENTS LAST MONTH. THIS STATEMENT REPRESENTS WHICH OF THE FOLLOWING?
DATA.
I'M A PATIENT. MY MEDICAL HISTORY INCLUDING INFORMATION FROM MYSELF AND MY PHYSICIANS IS STORED ON THE INTERNET. THIS IS AN EXAMPLE OF WHAT?
PHR
WHICH OF THE FOLLOWING IS AN EXAMPLE OF A PRIMARY PURPOSE OF THE MEDICAL RECORD?
PATIENT CARE MANAGEMENT
EXAMPLES OF PATIENT CARE DELIVERY USAGE OF THE MEDICAL RECORD INCLUDE WHICH OF THE FOLLOWING USES?
COMMUNICATION BETWEEN CAREGIVERS
THE PHR AND EHR ARE SYNONYMS.
PHR IS PATIENT AND EHR IS PHYSICIAN.
THE HEALTH RECORD IS THE PRINCIPLE REPOSITORY FOR DATA AND INFORMATION ABOUT THE HEALTHCARE SERVICES PROVIDED TO INDIVIDUAL PATIENTS.
TRUE
THE LAB TEST 'HEMOGLOBIN: 14.6GM/110ML' IS CONSIDERED INFORMATION.
FALSE.
ALL THE PRIMARY PURPOSES OF THE HEALTH RECORD ARE ASSOCIATED DIRECTLY WITH THE PROVISION OF PATIENT CARE.
FALSE
SUBMITTING HEALTH RECORD DOCUMENTATION TO A THIRD PARTY PAYER FOR THE PURPOSE OF SUBSTANTIATING A PATIENT BILL IS CONSIDERED A SECONDARY PURPOSE OF THE HEALTH RECORD.
FALSE.
USE OF THE HEALTH RECORD TO STUDY THE EFFECTIVENESS OF A GIVEN DRUG IS CONSIDERED A PRIMARY USE OF THE HEALTH RECORD.
FALSE.
WHICH OF THE FOLLOWING USERS OF THE HEALTH RECORD IS AN INSTITUTIONAL USER?
THIRD PARTY PAYER
WHICH OF THE FOLLOWING USERS WOULD UTILIZE AGGREGATE DATA?
PATIENT CARE MANAGERS AND SUPPORT STAFF
I WORK FOR AN ORGANIZATION THAT UTILIZES HEALTH RECORD DATA TO PROVE OR DISPROVE HYPOTHESES RELATED TO DISEASE. I WORK FOR:
RESEARCH ORGANIZATION
A USER OF HEALTH RECORDS INCLUDES ONLY CARE PROVIDERS WHO DOCUMENT IN THE HEALTH RECORD OR REFER TO IT FOR PATIENT CARE.
FALSE
I WORK FOR CMS. HOW WOULD I USE A HEALTH RECORD?
MAKE DECISIONS ON HEALTHCARE REIMBURSEMENT.
A PHYSICAL THERAPIST DOCUMENTING IN THE HEALTH RECORD IS AN INSTITUTIONAL HEALTH RECORD WORKER.
FALSE
AN AUDITOR WHO IS EMPLOYED BY MEDICARE IS REVIEWING A HEALTH RECORD FOR A MORTALITY STUDY. THEIS AUDITOR IS AN INDIVIDUAL HEALTH RECORD USER.
FALSE
CMS USES DATA TO ACCREDIT HOSPITALS.
FALSE
RESEARCH ORGANIZATIONS DEVELOP AND TEST EXPERIMENTAL PATIENT CARE PROTOCOLS.
TRUE
PATIENTS DO NOT HAVE THE RIGHT TO ADD MISSING INFORMATION TO THE HEALTH RECORD.
FALSE
A PHYSICIAN JUST RECEIVED NOTIFICATION FROM AN EHR SYSTEM THAT A PATIENT'S LAB TEST HAD A DANGEROUSLY HIGH VALUE. THIS IS AN EXAMPLE OF WHAT KIND OF CLINICAL TOOL?
CLINICAL DECISION SUPPORT
I JUST TOLD MY PHYSICIAN SOMETHING EMBARRASSING ABOUT MYSELF. I TOLD HIM BECAUSE I EXPECT HIM TO USE THE INFORMATION FOR MY CARE ONLY. THIS CONCEPT IS CALLED:
CONFIDENTIALITY
SOMEONE SUGGESTED THAT WE COLLECT A PATIENT'S EYE COLOR. THIS WAS NOT IMPLEMENTED. WHAT QUALITY CHARACTERISTIC WOULD BE THE JUSTIFICATION FOR NOT COLLECTING THIS INFORMATION?
RELEVANCY
IT WAS SUGGESTED THAT WE ENTER THE PATIENT'S AGE MANUALLY IN ALL OF OUR INFORMATION SYSTEMS. WHAT QUALITY CHARACTERISTIC WOULD BE THE JUSTIFICATION FOR NOT DOING THIS, BUT RATHER SHARING INFORMATION BETWEEN SYSTEMS?
CONSISTENCY
ACCORDING OF THE AHIMA DATA QUALITY MODEL, WHAT IS THE TERM USED TO DESCRIBE HOW DATA IS TRANSLATED INTO INFORMATION?
DATA ANALYSIS
DATA GRANULARITY
CHARACTERISTICS OF DATA WHOSE VALUES ARE DEFINED AT THE APPROPRIATE LEVEL OF DETAIL
SECURITY
A PROGRAM DESIGNED TO PROTECT PATIENT PRIVACY AND TO PREVENT UNAUTHORIZED ACCESS, ALTERATION, OR DESTRUCTION OF HEALTH RECORDS.
PRIVACY
AN INDIVIDUAL'S RIGHT TO CONTROL ACCESS TO HIS OR HER PERSONAL INFORMATION
DATA COMPREHENSIVENESS
A CHARACTERISTIC OF DATA THAT INCLUDES EVERY REQUIRED DATA ELEMENT
DATA RELEVANCY
A CHARACTERISTIC OF DATA WHERE THE DATA IS USEFUL.
WHICH TWO MAJOR TYPES OF DATA ARE CONTAINED IN THE HEALTH RECORD?
ADMINISTRATIVE AND CLINICAL
WHICH OF THE FOLLOWING TERMS REFERS TO STATE OF COUNTRY REGULATIONS THAT HEALTHCARE FACILITIES MUST MEET TO BE PERMITTED TO PROVIDE CARE?
LICENSURE
WHICH OF THE FOLLOWING WOULD NOT BE FOUND IN A MEDICAL HISTORY?
VITAL SIGNS
AN ATTENDING PHYSICIAN REQUESTS THE ADVICE OF ANOTHER PHYSICIAN WHO THEN REVIEWS THE HEALTH RECORD AND EXAMINES THE PATIENT. THE SECOND PHYSICIAN RECORDS IMPRESSIONS IN WHAT TYPE OF REPORT?
CONSULTATION REPORT
WHICH SPECIALIZED TYPE OF PROGRESS NOTE PROVIDES HEALTHCARE PROFESSIONALS IMPRESSIONS OF PATIENT PROBLEMS WITH DETAILED TREATMENT ACTION STEPS?
CARE PLAN
WRITTEN OR SPOKEN PERMISSION TO PROCEED WITH CARE IS CLASSIFIED AS:
EXPRESSED CONSENT
WHICH OF THE FOLLOWING REPORTS PROVIDES INFORMATION ON TISSUE REMOVED DURING A PROCEDURE?
LAB REPORT
SLEEPING PATTERNS, HEAD AND CHEST MEASUREMENTS, FEEDING AND ELIMINATION STATUS, WEIGHT, AND APGAR SCORES ARE RECORDED IN WHICH OF THE FOLLOWING RECORDS?
NEWBORN
WHICH OF THE FOLLOWING ISN'T CONSIDERED PATIENT DEMOGRAPHIC INFORMATION?
ADMITTING DIAGNOSIS
WHICH OF THE FOLLOWING ADMINISTRATIVE DOCUMENTS NAMES THE PATIENT'S CHOICE OF LEGAL REPRESENTATIVE FOR HEALTHCARE PURPOSES?
ADVANCE DIRECTIVE
WHICH TYPE OF HEALTH RECORD CONTAINS INFORMATION ABOUT CARE PROVIDED PRIOR TO ARRIVAL AT A HEALTHCARE SETTING AND DOCUMENTATIONS OF CARE PROVIDED TO STABILIZE THE PATIENT?
EMERGENCY CARE
PATIENT HISTORY QUESTIONNAIRES, PROBLEM LISTS, DIAGNOSTIC TESTS RESULTS, AND IMMUNIZATION RECORDS ARE COMMONLY FOUND IN WHICH TYPE OF RECORD?
AMBULATORY CARE
THE AMBULATORY SURGERY RECORD CONTAINS INFORMATION MOST SIMILAR TO:
HOSPITAL OPERATIVE RECORDS
WHICH STANDARDIZED TOOL IS USED TO ASSESS MEDICARE CERTIFIED REHABILITATION FACILITIES?
PATIENT ASSESSMENT INSTRUMENT
INTERDISCIPLINARY CARE PLANS ARE AN IMPORTANT PART OF WHICH TYPE OF HEALTH RECORD?
HOSPICE CARE
PORTIONS OF A TREATMENT RECORD MAY BE MAINTAINED IN A PATIENT'S HOME IN WHICH TWO TYPES OF SETTINGS?
HOME HEALTH AND END STAGE RENAL DISEASE
A PATIENT'S LEGAL STATUS, COMPLAINTS OF OTHERS REGARDING THE PATIENT, AND REPORTS OF RESTRAINTS OR SECLUSION WOULD BE FOUND MOST FREQUENTLY IN WHICH TYPE OF HEALTH RECORD?
BEHAVOIRAL HEALTH
PAPER RECORDS MY REQUIRE THINNING IN WHICH TWO SETTINGS?
LONG TERM CARE AND CORRECTIONAL SERVICES
A GROWTH AND DEVELOPMENT RECORD MAY BE FOUND IN WHAT TYPE OF RECORD?
PEDIATRIC
THE DOCUMENT THAT INDICATES CONSENT AND PAST MEDICAL CONDITIONS IS?
PROBLEM LIST
WHICH OF THE FOLLOWING IS AN ACCREDITING ORGANIZATION?
DNV
AN ACCREDITING ORGANIZATION IS AWARDED DEEMED STATUS BY MEDICARE. THIS MEANS THAT FACILITIES RECEIVING ACCREDITATION UNDER ITS GUIDELINES DO NOT NEED TO:
UNDERGO MEDICARE CERTIFICATION SURVEYS
WHICH GROUP FOCUSES ON ACCREDITATION OF MANAGED CARE AND PREFERRED PROVIDER ORGANIZATIONS?
NATIONAL COMMITTEE FOR QUALITY ASSURANCE
WHICH OF THE FOLLOWING REGULATIONS WOULD MOST LIKELY CONTAIN INFORMATION ON WHO IS AUTHORIZED TO ENTER DOCUMENTATION IN A PATIENT'S RECORD?
FACILITY RULES AND REGULATIONS
WHICH OF THE FOLLOWING GROUPS HAS INSTITUTED A HEALTH RECORD PROHIBITED ABBREVIATION LIST?
JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS
WHICH TYPE OF HEALTH RECORD INCLUDES BOTH PAPER AND COMPUTERIZED COMPONENTS?
HYBRID
WHICH OF THE FOLLOWING IS A DISADVANTAGE OF AN EHR OVER A PAPER BASED RECORD?
REQUIRES PROPERTY AND SECURITY MEASURES
IN AN INTEGRATED HEALTH RECORD, DOCUMENTATION BY HEALTH PROFESSIONALS IS ORGANIZED:
INTERMIXED IN DATE SEQUENCE
THE PATIENT INDICATES THAT HER PAIN IS WORSE. IN WHICH PART OF SOAP NOTE WOULD THIS INFORMATION BE RECORDED?
SUBJECTIVE.
WHICH OF THE FOLLOWING ELECTRONIC RECORD TECHNOLOGICAL CAPABILITIES WOULD ALLOW AN X-RAY TO BE SENT TO A PHYSICIAN IN ANOTHER STATE?
IMAGE PROCESSING
WHICH OF THE FOLLOWING IS TRUE OF PAPER BASED RECORDS?
THEY ARE SUSCEPTIBLE TO DAMAGE FROM FIRE OR FLOODS.
A DEFINITION OF WHAT CONSTITUTES A RECORD, RECORDING WHERE EACH COMPONENT IS LOCATED, AND NOTHING DATES OF FORMAT CHANGES ARE PARTICULARLY IMPORTANT IN:
HYBRID RECORDS
IN A PROBLEM ORIENTED HEALTH RECORD, PROBLEMS ARE ORGANIZED BY:
NUMBER
HEALTH LEVEL SEVEN HAS DEVELOPED GUIDELINES THAT ADDRESS WHICH ASPECT OF THE ELECTRONIC RECORD?
DEFINITIONS OF FUNCTIONS.
WHICH TYPE OF DATA INPUT MECHANISM IS COMMONLY USED IN BOTH PAPER AND ELECTRONIC ENVIRONMENTS?
TRANSCRIPTION
THE SYSTEM IN WHICH A HEALTH RECORD NUMBER IS ASSIGNED AT THE FIRST ENCOUNTER AND THEN USED FOR ALL SUBSEQUENT HEALTHCARE ENCOUNTERS IS THE:
UNIT NUMBERING SYSTEM.
THE PRIMARY GUIDE TO LOCATING A RECORD IN A NUMERICAL FILING SYSTEM IS THE:
MASTER PATIENT INDEX
ALL FORMS SHOULD:
CONTAIN A UNIQUE IDENTIFIER
THE HEALTH RECORD NUMBER IS TYPICALLY ASSIGNED BY:
PATIENT REGISTRATION
WHICH OF THE FOLLOWING IS USED TO LOCATED AN ELECTRONIC HEALTH RECORD?
HEALTH RECORD NUMBER
JOHN SMITH, TREATED AS A PATIENT AT A MULTI-HOSPITAL SYSTEM, HAS THREE MEDICAL RECORD NUMBERS. THE TERM USED TO DESCRIBE MULTIPLE HEALTH RECORD NUMBERS IS:
DUPLICATES
WHICH OF THE FOLLOWING SHOULD BE PART OF A COMPREHENSIVE MPI MAINTENENCE PROGRAM?
ADVANCED PERSON SEARCH
WHICH OF THE FOLLOWING IS TRUE ABOUT THE SOCIAL SECURITY NUMBER?
BOTH SSA AND AHIMA OPPOSE USING IT AS PATIENT NUMBER. STUPID.
THE MOST COMMON NUMBERING SYSTEM USED IN HEALTHCARE IS:
UNIT NUMBERING
WHICH IDENTIFICATION SYSTEM IS AT A DISADVANTAGE WHEN THERE ARE TWO PATIENTS WITH THE SAME NAME?
ALPHANUMERIC
THE MASTER PATIENT INDEX IS NECESSARY TO LOCATE HEALTH RECORDS WITHIN THE PAPER-BASED STORAGE SYSTEM FOR ALL THE TYPE OF FILING SYSTEMS EXCEPT:
ALPHABETIC
THE TERM USED TO DESCRIBE A COMBINATION OF PAPER-BASED AND ELECTRONIC HEALTH RECORDS IS:
HYBRID
WHICH OF THE FOLLOWING IS AN ADVANTAGE OF A CENTRALIZED UNIT FILING SYSTEM?
ONE LOCATION IN WHICH TO LOOK FOR RECORDS.
WHIC FILING SYSTEM IS CONSIDERED TO BE THE MOST EFFICIENT?
TERMINAL DIGIT
WHICH TYPE OF PAPER BASED STORAGE SYSTEM CONSERVES FLOOR SPACE BY ELIMINATING ALL BUT ONE OR TWO SIDES?
MOBILE FILING UNITS
WHAT FEATURE OF THE FILING FOLDER HELPS LOCATE MISFILES WITHIN THE PAPER BASED FILING SYSTEM
COLOR CODING
IN A PAER BASED SYSTEM, THE HIM DEPARTMENT ROUTINELY DELIVERS HEALTH RECORDS TO:
NURSING UNITS
WHICH OF THE FOLLOWING PAPER WEIGHTS WOULD BE THE MOST DURABLE FOR THE MEDICAL RECORD FOLDER?
TWENTY
WHAT MICROFILM FORMAT IS INSUFFICIENT WHEN PATIENTS HAVE MULTIPLE ADMISSIONS ON MICROFILMS?
ROLL
UNDER THE FALSE CLAIMS ACT, CLAIMS MAY BE BROUGHT UP TO HOW MANY YEARS?
GENERALLY 7, BUT COULD BE 10
RECORD RETENTION SHOULD BE BASED ON:
STATE REGULATIONS AND AHIMA REGULATIONS
WHICH OF THE FOLLOWING IS THE APPROPRIATE METHOD FOR DESTROYING MICROFILM?
SHREDDING
WHICH OF THE FOLLOWING IS THE APPROPRIATE METHOD FOR DESTROYING COMPUTERIZED DATA?
DEGAUSSING
THE TOOL USED TO TRACK PAPER BASED HEALTH RECORDS IS?
OUTGUIDE
WHAT SHOULD BE DONE WHEN THE HIM DEPARTMENT'S ERROR OR ACCURACY RATE IS DEEMED UNACCEPTABLE?
CORRECTIVE ACTION
THE FORMS DESIGN COMMITTEE:
PROVIDES OVERSIGHT FOR THE DEVELOPMENT, REVIEW, AND CONTROL OF FORMS AND COMPUTER SCREENS.
STATEMENTS THAT DEFINE THE PERFORMANCE EXPECTATIONS AND OR STRUCTURES OR PROCESSES THAT MUST BE IN PLACE ARE
STANDARDS
IN A PAPER BASED SYSTEM, INDIVIDUAL RECORDS ARE ORGANIZED IN A PRE-ESTABLISHED ORDER CALLED:
ASSEMBLY
REVIEWING A HEALTH RECORD FOR MISSING SIGNATURES AND MISSING MEDICAL REPORTS IS:
ANALYSIS
REVIEWING THE RECORD FOR DEFICIENCIES AFTER THE PATIENT IS DISCHARGED FROM THE HOSPITAL IS AN EXAMPLE OF WHAT?
RETROSPECTIVE REVIEW
INCOMPLETE RECORDS THAT ARE NOT COMPLETED BY THE PHYSICIAN WITHIN THE TIME FRAME SPECIFIED IN THE HEALTHCARE FACILITY'S POLICIES ARE CALLED:
DELINQUENT RECORDS
IN A PAPER BASED RECORD, ERROS SHOULD BE COMPLETELY OBLITERATED.
FALSE
AN ADDENDUM SHOULD DOCUMENT THE DATE THE EVENT ACTUALLY HAPPENED, NOT THE DATE IT WAS DOCUMENTED.
FALSE
THE BEST PRACTICE FOR FORMS DESIGN IS TO USE WHITE PAPER AND BLACK INK.
TRUE
WHICH OF THE FOLLOWING CHART PROCESSING ACTIVITIES IS ELMINATED WITH AN EHR THAT USES SCANNED IMAGES?
ASSEMBLY
ONE OF THE ADVANTAGES OF AN EDMS IS THAT IT CAN:
HELP MANAGE WORK TASKS
WHICH FORM INDICATES THAT A DOCUMENT HAS BEEN REMOVED FROM STANDARD VIEW?
RETRACTION
WHAT IS THE PROCESS OF CHECKING INDIVIDUAL DATA ELEMENTS, REPORTS, OR FILES AGAINST EACH OTHER TO RESOLVE DISCREPANCIES?
RECONCILIATION
WHICH OF THE FOLLOWING COULD BE USED TO DETERMINE IF SOMEONE HAS THE RIGHT TO VIEW A HEALTH RECORD?
PHOTO IDENTIFICATION
VERSION CONTROL OF DOCUMENTS IN THE EHR REQUIRES:
POLICIES AND PROCEDURES.
WHICH OF THE FOLLOWING IS A RISK OF COPYING AND PASTING?
SYSTEM NOT RECORDING WHO ENTERED DATA
WHEN RECORDS FROM OTHER PLACES ARE USED IN CLINICAL DECISION MAKING HOW IS THIS DOCUMENTED IN THE EHR?
THEY ARE SCANNED AND FILED INTO THE EHR.
WHICH TERM VERIFIES CLAIM OF IDENTITY?
AUTHENTICATION
HOW ARE AMENDMENTS HANDLED IN THE EHR?
THE AMENDMENT MUST HAVE A SEPARATE SIGNATURE, DATE, AND TIME
EHR DATA ARE CAPTURE BY SCANNING AND DIRECT ENTRY
TRUE
DATA VALIDATION INCLUDES AN UNDO BUTTON
FALSE
POLICIES SHOULD ADDRESS HOW THE PATIENT INFORMATION WILL BE REMOVED FROM COMPUTERS AT THE END OF THEIR USEFUL LIFE.
TRUE
DATA QUALITY BEGINS AT THE POINT OF CREATION
TRUE
AUTHORIZATION IS IDENTIFYING A PATIENT THROUGH THE USE OF A USER NAME.
FALSE
IF ONE NEEDED TO KNOW THE NUMBER OF C-SECTIONS PERFORMED BY A CERTAIN DOCTOR, WHICH OF THE FOLLOWING INDICES WOULD BE USED TO IDENTIFY THE CASES?
OPERATION INDEX
THE COMPUTER SYSTEM THAT MAY SERVE AS THE MPI FUNCTION IS THE:
PATIENT REGISTRATION SYSTEM
A CHRONOLOGICAL LISTING OF DATA IS CALLED:
REGISTER
ONE OF THE MOST SOUGHT AFTER ACCREDITATION DISTINCTION BY HEALTHCARE FACILITIES IS OFFERED BY THE:
JOINT COMMISSION
STATEMENTS THAT DESCRIBE GENERAL GUIDELINES THAT DIRECT BEHAVOIR OR DIRECT CONSTRAIN DECISION MAKING ARE CALLED:
POLICIES
STEP BY STEP INSTRUCTIONS ON HOW TO COMPLETE A TASK ARE CALLED:
PROCEDURES