The master patient index must, at a minimum include sufficient information to

Which of the following is NOT a safety hazard in the file area of the HIM Department?

Which of the following lists is in correct alphabetical order?

In the master patient index, which is filed by last name, Jill Thomas-Jones would be

Which one of the following is NOT an advantage of a computerized master patient index?

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

A quarterly review reveals the following data for Springfield Hospital:

What is the percentage of incomplete records during this quarter?

Which of the following is a secondary data source that be used dsto quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

As a new HIM manager of an acute care facility, you have been asked to update the facilitys policy for a physicians verbal orders in accordance with Joint
Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

An example of a primary data source for health care statistics other than the patient health record is the

Under which of the following conditions can an original patient health record by physically removed from the hospital?

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and

In a manual record tracking system, outguides replace a file that has been checked out of the system. A secondary function of outguides is to

Which of the following is a type of laser technology that is ideal for health records because it stores data in a permanent capacity, prohibiting users from altering, misfiling, or erasing data?

Which method of identification of authorship or authentication of entries would be in appropriate to use in a patient’s health record?

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

As supervisor of the cancer registry, you report the registrys annual caseloads to administration. The most efficient way to retrieve this information would be to use

The old practice of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patients record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

Which of the following is least likely to be identified by the deficiency analysis clerk?

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

An example of objective entry in the health record supplied by a health care practitioner is the

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

In creating a new form or computer view, the designer should be most driven by

Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should

As the Data Security Officer for your institution, you plan to implement a log-on process for electronic signing that is LEAST susceptible to improper delegation of use. The method you will recommend is

Which of the following is a form or view that is typically seen in the health record of a long-term care patient, but is rarely seen in records of a acute care patients?

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?

In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent?

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1.
Which of the following statement regarding the history and physical is ture in this situation? Completion and charting of the H&P indicates.

As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that will contribnute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for decision support regarding drug dosages and contraindications. You think they are ready for a

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate

As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility’s

A risk manager needs to locate a full report of a patients fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS would be

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

One distinct advantage of the HER over paper-based health records is the

In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of Him department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint
Commission standards your first recommended change is to

The foundation for communicating all patient care goals in long-term care settings is the

The minimum length of time for retaining original medical records is primarily governed by

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it.
Another step you will need to take is to

The best example of point-of-care service and documentation is

The first cancer patient seen in your facility on January 1, 2008, was diagnosed with colon cancer, with no known history of previous malignancies. Th eaccession number assigned to this patient is

Joint Comission requires the attending physician to countersign health record documentation that is entered by

Discharge summary documentation must include

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of

A health record analyst needs to quickly compare all lab values during one hospitalization. The paper-based health record format best suited for this purpose is

A good first step toward protecting the security of data contained in a health information computer system would be to

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.