Show:
Purpose and Function of Health Records
Data Characteristics
Filing
Content/Structure
EHR
100
What type of health record includes both paper and computerized components?
Hybrid
100
True or False: Data and information mean the same thing.
False - data is raw facts and figures & information is data converted to a meaningful format
100
What is the purpose of color coding records?
Aids in preventing misfiles & helps to speed up filing and retrieval
100
What two major types of data are found in the medical record?
Clinical and Administrative
100
What does EHR stand for?
Electronic Health Record
200
What is the primary function of the health record?
To store patient care data and information
200
A numerical measurement carried out to the appropriate decimal place is an example of which data charcterisitc?
Data granularity
200
How much shelving space should be allowed for expansion?
25%
200
In the SOAP style of documentation, the statement "patient moving about very cautiously, appears to be in pain" is what?
Objective
200
What is point of care charting?
Charting/entering of patient information at the time the patient is being seen.
300
Who are the primary users of the health record?
The clinical professionals who provide direct patient care.
300
Data that includes all required elements describes which data characteristic?
Data completeness
300
In paper based system, which chart would be filed immediately in front of a medical record numbered 02-05-25 in terminal digit order?
01-05-25
300
In this facility the integrated health record components are arranged in strict chronological order. The facility is utilizing what type of record format?
Integrated health record
300
What is the guide that outlines all functional standards for electronic health records called?
HL7
400
The right of individuals to control access to their personal health information defines:
Privacy
400
The admitting form on Mr. Jackson's health rcord indicates his DOB is May 8, 1945. On the discharge summary, Mr. Jackson's birth date is recorded as March 8, 1945. Which data quality element is missing from Mr. Jackson's health record?
Data consistency
400
A file clerk is asked to pull all inpatient health records on Marsha Jones. After referencing the MPI, the file clerk pulls Marsha's inpatient records from three different locations in the permanent files. Each record has its own health record number and all three numbers are different. What type of numbering system is being used at the facility?
Serial
400
Which report in the medical record describes a surgical procedure undergone by a patient?
Operative Report
400
Why is an ideal EHR system one that requires point of care charting?
Point of care charting supports clinical decision making
500
The expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose, is the definition of:
Confidentiality
500
The health record states the patient's favorite color is purple. There is no correlation between the patient's favorite color and anything else in the health record. This statement regarding favorite color is an example of an incorrect use of data _________.
relevancy
500
AHIMA's retention standards recommend that the master patient index (MPI) be maintained:
permanently
500
In the medical history, a detailed chronological description of the development of the patient's illness is referred to as the:
History of present illness (HPI)
500
A program that provides clinical reminders to a physician is utilizing:
Clinical Decision Support