Fundamentals of Managing Health Records
Understanding the Fundamentals of Managing Health Records
- Your hospital is transitioning from paper-based records to electronic health records. Right now, part of
The record is paper, and some of it has been transitioned to electronic formats. AHIMA refers to this as a(n)
_______ Health record.
- source-oriented
- integrated
- problem-oriented
- hybrid
- Which of the following is required by the Joint Commission for ambulatory charts?
- Discharge summary
- Medication list
- Consent to treat
- Problem list
- You’re reviewing patient information in which resolution is a big factor. What system are you most likely
to be using?
- Pharmacy
- Biomedical
- Radiology
- Dictation/transcription
- Which of the following is an example of a secondary record?
- Demographic data
- Lab results
- SOAP note
- Billing claim
- In reverse chronological order, the _______ patient record is the most common record used.
- problem-oriented
- integrated
- hybrid
- source-oriented
- Admission and discharge notes are examples of
- demographic data.
- primary records.
- secondary records.
- claims.
- Which of the following is required by CMS?
- DEEDS
- UCDS
- OASIS
- NCDB
- You sit on the electronic health record committee that has decided to get systems that work best for each
department. This method is known as the _______ approach.
- best-of-breed
- integrated systems
- LOINC
- hanging protocol
- Which of the following requires that the criteria of message integrity, nonrepudiation, and user
authentication be used?
- Flow sheets
- Nomenclature
- EHR forms
- Electronic signatures
- Which of the following is an example of a secondary record?
- Dental record
- Ambulatory care record
- MPI
- Physician order
- Which of the following is required by the CMS?
- Refusal of treatment
- Advanced directive
- Medicare patient rights statement
- HIPAA consent
- Which of the following is used for planning care in an SNF?
- Data sets
- SOAP
- Case management
- RAI
- The nurse indicates that the patient in Room 302 is DNR. Where would you look to confirm this?
- Patient rights statement
- Advance directives
- Disclosure records
- Assignment of benefits
- The admission clerk misspells a patient’s name and therefore can’t find him in the system, so a new
number gets assigned and a chart created. This problem is a common downfall of
- electronic records.
- common names.
- paper records.
- unit numbering.
- Which of the following is considered a public health record?
- Medical history
- Organ donor
- Referral consult
- Death record
- Which of the following does AHIMA recommend keeping permanently?
- Death registry
- Mammography
- Children’s records
- Pathology reports
- You’re filing a patient’s paper record with the number 462-99-00. Your department is probably using
which filing system?
- Alphanumeric
- Straight numeric
- Family numbering
- Serial-unit
- Which of the following is often used to meet Joint Commission compliance?
- Unit numbering
- Serial-unit numbering
- Serial numbering
- Family numbering
- The downfall of this numbering system is that there may be multiple records for one patient.
- Family numbering
- Unit numbering
End of exam
- Serial-unit numbering
- Serial numbering
- You’re looking at a patient’s paper record in which all the physician notes are grouped together in one
section, the lab results are grouped together in another section, and the nursing notes are organized in yet
another section. Which type of record are you most likely viewing?
- Hybrid
- Integrated
- Source-oriented
- Problem-oriented