• 23 AUG 18
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    Fundamentals of Managing Health Records

    Understanding the Fundamentals of Managing Health Records

    1. 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.

    1. source-oriented
    2. integrated
    3. problem-oriented
    4. hybrid
    5. Which of the following is required by the Joint Commission for ambulatory charts?
    6. Discharge summary
    7. Medication list
    8. Consent to treat
    9. Problem list
    10. You’re reviewing patient information in which resolution is a big factor. What system are you most likely

    to be using?

    1. Pharmacy
    2. Biomedical
    3. Radiology
    4. Dictation/transcription
    5. Which of the following is an example of a secondary record?
    6. Demographic data
    7. Lab results
    8. SOAP note
    9. Billing claim
    10. In reverse chronological order, the _______ patient record is the most common record used.
    11. problem-oriented
    12. integrated
    13. hybrid
    14. source-oriented
    15. Admission and discharge notes are examples of
    16. demographic data.
    17. primary records.
    18. secondary records.
    19. claims.
    20. Which of the following is required by CMS?
    21. DEEDS
    22. UCDS
    23. OASIS
    24. NCDB
    25. 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.

    1. best-of-breed
    2. integrated systems
    3. LOINC
    4. hanging protocol
    5. Which of the following requires that the criteria of message integrity, nonrepudiation, and user

    authentication be used?

    1. Flow sheets
    2. Nomenclature
    3. EHR forms
    4. Electronic signatures
    5. Which of the following is an example of a secondary record?
    6. Dental record
    7. Ambulatory care record
    8. MPI
    9. Physician order
    10. Which of the following is required by the CMS?
    11. Refusal of treatment
    12. Advanced directive
    13. Medicare patient rights statement
    14. HIPAA consent
    15. Which of the following is used for planning care in an SNF?
    16. Data sets
    17. SOAP
    18. Case management
    19. RAI
    20. The nurse indicates that the patient in Room 302 is DNR. Where would you look to confirm this?
    21. Patient rights statement
    22. Advance directives
    23. Disclosure records
    24. Assignment of benefits
    25. 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

    1. electronic records.
    2. common names.
    3. paper records.
    4. unit numbering.
    5. Which of the following is considered a public health record?
    6. Medical history
    7. Organ donor
    8. Referral consult
    9. Death record
    10. Which of the following does AHIMA recommend keeping permanently?
    11. Death registry
    12. Mammography
    13. Children’s records
    14. Pathology reports
    15. You’re filing a patient’s paper record with the number 462-99-00. Your department is probably using

    which filing system?

    1. Alphanumeric
    2. Straight numeric
    3. Family numbering
    4. Serial-unit
    5. Which of the following is often used to meet Joint Commission compliance?
    6. Unit numbering
    7. Serial-unit numbering
    8. Serial numbering
    9. Family numbering
    10. The downfall of this numbering system is that there may be multiple records for one patient.
    11. Family numbering
    12. Unit numbering

    End of exam

    1. Serial-unit numbering
    2. Serial numbering
    3. 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?

    1. Hybrid
    2. Integrated
    3. Source-oriented
    4. Problem-oriented

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