Providing standardized medical terms to eliminate variance in the naming of all
diseases, conditions, and procedures. For example the terms bunionectomy, McBride
procedure and repair of hallus valgus all describe the same surgery. - ANSWER
Vocabulary Standards
Data consistency ensures information about a patient is accurate and identical
throughout an entire patient record. - ANSWER Data Consistency
Which health record employs a tabulated list of the patient's current and past problems?
ANSWER Problem-Oriented health record
What do you call the process by which connections may be made between two systems?
Example-two different code systems to represent comparable codes allows information
originally captured for one purpose to be transformed and used for another purpose.
ANSWER Data Mapping
For whom, besides the HIM department, would you want to link the records in the case
of a duplicate health record? - ANSWER Record source, example: Laboratory
What type of analysis occurred comparing omitted clinical information received from
external providers to required clinical information to make an accurate diagnosis? -
ANSWER Gap Analysis
Who would be responsible for oversight in development, review, and control of forms
and computer screens? - ANSWER Clinical Forms Committee
What type of index would be maintained in a list in diagnosis code number order for
patients discharged from a facility during a particular period of time? - ANSWER
Disease Index
,In a database the LAST_NAME column in a table would be considered a: - ANSWER Data
Element
The ownership of hospital records, which refers to health records, x-rays, laboratory
reports, and consultation reports, related to the care provided to a patient, rests with: -
ANSWER The Hospital
In general, how long should healthcare facilities retain the master patient index? -
ANSWER Permanently
Which of the following is the health record component that addresses the patient's
current complaints and symptoms and lists that patient's past medical, personal, and
family conditions? - ANSWER Medical History
What information is collected during day-to-day operations of a healthcare organization
that has value within an organization? - ANSWER Information Assets
What do they call a descriptive list of data elements to be collected in an information
system or database whose purpose is to make sure that the same terms are used in
collecting and interpreting different pieces of information? - ANSWER Data Dictionary
What is the best definition of system of record (SOR)? - ANSWER Authoritative source
for data about an entity
Results of a urinalysis and all blood tests performed would be found in what part of a
healthcare record? ANSWER Laboratory Findings
A patient's gender, phone number, address, next of kin, and insurance policy holder
information would be considered what kind of data? ANSWER Administrative Data
What requires that the attributes and values of data are defined at the correct level of
, detail for the intended use of the data? - ANS Data Granularity
How does the HIM department assist the patient registration department? - ANS Assigns
the Health Record Number
A hospital's EHR defines the expected values of the gender data element as female,
male, and unknown. Specificity of this type is referred to as: - ANSWER Data Precision
What name is given to anticipated values of data? - ANSWER Data Precision
Giving approval to a healthcare organization based on whether the organization has met
a set of voluntary standards refers to: - ANSWER Accreditation
What does it mean when the data about the patient is valid and consistent throughout
the patient's stay? - ANSWER Data Consistency
If an older version of a code set is being linked to a newer version, what is it called? -
ANSWER Forward Mapping
A web page, specially designed, which provides secured access for the data is: -
ANSWER Portal
What is the ethical principle being followed when a health information management
professional makes sure that patient information is only released to those who legally
have a right to have the information? - ANSWER Beneficence
The release of information function requires the HIM professional to have knowledge of?
- ANSWER Federal and State Confidentiality Laws
What is the most common term applied to the person within an organization who is
responsible for protecting health information in concert with the court system?
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