Term
| What is a secondary purpose of the health record? |
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Definition
| to generate a report to be used in performance improvement |
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Term
| What is an institutional user of the health record? |
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Definition
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Term
| How do patient care managers and support staff use the data documented in the health record? |
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Definition
| to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided |
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Term
| What best describes the concept of confidentiality? |
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Definition
| the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose |
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Term
Which of the following statements does not pertain to paper-based health records?
a. They have a built-in access control mechanism.
b. They are kept in locked storage areas that are accessible only to authorized staff.
c. They are logged out according to the organization’s prescribed procedure.
d. They are forwarded to the appropriate service area when needed for patient care purposes. |
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Definition
| a. They have a built-in access control mechanism. |
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Term
Which of the following is an advantage offered by computer-based clinical decision support tools?
a. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature.
b. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends.
c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives.
d. all of the above |
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Definition
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Term
| The hospital where I work is transitioning to the EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as: |
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Definition
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Term
| Critique this statement: Data and information mean the same thing. |
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Definition
| This is a false statement as data is raw facts and figures and information is data converted into a meaningful format |
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Term
Which of the following statements does NOT pertain to electronic health records (EHRs)?
a. EHR technologies and systems must not intrude on the patient and provider relationship.
b. EHRs are filed in paper folders.
c. In the United States, a national health information infrastructure is being designed to support EHRs.
d. Clinicians use computer keyboards when documenting in the EHR. |
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Definition
| b. EHRs are filed in paper folders. |
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Term
Which of the following is a secondary purpose of the health record?
a. support for provider reimbursement
b. support for patient self-management activities
c. support for research
d. support for patient care delivery |
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Definition
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Term
| Use of the health record by a clinician to facilitate quality patient care is considered |
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Definition
| a primary purpose of the health record |
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Term
| Use of the health record to monitor bioterrorism activity is considered |
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Definition
| a secondary purpose of the health record |
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Term
| How do accreditation organizations use the health record? |
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Definition
| to determine whether standards of care are being met |
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Term
| How do research organizations use the health record? |
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Definition
| to examine results of experimental protocols |
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Term
| Attorneys for healthcare organizations use the health record to |
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Definition
| protect the legal interests of the facility and its health care providers |
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Term
| Our record has all of the lab filed together, all of the progress notes file together, and so |
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Definition
| Source oriented health record |
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Term
Inaccurate data recorded in the health record could
a. compromise quality patient care
b. contribute to incorrect assumptions by policy makers
c. invalidate research findings
d. all of the above |
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Definition
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Term
| The term used to describe expected data values is |
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Definition
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Term
| Protection of healthcare information from damage, loss, and unauthorized alteration is |
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Definition
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Term
| Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using? |
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Definition
| Computerized physician/provider order entry |
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Term
| The paper-based health record format that organizes all forms in chronological order is known as |
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Definition
| the integrated health record |
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Term
| Critique this statement: The health record documents services provided by allied health professionals and a patient’s family. |
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Definition
| This is a false statement as the health record documents the care provided by healthcare professionals |
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Term
| An individual’s right to control access to his or her personal information is known as |
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Definition
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Term
| When all required data elements are included in the health record, the quality characteristic for ________ is met. |
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Definition
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Term
| Critique this statement: Patient care managers are individual users of health records. |
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Definition
| This is a true statement. |
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Term
| What are the six attributes associated with the storage of patient care documentation? |
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Definition
| quality, accessibility, security, flexibility, connectivity, and efficiency |
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Term
| Define the quality attribute associated with the storage of patient care documentation |
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Definition
| Data must be correct, easily obtainable, complete, reliable, up-to-date, defined clearly and at the correct level of detail for the data’s intended use, precise, and useful. |
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Term
| Define the accessibility attribute associated with the storage of patient care documentation |
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Definition
Authorized users of the health record must be able to easily access information when and where they need it.
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Term
| Define the security attribute associated with the storage of patient care documentation. |
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Definition
The protection of the privacy of individuals and the confidentiality of health records, allowing only authorized users to access health records. This includes protecting the healthcare information from damage, loss, and unauthorized alteration.
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Term
| Define the flexibility attribute associated with the storage of patient care documentation. |
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Definition
| Data should be readily available and meaningful to all the record’s intended users. |
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Term
| Define the connectivity attribute associated with the storage of patient care documentation. |
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Definition
The capacity of health record systems to provide communication linkages and allow the exchange of health record data among information systems.
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Term
| Define the efficiency attribute associated with the storage of patient care documentation. |
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Definition
Systems and processes regarding data storage that are accomplished with the least amount of time and work.
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Term
| What are some new roles for HIM professionals in the future? |
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Definition
The health information manager has new responsibilities and roles as new technologies transform health records from paper to electronic mediums - Developing good user interfaces for electronic medical records, computer data security and privacy, and exchange of health information electronically are new areas of focus.
New roles for HIM professionals include the health information manager for integrated systems, who is in charge of the organization-wide direction of health information functions; the clinical data specialist, who is responsible for data management functions; patient information coordinator, who assists consumers in managing their personal health information; as well as the data quality manager, the information security manager, and other new roles for the health information management professionals. |
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