HIM 141 Exam 2 || 100% Accurate Answers.
Delinquent record correct answers A health record that remains incomplete (due to missing or
incomplete document or signature) for a specified number of days as defined in the medical staff
rules and regulations, generally 15-30 days.
Addendum to health records correct answers A late entry or a correction to the medical record;
addendums are dated the day they are written, then signed and time stamped.
Microfilm jacket correct answers The roll film would be cut into strips and inserted into 4"x6"
jackets with sleeves. Multiple jackets containing all episodes of care that have been microfilmed
can be filed together to maintain the unit record.
Terminal-digit filing system correct answers In this type of medical record filing system, the last
digit or group of last digits is the primary unit used for filing. The middle digits are called the
secondary unit and the first digits are the tertiary unit. The most efficient of the numeric filing
systems.
Ex: 44-37-98 is filed as File section 98, shelf number 37, and folder number 44.
Free-text data correct answers ________ are the unstructured narrative data that are the result of
a person typing data into an information system. The nature of the data is undefined, unlimited,
and unstructured.
Version Control in the EHR correct answers Identifies which version(s) of the documents is
available to the user. Access to all except the current version should be controlled to avoid
confusion about which version is correct.
Rules for alphabetic filing correct answers 1) File record by last name, followed by first name
and middle initial.
2) Ignore apostrophes and spaces in last names.
3) Abbreviations in last names are spelled out.
4) Ignore hyphens in last names.
5) If a name is given as an initial, "file nothing before something". Ex. Smith, J is filed before
Smith, Jane.
6) Make a policy stating how Mac and Mc will be filed.
Terminal-digit number sequence correct answers Terminal (last), secondary (middle), tertiary
(first).
Forms design standards committee correct answers A forms standards design committee should
be established to design and approve new forms and revisions, computer screens and other data
capture tools. The committee should include reps from HIM, Med staff, nursing staff,
purchasing, info svcs, performance improvement, support depts, and forms vendor reps.
, Forms design standards correct answers Fixed rules that must be followed to ensure effective
forms design principles are used. Guidelines provide general direction about the design of the
form.
Form numbering correct answers A unique number should be assigned to each form. There
should be a master form index and a copy of all forms should be maintained. The master form
index includes the title, number, origination date, revision dates, purpose, and legal requirements.
Information correct answers Data that have been turned into something meaningful. Example:
Hospital A discharged 560 patients last month, which was up 10 percent from the prior month
and 20 percent from this time last year.
Data correct answers Raw facts and figures collected together for reference or analysis. Example:
Hospital A discharged 560 patients last month.
Institutional users of the health record correct answers Organizations that need access to health
records to accomplish their mission.
-healthcare delivery organizations
-third-party payers
-medical review organizations
-research organizations
-educational organizations
-accreditation organizations
-government licensing agencies
-policy-making bodies
Alphabetical Filing correct answers health records are arranged in the same sequence as the
alphabet
Clinical Decision Support (CDS) correct answers Assists physicians and other users when
making decisions regarding medications, diagnoses, and such based on the information entered
into the EHR.
The element that is typically found in the paper health record correct answers The health record
number is a key data element in the MPI as it is a unique identifier for the patient. The MPI is
used to look up the patient's health record number. The MPI is an important element of a
numeric filing system as it allows the user to look up the patient's health record number so the
record can be located. In enterprises with more than one healthcare organization, an EMPI is
used to link the patient's information at different healthcare facilities.
What type of healthcare organization would use an alphabetic filing system? correct answers A
physician practice with a small volume of health records.
Which type of numeric filing system is the most efficient? correct answers Terminal-digit filing
system because it distributes health records evenly throughout the filing units. It is also effective
for healthcare facilities with a heavy record volume.
Delinquent record correct answers A health record that remains incomplete (due to missing or
incomplete document or signature) for a specified number of days as defined in the medical staff
rules and regulations, generally 15-30 days.
Addendum to health records correct answers A late entry or a correction to the medical record;
addendums are dated the day they are written, then signed and time stamped.
Microfilm jacket correct answers The roll film would be cut into strips and inserted into 4"x6"
jackets with sleeves. Multiple jackets containing all episodes of care that have been microfilmed
can be filed together to maintain the unit record.
Terminal-digit filing system correct answers In this type of medical record filing system, the last
digit or group of last digits is the primary unit used for filing. The middle digits are called the
secondary unit and the first digits are the tertiary unit. The most efficient of the numeric filing
systems.
Ex: 44-37-98 is filed as File section 98, shelf number 37, and folder number 44.
Free-text data correct answers ________ are the unstructured narrative data that are the result of
a person typing data into an information system. The nature of the data is undefined, unlimited,
and unstructured.
Version Control in the EHR correct answers Identifies which version(s) of the documents is
available to the user. Access to all except the current version should be controlled to avoid
confusion about which version is correct.
Rules for alphabetic filing correct answers 1) File record by last name, followed by first name
and middle initial.
2) Ignore apostrophes and spaces in last names.
3) Abbreviations in last names are spelled out.
4) Ignore hyphens in last names.
5) If a name is given as an initial, "file nothing before something". Ex. Smith, J is filed before
Smith, Jane.
6) Make a policy stating how Mac and Mc will be filed.
Terminal-digit number sequence correct answers Terminal (last), secondary (middle), tertiary
(first).
Forms design standards committee correct answers A forms standards design committee should
be established to design and approve new forms and revisions, computer screens and other data
capture tools. The committee should include reps from HIM, Med staff, nursing staff,
purchasing, info svcs, performance improvement, support depts, and forms vendor reps.
, Forms design standards correct answers Fixed rules that must be followed to ensure effective
forms design principles are used. Guidelines provide general direction about the design of the
form.
Form numbering correct answers A unique number should be assigned to each form. There
should be a master form index and a copy of all forms should be maintained. The master form
index includes the title, number, origination date, revision dates, purpose, and legal requirements.
Information correct answers Data that have been turned into something meaningful. Example:
Hospital A discharged 560 patients last month, which was up 10 percent from the prior month
and 20 percent from this time last year.
Data correct answers Raw facts and figures collected together for reference or analysis. Example:
Hospital A discharged 560 patients last month.
Institutional users of the health record correct answers Organizations that need access to health
records to accomplish their mission.
-healthcare delivery organizations
-third-party payers
-medical review organizations
-research organizations
-educational organizations
-accreditation organizations
-government licensing agencies
-policy-making bodies
Alphabetical Filing correct answers health records are arranged in the same sequence as the
alphabet
Clinical Decision Support (CDS) correct answers Assists physicians and other users when
making decisions regarding medications, diagnoses, and such based on the information entered
into the EHR.
The element that is typically found in the paper health record correct answers The health record
number is a key data element in the MPI as it is a unique identifier for the patient. The MPI is
used to look up the patient's health record number. The MPI is an important element of a
numeric filing system as it allows the user to look up the patient's health record number so the
record can be located. In enterprises with more than one healthcare organization, an EMPI is
used to link the patient's information at different healthcare facilities.
What type of healthcare organization would use an alphabetic filing system? correct answers A
physician practice with a small volume of health records.
Which type of numeric filing system is the most efficient? correct answers Terminal-digit filing
system because it distributes health records evenly throughout the filing units. It is also effective
for healthcare facilities with a heavy record volume.
