HIM 101 FINAL EXAM QUESTIONS
WITH CORRECT ANSWERS |
ALREADY PASSED
What controls which version of the document will be viewable within the health record? -
Answer- version control - example one unsigned and one signed - documents must be
flagged when an earlier version of a document exists and the date and time of the
availability of each version of the document must be clearly documented.
Can free-text data be easily located, retrieved, and manipulated by a search engine? -
Answer- Free-text data is undefined, unlimited, and unstructured. It is more difficult for a
search engine to find, retrieve, and manipulate its data than structured text.
Where does free-text data exist in the health record? - Answer- Dictated and transcribed
medical reports are an example. Many advantages of manipulation of data that the EHR
offers are lost when the health record is comprised of large amounts of unstructured
data.
What are some specific risks to documentation integrity when using copy functionality? -
Answer- -Inaccurate or outdated information that may adversely impact patient care, -
Inability to identify the author or what they thought. - Inability to identify when the
documentation was created. - Inability to accurately support or defend E/M codes for
professional or technical billing notes. - Propagation of false information. - Internally
inconsistent progress notes
Work Flow of digital dictation - Answer- 1 physician dictates a medical report and the
transcriptionist transcribes the dictation into a structured medical report. 2. The
transcribed reports are electronically transmitted to the EHR. The EDMS attaches an
auto-signature deficiency and the transcribed report is then electronically routed to a
physician work queue for signature.
What is another method used to capture dictated reports in the EHR - Answer- Voice
recognition technology - computer software captures the dictation and converts the
dictation to text. Back end voice recognition software or voice recognition at the point of
transcription is most commonly used for routine transcription of reports. As the practice
of medical transcription evolves and voice recognition software is utilized, emphasis is
,placed on medical language editing, data quality control, and text/document
management.
EHR reconciliation processes - Answer- As with paper-based and hybrid records,
electronic health records require that the HIM professional verify that there is an EHR
present in the system for every discharged patient and verification of reports.
Data mining - Answer- process of analyzing data from different perspectives and
summarizing it into useful information. Analytical tool for large amounts of data. It is the
"process of extracting information from a database and then quantifying and filtering
discrete, structured data" (AHIMA)
Access Control for EHRs - Answer- The center of Medicare and Medicaid Services EHR
certification criteria requires access control of the EHR. It states: "Assign a unique name
and/or number for identifying and tracking user identity and establish controls that
permit only authorized users to access electronic health information"
HIMs most important functions - Answer- storage and retrieval of patient information.
Additional functions managed: Research and statistics, Cancer and/or trauma registries,
and Birth certificate completion
Critical support services managed by HIM - Answer- Record processing, Monitoring of
record completion, transcription, release of patient information, clinical coding,
abstracting, and clinical data analysis
HIM functions are: - Answer- information centered and involves ensuring information
quality, security, and availability.
What dictates how the specific functions are carried out? - Answer- The medium in
which the information is stored.
What is the goal of the health record system? - Answer- To ensure that accurate
information is available to authorized users to support quality patient care.
What is record reconciliation? - Answer- Hybrid System, upon patient discharge, receipt
of the health record is checked with a discharge list for completeness.
What are the most fundamental responsibilities of most HIM departments? - Answer-
storage and retrieval, record processing, record completion, transcription, release of
information (ROI), and clinical coding
What is the most important index used by the HIM department? What is it? What is its
function? - Answer- Master Patient Index (MPI) and is the permanent record of every
patient ever seen in the healthcare entity. The MPI functions as the primary guide to
locating pertinent demographic data about the patient and his or her health record
number. It is the initial point of documentation of the health record
,What is an Enterprise Master Patient index (EMPI)? - Answer- references all patients in
two or more facilities (ie integrated healthcare delivery system or health information
exchange (HIE).
What can function as a MPI? - Answer- Often the patient registration system aka
registration, admission, discharge, and transfer system (R-ADT) functions as the MPI
What are the benefits of an electronic system? - Answer- ability to access data by more
than one individual at a time, edit checks can be applied against specific fields in the
database to better ensure data accuracy, can be easily cross-referenced (when a
patient has used more than one name during hospital or clinic visits), permits the use of
several search techniques for locating an existing patient's information.
When searching for a patient's record, what data elements can be used? - Answer-
medical record or billing number, date of birth, or social security number.
Maintenance - To ensure the integrity of the MPI, several quality control mechanisms
are essential and include: - Answer- Quality - MPI prone to errors: misspellings,
incorrect demographic data, transposition of numbers, and typographical errors are a
few. Can cause treatment errors, billing problems and distorting data analysis of the
organization's patient population.
Duplicate, Overlay, and Overlap Medical Record Number Issues - Patient info not found
upon admission and new record created; Or patient matched with wrong health record
What is overlay? - Answer- A patient is assigned another patient's medical record
number comingling the medical information of both patient's resulting in problems in
identifying what medical information belongs to which patient
What is overlap? - Answer- When more than one medical record number exists for the
same patient within an enterprise at different facilities or in different databases. Often
occur in organization with multiple facilities or can occur in the health information
exchanges. Frequently problem arises when there are facility or organization mergers
and an enterprise master person/patient index (EMPI) is created
Strategies for MPI Integrity - Answer- Integrity must be maintained in order to avoid
patient safety, customer service, risk management, legal and other issues. MPI cleanup
process - uses matching algorithms to identify and fix these problems. 3 types: are often
part of the MPI application: a DETERMINISTIC algorithm requires an exact match of
combined data elements such as name, birth date, sex, and social security number.
PROBABILISTIC algorithm is base on complex mathematical formulas that analyze
facility specific MPI data to determine precisely matched weight probabilities for attribute
values of various data elements. RULES-BASED algorithm assigns weights, for
significant values, to particular data elements and later uses these weights in the
comparison of one record to another.
, The management of high-quality, error free MPI requires constant maintenance that
includes:
What is first line of defense? - Answer- oversight, evaluation, and correction of errors.
Prevention of problems should be the front line of defense. Communication back to the
department responsible for the errors is key to providing awareness of the importance of
the MPI and identifying opportunities for training and workflow issues.
HIE - Answer- Health Information Exchange= the sharing of health information
electronically among two or more entities and also an organization that provides
services to accomplish this information exchange.
What is the purpose of an HIE organization? - Answer- to increase the availability of
health information to authorized stakeholders in order to improve quality and safety of
healthcare delivery across the continuum.
How do they ensure the integrity of patient identity in health information exchange -
Answer- Standardization of health information exchange practices is paramount.
Paper based identification systems patient ID:
Serial numbering System - Answer- Patient receives a unique numerical identifier for
each encounter or admission to a healthcare facility. Disadvantage: information about
the patient's care and treatment is filed in separate health records and at separate
locations. retrieval more difficult. inefficient.
Unit numbering system - Answer- most commonly used in large facilities. Patient
receives a unique number on his first admission and the same number is used for
subsequent encounters. Method most commonly used as the unique identifier in the
EHR environment.
Serial Unit Numbering System - Answer- numbers are assigned in a serial manner, just
as they are in the serial numbering system. However, during each new patient
encounter, the previous health records are brought forward and filed under the last
assigned health record number.
Where should the process for checking patient records be located? - Answer- in the
facility's charting policies and procedures
The system in which a health record number is assigned at the first encounter and then
used for all subsequent healthcare encounters is the: - Answer- Unit numbering system
The primary guide to locating a record in a numerical filing system is the - Answer-
Master Patient Index MPI
What type of algorithm(s) may be used to identify duplicate medical record numbers? -
Answer- Deterministic, Probabilistic, and Rules Based.
WITH CORRECT ANSWERS |
ALREADY PASSED
What controls which version of the document will be viewable within the health record? -
Answer- version control - example one unsigned and one signed - documents must be
flagged when an earlier version of a document exists and the date and time of the
availability of each version of the document must be clearly documented.
Can free-text data be easily located, retrieved, and manipulated by a search engine? -
Answer- Free-text data is undefined, unlimited, and unstructured. It is more difficult for a
search engine to find, retrieve, and manipulate its data than structured text.
Where does free-text data exist in the health record? - Answer- Dictated and transcribed
medical reports are an example. Many advantages of manipulation of data that the EHR
offers are lost when the health record is comprised of large amounts of unstructured
data.
What are some specific risks to documentation integrity when using copy functionality? -
Answer- -Inaccurate or outdated information that may adversely impact patient care, -
Inability to identify the author or what they thought. - Inability to identify when the
documentation was created. - Inability to accurately support or defend E/M codes for
professional or technical billing notes. - Propagation of false information. - Internally
inconsistent progress notes
Work Flow of digital dictation - Answer- 1 physician dictates a medical report and the
transcriptionist transcribes the dictation into a structured medical report. 2. The
transcribed reports are electronically transmitted to the EHR. The EDMS attaches an
auto-signature deficiency and the transcribed report is then electronically routed to a
physician work queue for signature.
What is another method used to capture dictated reports in the EHR - Answer- Voice
recognition technology - computer software captures the dictation and converts the
dictation to text. Back end voice recognition software or voice recognition at the point of
transcription is most commonly used for routine transcription of reports. As the practice
of medical transcription evolves and voice recognition software is utilized, emphasis is
,placed on medical language editing, data quality control, and text/document
management.
EHR reconciliation processes - Answer- As with paper-based and hybrid records,
electronic health records require that the HIM professional verify that there is an EHR
present in the system for every discharged patient and verification of reports.
Data mining - Answer- process of analyzing data from different perspectives and
summarizing it into useful information. Analytical tool for large amounts of data. It is the
"process of extracting information from a database and then quantifying and filtering
discrete, structured data" (AHIMA)
Access Control for EHRs - Answer- The center of Medicare and Medicaid Services EHR
certification criteria requires access control of the EHR. It states: "Assign a unique name
and/or number for identifying and tracking user identity and establish controls that
permit only authorized users to access electronic health information"
HIMs most important functions - Answer- storage and retrieval of patient information.
Additional functions managed: Research and statistics, Cancer and/or trauma registries,
and Birth certificate completion
Critical support services managed by HIM - Answer- Record processing, Monitoring of
record completion, transcription, release of patient information, clinical coding,
abstracting, and clinical data analysis
HIM functions are: - Answer- information centered and involves ensuring information
quality, security, and availability.
What dictates how the specific functions are carried out? - Answer- The medium in
which the information is stored.
What is the goal of the health record system? - Answer- To ensure that accurate
information is available to authorized users to support quality patient care.
What is record reconciliation? - Answer- Hybrid System, upon patient discharge, receipt
of the health record is checked with a discharge list for completeness.
What are the most fundamental responsibilities of most HIM departments? - Answer-
storage and retrieval, record processing, record completion, transcription, release of
information (ROI), and clinical coding
What is the most important index used by the HIM department? What is it? What is its
function? - Answer- Master Patient Index (MPI) and is the permanent record of every
patient ever seen in the healthcare entity. The MPI functions as the primary guide to
locating pertinent demographic data about the patient and his or her health record
number. It is the initial point of documentation of the health record
,What is an Enterprise Master Patient index (EMPI)? - Answer- references all patients in
two or more facilities (ie integrated healthcare delivery system or health information
exchange (HIE).
What can function as a MPI? - Answer- Often the patient registration system aka
registration, admission, discharge, and transfer system (R-ADT) functions as the MPI
What are the benefits of an electronic system? - Answer- ability to access data by more
than one individual at a time, edit checks can be applied against specific fields in the
database to better ensure data accuracy, can be easily cross-referenced (when a
patient has used more than one name during hospital or clinic visits), permits the use of
several search techniques for locating an existing patient's information.
When searching for a patient's record, what data elements can be used? - Answer-
medical record or billing number, date of birth, or social security number.
Maintenance - To ensure the integrity of the MPI, several quality control mechanisms
are essential and include: - Answer- Quality - MPI prone to errors: misspellings,
incorrect demographic data, transposition of numbers, and typographical errors are a
few. Can cause treatment errors, billing problems and distorting data analysis of the
organization's patient population.
Duplicate, Overlay, and Overlap Medical Record Number Issues - Patient info not found
upon admission and new record created; Or patient matched with wrong health record
What is overlay? - Answer- A patient is assigned another patient's medical record
number comingling the medical information of both patient's resulting in problems in
identifying what medical information belongs to which patient
What is overlap? - Answer- When more than one medical record number exists for the
same patient within an enterprise at different facilities or in different databases. Often
occur in organization with multiple facilities or can occur in the health information
exchanges. Frequently problem arises when there are facility or organization mergers
and an enterprise master person/patient index (EMPI) is created
Strategies for MPI Integrity - Answer- Integrity must be maintained in order to avoid
patient safety, customer service, risk management, legal and other issues. MPI cleanup
process - uses matching algorithms to identify and fix these problems. 3 types: are often
part of the MPI application: a DETERMINISTIC algorithm requires an exact match of
combined data elements such as name, birth date, sex, and social security number.
PROBABILISTIC algorithm is base on complex mathematical formulas that analyze
facility specific MPI data to determine precisely matched weight probabilities for attribute
values of various data elements. RULES-BASED algorithm assigns weights, for
significant values, to particular data elements and later uses these weights in the
comparison of one record to another.
, The management of high-quality, error free MPI requires constant maintenance that
includes:
What is first line of defense? - Answer- oversight, evaluation, and correction of errors.
Prevention of problems should be the front line of defense. Communication back to the
department responsible for the errors is key to providing awareness of the importance of
the MPI and identifying opportunities for training and workflow issues.
HIE - Answer- Health Information Exchange= the sharing of health information
electronically among two or more entities and also an organization that provides
services to accomplish this information exchange.
What is the purpose of an HIE organization? - Answer- to increase the availability of
health information to authorized stakeholders in order to improve quality and safety of
healthcare delivery across the continuum.
How do they ensure the integrity of patient identity in health information exchange -
Answer- Standardization of health information exchange practices is paramount.
Paper based identification systems patient ID:
Serial numbering System - Answer- Patient receives a unique numerical identifier for
each encounter or admission to a healthcare facility. Disadvantage: information about
the patient's care and treatment is filed in separate health records and at separate
locations. retrieval more difficult. inefficient.
Unit numbering system - Answer- most commonly used in large facilities. Patient
receives a unique number on his first admission and the same number is used for
subsequent encounters. Method most commonly used as the unique identifier in the
EHR environment.
Serial Unit Numbering System - Answer- numbers are assigned in a serial manner, just
as they are in the serial numbering system. However, during each new patient
encounter, the previous health records are brought forward and filed under the last
assigned health record number.
Where should the process for checking patient records be located? - Answer- in the
facility's charting policies and procedures
The system in which a health record number is assigned at the first encounter and then
used for all subsequent healthcare encounters is the: - Answer- Unit numbering system
The primary guide to locating a record in a numerical filing system is the - Answer-
Master Patient Index MPI
What type of algorithm(s) may be used to identify duplicate medical record numbers? -
Answer- Deterministic, Probabilistic, and Rules Based.
