BUSI 505 Chapter 4
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1. In centralized registration, patients presenting
for any type of care are registered through one central
area.
2. Demographic data include all of the following
EXCEPT
a.) gender
b.) date of birth
c.) reason for visit
d.) presenting symptoms
c.) reason for visit
d.) presenting symp-
toms
3. Why is it essential to keep the Master Patient
(Person) Index up to date? Other patient records
are not kept permanent-
ly, The master entry con-
nects all of a given pa-
tient's encounters, and It
is a permanent listing of
all patients at a given fa-
cility.
4. Which of the following data elements are re-
quired in individual encounter entries in the MPI?
a.) Type of patient insurance
b.) Encounter/service type
c.) Admission/encounter date
d.) Account number for the encounter
b.) Encounter/service
type, c.) Admission/en-
counter date, and c.) Ac-
count number for the en-
counter
5. Why is the MPI important? It links all of a patient's
encounters in a health
system, it is a perma-
nent record of patient
encounters, and it is the
link between administra-
tive and clinical data.
6. What is the correct name for a medical record
system that uses both paper and electronic med-
ical records?
Hybrid
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7. Each patient has how many entries in the Master
Patient (Person) Index? One master entry
8. What is the definition of a legal health record? A health record identi-
fied by facility policy pre-
sented in response to a
subpoena.
9. What happens immediately after the health
record is assembled in a paper record system? The record is analyzed
for missing documenta-
tion
10. Define voice recognition software Software that converts
spoken language into
written text.
11. Explain why deficiency reporting is important. Proper reimbursement
for healthcare may not
be paid, Missing infor-
mation may affect the
care of the patient, De-
ficiencies may cause a
facility to lose accredita-
tion.
12. What is the purpose of the eSignature? Authenticate the doc-
umentation by the
provider.
13. What makes the EHR better than using a paper
chart? Data are entered in real
time, data entered at the
point of care, less risk of
lost medical records.
14. What is the role of the clinical documentation
specialist in healthcare facilities? Liaison with medical
staff and coders to im-
proved documentation
quality.
15. Coding is a part of the reimbursement cycle
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16. What is the difference between data and informa-
tion? Data are individual
facts; information is
drawn from facts.
17. What happens when all of the necessary docu-
mentation is not found in the patient chart? Missing information may
be cause for legal is-
sues, missing informa-
tion may lead to an in-
correct diagnosis, and
missing information may
lead to a lower reim-
bursement.
18. Whether an automated registration system is
used or a manual system is used in assigning
MPI numbers, how is the medical record number
assigned?
typically using 5 or more
digits
19. Which filing system is the most popular method
for paper medical records? Terminal digit
20. Why is terminal digit filing easy to use? It can be divided into
three sections from
00-99
21. What does the acronym WORM mean? Write once, read many
22. What are the three types of filing units used to
house paper records? open shelf units, com-
prehensible files, and fil-
ing cabinets
23. What should one consider when selecting a filing
system for health records? Number of patients
seen yearly, the record
retention period, and
current filing space used
24. In a client/server configuration, the
_____________ runs the EHR software in the clin- client computer; server
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ic, and the _____________ stores the patient data
and additional supporting software for the EHR.
25. What is the difference between hosted and
web-based EHR storage? Web-based is a pure
cloud solution hosted on
the web; hosted is on a
remote server accessed
via the internet.
26. Who is typically responsible for drafting the
record retention plan? HIM Director
27. Every facility should have in place a
______________ describing how inactive
records are stored.
record retention plan
28. Which of the following influence the retention
plan? HIPAA, Conditions of
Participation, Accredita-
tion standards, and Fed-
eral and state laws.
29. Which is the most economical, space-saving
method for storing paper records? Optical Disk
30. _____________ is the process of storing inactive
records in a box off-site. Warehousing
31. According to HIPAA, which of the following must
be included in the business associate contract
for the destruction of records?
The method used to de-
stroy and dispose of
records, the length of
time between acquisi-
tion and disposal, and
the damages or in-
demnity the organiza-
tion must pay in the
event of unauthorized
disclosure
32. What governs the record retention policy for
archived records?
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State laws, Federal reg-
ulations, and liability in-
surance
33. What is a subcategory of record retention? Archiving records
34. Who is responsible for writing the disaster plan? Chief Information Offi-
cer
35. Which of the following demonstrate the "concur-
rent" development of health records? Operative notes being
dictated as soon as
surgery is completed,
nurses charting daily on
patient, test results be-
ing entered as complet-
ed
36. What are some of the benefits of simultaneous
data entry and usage? Data is entered in real
time, and data can be
entered at the point of
care.
37. What types of documents might be considered
to be part of the legal health record? Hospital admission and
discharge information,
reports from automo-
bile accidents, provider
notes
38. How does an auditor's review for deficiencies in
an EHR differ from a review of a paper record? Automated record com-
pletion software can be
utilized to assist with
chart audits.
39. What are some of the benefits of simultaneous
data entry and usage in regards to patient care? fewer duplicate tests,
the EHR can be shared
with all providers taking
care of the patient, and
no delay in treatment of
patients
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40. Why is it easier for a coder to use the EHR rather
than paper for coding? The EHR is current,
coding may be done
concurrently
41. Why is coding such an important part of the
reimbursement cycle? Coding of diagnoses
and procedures is re-
quired to submit insur-
ance claims
42. How is terminal digit filing completed? Last two digits are the
primary and are used
first, second two digits
are the middle digits and
are used second, first
two digits are the ter-
tiary and are used last
43. Where is the client/server located for most hos-
pitals and physician offices? On location in the facili-
ty.
44. In a ____________ storage solution, the health
data and application software are hosted remote-
ly by the vendor.
cloud-based
45. Who oversees the record retention plan? HIM director
46. For how many years does CMS require a facility
to keep patient records? 6 years from date of cre-
ation
47. Which of the following are methods of archiving
medical records? server storage, magnet-
ic tape storage, and op-
tical storage
48. What are some of the reasons that a facility
needs a disaster plan in place? Required by Meaning-
ful Use, HITECH, and
HIPAA, patients know
that the facility has
access to their med-
ical records in event of
a disaster, and allows
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providers access in the
event of a disaster
49. The _____________ health record is compiled
while the patient is actively being seen and treat-
ed
concurrent
50. Centralized Registration: Type of hospital regis-
tration in which all pa-
tients presenting for any
type of care are regis-
tered through one cen-
tral area, regardless of
the type of care being
sought.
51. Client/server: The use of computers in
a network where func-
tions are split between
server tasks and client
tasks. The client com-
puter makes requests
of the more powerful
server computer in or-
der to undertake local
processes.
52. Clinical documentation improvement (CDI): The review of health
records, usually concur-
rently, to ensure that the
documentation in the
health record is at the
level of specificity that
allows for code assign-
ment that accurately de-
picts the patient's diag-
noses and procedures
performed.
53. Cloud-based solution:
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Service in which soft-
ware and data are
stored on remote com-
puters and accessed
by a local computer
through the Internet,
typically using a brows-
er.
54. Decentralized registration: Type of hospital regis-
tration in which there are
multiple points of patient
access, depending on
the type of care being
sought.
55. Demographic data: Administrative data that
identify the pa-
tient-name, date of
birth, address, and gen-
der.
56. Disaster recovery planning: Consists of having a
backup infrastructure to
support business conti-
nuity after a disruptive
event.
57. Hybrid record: health record main-
tained in paper for-
mat, electronic format,
and/or in the form of
recordings on tracings
derived from diagnostic
tests.
58. Jukebox: A means of storing mul-
tiple optical disks us-
ing a robotic arm that
loads and unloads op-
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tical disks for deliv-
ery of requested health
records.
59. Legal health record: The health record, iden-
tified by facility policy,
that is considered the
official business record
and that would be pre-
sented if subpoenaed.
60. Master patient (person) index (MPI): A permanent listing of
all patients who have
been admitted to or re-
ceived care in a health-
care facility. It is the
key to locating patient
records in a facility and
is maintained perma-
nently.
61. Medical record number: A unique numeric iden-
tifier for each patient
seen in a health facility.
62. Record retention plan: A written policy that doc-
uments the length of
time a healthcare fa-
cility retains its health
records, the form in
which the records will be
kept, and the location(s)
of the records.
63. Straight numeric (sequential) filing: Records are filed in se-
quential numeric order.
64. Terminal digit filing: Breaking a medical
record number into seg-
ments of single or mul-
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tiple digits, with filing
based on the last seg-
ment as the primary file
placement, followed by
the middle segment and
then the first segment.
65. WORM technology: WORM is an acronym
for "Write once, read
many" meaning that
records may be read nu-
merous times, but noth-
ing on the disk can be
altered in any way.
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