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Health Information Management Technology 4th Ed By Sayles -Test Bank

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Health Information Management Technology 4th Ed By Sayles -Test Bank

Health Information Management Technology An Applied Approach Fourth Edition

Instructor’s Manual

Chapter 7 Health Information Functions

Lesson Plan Background and Instructional Delivery This chapter focuses on the functions required by the processing of paper records, hybrid records, and the electronic health record, including storage and retrieval, chart processing, monitoring of chart completion, transcription, release of information, and clinical coding. Storage and maintenance of the health record is the most fundamental HIM function and affects all other functions. If records and information are not stored and maintained appropriately, then it is almost impossible to perform other tasks. This chapter discusses filing systems, storage systems, microfilming, remote storage, chart tracking, and quality monitoring of paper-based record systems. The HIM functions of hybrid and electronic health records systems are also discussed. In addition to the typical HIM functions, other related functions that are sometimes performed by the HIM department are also discussed, including research and statistics, cancer and trauma registries, and birth certificates. Figure 7.1 of the chapter provides a description of a fictional HIM department. This fictional department will help students to visualize how all the various services and functions of the HIM department are integrated. Review the department organization with students and discuss the HIM functions. Students may have been exposed to other HIM departments through work, site visits or rotations. This is a good opportunity to discuss differences and similarities among organizational structures and functions of HIM departments. Secondary uses of health data are also discussed in this chapter. Indexes and registers support functions for areas such as coding and research and statistics. This section covers the customary indexes and registers. Patient registration is discussed as the starting point of the health record with the collection of demographic information, admitting diagnosis, and payment information. Points of registration are described for a large healthcare facility. Discussion of the need for coordination and consistency of registration activities should be emphasized with regard to data integrity, completeness, and accuracy. If possible, obtain registration forms from various points of patient registration and compare these for consistency. The interdepartmental relationships in regards to data integrity and health record content should be discussed. The next section of the chapter covers the management of the health record content and processes. Joint Commission accreditation is discussed, with examples of the HIM monitoring activities that assist in determining compliance with Joint Commission standards. The instructor should discuss other examples of the HIM department’s involvement in the accreditation process. Forms design and development are also covered. In most acute care facilities, the medical records committee serves as the forms committee.   Chapter Outline Learning Objectives Key Terms Introduction Theory into Practice HIM Functions and Services Master Patient Index Maintenance of Master Patient Index Patient Identity in a Health Information Exchange Environment Identification Systems Identification Systems for Paper-Based Health Records Serial Numbering System Unit Numbering System Serial-Unit Numbering System Alphabetic Identification and Filing System Identification Systems for Electronic Health Records HIM Functions in a Paper-based Environment Record Storage and Retrieval Functions Filing Systems for Paper-based Health Records Alphabetic Filing Systems Numeric Filing Systems Alphanumeric Filing Systems Centralized Unit Filing Systems Storage Systems for Paper-based Records Filing Cabinets or Shelving Units File Folders Microfilm-Based Storage Systems Off-Site Storage Systems Imaged-Based Storage Systems Retrieval and Tracking Systems for Paper-based Records Retention and Destruction of Paper-based Records Retention Destruction Record Processing of Paper-based Records Admission and Discharge Record Reconciliation for Paper-based Records Record Assembly Function for Paper-based Records Deficiency Analysis for Paper-based Records Monitoring Completion of Paper-based Records Authorization and Access Control for Paper-based Records Forms Design, Development and Control for Paper-based Records Forms Design and Development Clinical forms Committee Forms Control, Tracking, and Management Quality Control Functions in Paper-based Systems Storage and Retrieval Record Processing HIM Functions in a Hybrid Environment Record Storage, Retrieval, and Retention of Hybrid Records Use of Electronic Document Management Systems Workflow Using an EDMS Record Retention Handling Corrections Search, Retrieval and Manipulation Authorization and Access Control for Hybrid Records Quality Control Functions for Hybrid Records Quality in Record Processing Reconciliation in the Hybrid Records Issues and Challenges with Hybrid Records HIM Functions in an Electronic Environment Transition Functions to an EHR Record Filing and Tracking of EHRs Record Processing of EHRs Version Control of EHRs Management of Free Text in EHRs Management and Integration of Digital Dictation, Transcription and Voice Recognition Reconciliation Processes for EHRs Managing Other Electronic Documentation E-mail Voice Mail Handling Materials from Other Facilities Search, Retrieval and Manipulation Functions of EHRs Access Control for EHRs Identification Authentication Authorization Nonrepudiation Handling Amendments and Corrections in EHRs Purge and Destruction of EHRs Quality Control Functions for EHRs Medical Transcription Management of Medical Transcription Quality Control Release of Information (ROI) ROI Quality Control Legal Health Record Tracking and Report of Disclosures Clinical Coding Quality Control in Clinical Coding Revenue Cycle Management Other HIM Functions Data Reporting and Interpretation Maintenance of Indexes and Registries Disease and Operation Indexes Physician Index Registries Birth Certificates HIM Interdepartmental Relationships Patient Registration Billing Department Patient Care Departments Information Systems Participation on Medical Staff and Organizational Committee Managing Documentation Requirements Virtual HIM Accreditation and Licensing Documentation Requirements Monitoring of Accreditation, Licensure, and Standards Requirements Management and Supervisory Processes Policy and Procedure Development Future Direction in Health Information Management Technology Real-World Case Summary References Learning Objectives • Identify typical health information management functions • Explain the purpose and techniques used for the maintenance of the master patient index in paper-based and electronic environments • Identify operational techniques for managing traditional HIM functions in paper-based, hybrid, and electronic record environments • Discuss techniques used in the processing, storage, retrieval, and maintenance of health records in paper-based, hybrid and electronic environments • Explain the use of quality control techniques used for paper-based, hybrid, and electronic health records and for supporting services such as medical transcription, release of information, and coding functions • Discuss the concept of the legal health record and how it is applied • Describe practices for authorization and access control of health records in paper-based, hybrid, and electronic formats • Recognize the interrelationship between the HIM department and other key departments within the healthcare organization • Describe the purpose, development, and maintenance of registries and indexes such as the master patient index, disease index, and operation indexes • Discuss the functions and responsibilities of common HIM support services, including cancer and trauma registries, birth certificate completion, and statistical and research services • Explain the relationship of accreditation, licensing, and standards requirements to HIM functions and how compliance with these is monitored • Describe techniques used in the management of the HIM department, such as policy and procedure development and the budgeting process   Key Terms Abstracting Access control Alphabetic filing system Alphanumeric filing system APC grouper Authentication Authorization Back-end speech recognition Certificate of destruction Clinical coding Computer-assisted coding (CAC) Concurrent review Corrections Deemed status Deficiency slip Delinquent record Destruction Digital dictation Duplicate medical record number Encoder Enterprise master person/patient index (EMPI) Free-text data Front-end speech recognition Health information exchange (HIE) Health record number Hybrid record Index Joint Commission Legal health record Master patient index (MPI) Medical transcription Middle-digit filing system MS-DRG grouper Natural language processing (NLP) Nonrepudiation Numeric filing system Operation index Outguide Overlap Overlay Patient account number Policies Procedures Purged records Quantitative analysis Reassignment Record completion Record processing Record reconciliation Registry Release of information (ROI) Requisition Resequencing Retention Retraction Retrospective review Serial numbering system Serial-unit numbering system Standard Storage and retrieval Straight numeric filing system Terminal-digit filing system Transcription Unit numbering system Version control Virtual HIM Voice recognition technology Activities Site Visit 1. Have students perform tasks in clinical coding, medical transcription, storage and retrieval, chart completion, or release of information, or shadow an employee performing one of these tasks. Students may then write a procedure for the task they performed or observed. The students can use the format for the procedure as shown in the sample procedure in figure 8.22 of the textbook. 2. During clinical rotations or a site visit to an acute care facility, have students gather information using the question inventories below. These question inventories cover the release of information function, chart completion process, and storage and retrieval functions. Questions can be modified as necessary to accommodate information at non-acute facilities. After the questions are answered, have the students compare and contrast their site observations/experiences with classroom and textbook discussions. Question Inventory: Storage and Retrieval Note: Some questions for this activity may be covered in other chapters of the textbook. Numbering System 1. What type of numbering system(s) is used by this facility? Describe. Storage (Filing) System 1. What type of health record storage system is used (for both paper-based, hybrid, and electronic systems)? Briefly describe the system(s). What are the advantages and disadvantages of the system(s)? 2. How does the facility define an active chart? What is considered the legal health record? 3. Is a centralized unit filing system used? Explain. 4. How long are records retained? 5. Is microfilm or off-site storage used? If so, describe the process. Record Control 1. Describe methods of record control (for example, outguides, policies for record requests, audit trails, passwords, and access monitors). 2. Describe the chart tracking system used. Filing Facilitators 1. Describe methods used to facilitate the storage and retrieval process (for example, color-coded labels, terminal digit, purging, year label, bar coding, or header sheets). 2. Is there adequate space for expansion? Consider the physical space for paper-based records and computer space for the EHR. 3. For paper-based systems, estimate the current linear filing inches of the permanent record storage area. Describe how you determined this number. 4. For the EHR, describe the level of computer storage needed to maintain the electronic health records. Forms 1. Name at least one aspect of forms design/control you would suggest changing, if you were responsible for forms control in this facility. For electronic or hybrid health records, name at least one aspect of screen design or navigation, you would suggest changing. Why? Loose Report Filing 1. Who is responsible for ensuring that loose reports are filed in the patient health record? 2. Is there a backlog of loose filing? If so, estimate the amount of loose sheets needing to be filed. Describe how you determined this number. 3. How long would you estimate it would take to file this backlog? How did you determine this time period? Regulatory Requirements 1. Which policies and procedures pertaining to the storage and retrieval function are based on standards established by regulatory agencies? What are the regulatory standards? What agency established these standards? Be specific. Question Inventory: Chart Completion Process 1. Is there an established chart order for the facility? 2. What type of chart format (source-oriented, problem-oriented, or integrated) is used by this facility? Describe. 3. What type of deficiencies are analyzed for chart completion? Is this type of analysis considered qualitative or quantitative and why? 4. Describe how chart deficiencies are marked (for example, colored clips or tags, paper clips, or electronic tags). 5. Is the assembly/analysis or the prepping/imaging process concurrent? If so, explain how this works. 6. If there is an incomplete filing area, what type of filing system is used for this area? Is this type of filing system effective and efficient? Why or why not? Describe the filing system. 7. Describe the chart deficiency database. 8. Create a flow chart of the flow of the health record from discharge to permanent filing. (If you are in an outpatient setting, create a flow chart relevant to your setting.) Policy 1. At what point is the chart considered delinquent? Why was this timeframe selected? If this question is not applicable to your setting, explain why it is not. 2. How are the physicians notified that they have records to complete? 3. What are the consequences if a physician does not complete his/her incomplete or delinquent records? Explain. 4. Are there quantity and/or quality standards established for the tasks related to assembly/analysis, prepping/scanning and quality review? Regulatory Requirements 1. Which policies and procedures pertaining to chart completion are based on standards established by regulatory agencies? What is the name of the agency and what are the regulatory standards? Be specific. Question Inventory: Release of Information General Release of Information 1. What types of requests for information are received by the department or facility (for example, patient, attorneys, Bureau of Disability, or other healthcare providers)? 2. How many written requests are received monthly? 3. Is a copying service used? How many days a week is the copying service available? 4. What is the average turnaround time for completing requests? 6. What is the cost to the requester for record copies and/or form completion? Explain. 7. Create a flow chart to show the process and logic of the release of information function for this facility. 8. Describe the database or manual system used to track release of information. Authorization Requirements 1. What does the facility require in order for an authorization to be valid? 2. When an authorization is found to be invalid, what steps are taken? 3. What information is considered non-privileged by the facility? Subpoenas 1. How are subpoenas handled at this facility? Be specific. 2. Who accompanies the record to court? Describe a typical day at court when appearing with a medical record. Regulatory Issues 1. What legal principles, policies, regulations, and standards control the release of information and the request for information? Be specific. State how the facility meets these requirements. Projects 1. Numeric Filing Exercise: For this project students will use index cards labeled with health record numbers to practice terminal digit and middle digit filing. Create health record number labels • In Microsoft Word 2007 click Mailings,” click on “labels” • Click on the “label” tab • Click on “options” • Select product number (example Avery 5160) • Click “ok” • Click on “New Document” (blank label page will display) Type one health record number on each label. Center numbers on labels. (See sample label page at end of this section of Instructor Manual. You may use the health record numbers from the sample. Keys are based on this sample set of numbers.) Put each label on a separate index card. The stack of index cards simulates a stack of health records that need to be filed. Have students put the index cards in terminal digit order (TDO). Students can check their accuracy against the answer key. Have students repeat the process by putting the index cards in middle digit order. 2. HIM Databases: Have students identify the data fields that should be collected for the databases maintained in the HIM department. Examples of the databases maintained by HIM include release of information, master patient index, chart tracking, chart deficiency, and clinical coding abstract. If students have knowledge of Microsoft Access, have students build a database for one or more of the functions listed above. Lecture Use the enclosed PowerPoint slides as a lecture guide. Additional Readings Joint Commission on Accreditation of Healthcare Organizations. Hospital Accreditation Standards. Joint Commission: Oakbrook Terrace, IL. Keys Real-World Case Discussion Questions 1. Discuss how the hybrid record will change the role of the HIM professionals working in the Health Records Department. There is no longer the need to have employees assemble the chart into the prescribed order. The barcode identifying the type of form will allow the system to index the form into the correct location in the record. These employees will prepare paper portions of the health record for scanning. The health record would still be analyzed for completion. Chart completion is facilitated as the record can be accessed from remote locations. Quality checks on scanned images are needed to assure the readability before paper records are destroyed. Work queues are used to facilitate the workflow and identify records awaiting various HIM functions. As the facility captures data in a more structured format, the medical coder will verify the codes assigned by the computer. As meaningful use (MU) evolves the HIM professional will assist in demonstrating that MU criteria have been met. 2. As this department continues to move toward an electronic health record, discuss how computer assisted coding (CAC) could be adopted. More structured data included in the health record will allow the CAC system to search the health record and assign codes using build in rules and coding principles. Have students research CAC systems and evaluate how the role of the medical coder will change. Application Exercises 1. Internet Search Exercise: Do an Internet search to locate vendors of electronic health record (EHR) systems. From your search, develop an electronic scrapbook of different electronic health records systems, including price information, if available. Make a table that compares the available products. Review the comparisons and conclusions to see that the student demonstrates an understanding of the EHR systems Suggested format of students’ comparison table: The table could include the following information. 1) Vendor: Name of vendor. 2) Product Name: Most vendors offer many EHR products depending on the type of facility for which the product is used. Enter the product name here. 3) Website: Enter the URL of where the student found the demonstration and/or product information. YouTube offers many short video demonstrations of EHRs. 4) Functionality: In this column list the main features (functionalities) of the EHR systems. (for example, does the system include a practice management or registration module, templates for documentation, free-text, voice recognition, computerized-assisted coding, computerized physician order entry, e-prescribing, and such) 5) Type of setting: Enter here whether the product is marketed for the physician office setting, hospital, or other healthcare setting. 6) Certified: Enter here whether or not the EHR product is certified. If the product is certified note the specific certification. Vendor Product Name Website (URL) Functionality Type of setting Certified Have students compare the paper-based health record described in this chapter with the EHR systems described in their table. Answers will vary based on student response. 2. Health Record Forms Assessment: Collect samples of different health record forms. Make a checklist of the properties that should be included in good forms development. Compare your samples against the properties on your checklist. What recommendations would you make for improvement on the forms design? Direct students to the section in the chapter that discusses forms design. Ask students to develop a data collection form to serve as a checklist or provide a checklist for the students. Discuss their recommendations. Answers will vary based on student response. 3. Destruction of Health Information. Do an Internet search to locate three vendors that destroy paper health records. Compare and contrast their services. Answers will vary based on student response. 4. Retention of Health Information. Research the retention requirements for your state include health records, radiology films, and other formats/records. Answers will vary by state. Review Quiz Instructions: Choose the most appropriate answer for the following questions. 1. Removing health records from the storage area to allow space for more current records is called: a. Purging records. b. Assembling records. c. Logging records. d. Cycling records. 2. Which type of microfilm does not allow for a unit record to be maintained? a. Roll microfilm b. Jacket microfilm c. Microfiche d. Micrographics 3. Which of the following is not true about document imaging? a. It allows random access for retrieval of documents. b. It can be viewed by more than one person at a time. c. It can be viewed from locations remote from the HIM department. d. It is a paperless system. 4. Which system records the location of health records removed from the filing system and documents the return of the health records? a. Chart deficiency system b. Chart tracking system c. Abstracting system d. None of the above 5. “Loose” reports are health record forms that: a. Are maintained separately from the health record. b. Are not part of the legal health record. c. Are received by the HIM department and added to the health record after it has been processed. d. Are misfiled. 6. In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the: a. Incomplete record file. b. Permanent file. c. Temporary file. d. Remote storage file. 7. In which of the following systems are all encounters or patient visits kept in one folder? a. Serial numbering system b. Unit numbering system c. Straight numerical filing system d. Middle-digit filing system 8. Which of the following is the key to the identification and location of a patient’s health record? a. Disease index b. Outguide c. Deficiency slip d. MPI 9. Which of the following numbering systems is best for maintaining the encounters of a patient together? a. Unit b. Serial-unit c. Serial d. Alphabetic 10. In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers? a. Unit b. Serial c. Terminal-digit d. Alphabetic 11. Which of the following is not usually a part of quantitative analysis review? a. Checking that all forms contain the patient’s name and health record number b. Checking that all forms and reports are present c. Checking that every word in the record is spelled correctly d. Checking that reports requiring authentication have signatures 12. Which of the following is not true of good forms design for paper forms? a. Every form should have a unique identification number. b. Every form should have a clear, concise title. c. Bright colors should be used to identify forms. d. Paper ranging from twenty to twenty-four pounds in weight should be used for forms that will be copied, faxed, or scanned. 13. Which of the following is not true of good forms design for electronic forms? a. Keystrokes should be minimized by using pop-up menus. b. Electronic forms should use completeness checks. c. Electronic forms should use radio buttons for multiple selections of items. d. Electronic forms should use text boxes to enter text. 14. Which of the following is a disadvantage of alphabetic filing? a. Easy to train new personnel to file b. Uneven expansion of file shelves or cabinets c. Ease of creation d. No reliance on an index or authority file 15. In healthcare organizations, what is the database that is used to locate the medical record number usually called? a. MPI b. Disease index c. Physician index d. Patient registry 16. Which of the following is a request from a clinical area to charge out a health record? a. Outguide folder b. Requisition c. MPI d. Patient registry 17. What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches? a. 42 inches b. 3,600 inches c. 252 inches d. 216 inches 18. A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review. a. Prospective b. Retrospective c. Concurrent d. Peer 19. A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record. a. Suspended b. Delinquent c. Pending d. Illegal 20. In which department/unit does the health record typically begin? a. HIM department b. Patient registration c. Nursing unit d. Billing department 21. When a hospital accredited by Joint Commission is considered to be in compliance with Medicare’s Conditions of Participation, this is called: a. Adjuvant accreditation b. Deemed status c. Conditional accreditation d. Dual accreditation 22. Which of the typical HIM functions assist in monitoring and compliance of the health care facility with Joint Commission standards? a. Release of information b. Record processing c. Transcription d. All of the above 23. A functionality of the electronic health record that allows patients access to their protected health information (for example, lab results) is: a. Access control b. Authentication c. Patient portal d. Record reconciliation 24. The future role of the HIM professional is expected to change due to: a. Advances in technology b. Implementation of new clinical coding system c. Evolution of the EHR d. All of the above 25. Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called: a. Elements of performance b. Fact sheets c. Ad hoc reports d. Registers Test Bank With Key Instructions: For each item, complete the statement correctly or choose the most appropriate answer. 1. The services provided by HIM departments in acute care hospitals usually include all the following except: a. medical transcription b. Medical billing c. Clinical coding d. Release of information 2. The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the: a. Patient registration department b. Patient care unit c. Billing department d. HIM department 3. As an HIM professional, you would be directly responsible for tracking the compliance with the Joint Commission’s standard for the: a. Physical plant safety report b. Averaged quarterly medical record delinquency rate. c. Allowable outstanding account receivables d. Medication errors 4. Which of the following tasks would the HIM department not perform in an electronic health record system? a. Document imaging b. Analysis c. Assembly d. Indexing 5. The master patient index: a. Is the most important index maintained by the HIM department: b. Contains basic demographic information about the patient: c. Is commonly part of the admission, discharge, and transfer computer system: d. All of the above 6. Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 36-45-99 37-45-99 38-45-99 a. Straight numerical b. Terminal digit c. Middle digit d. Unit 7. The annual volume statistics for New Town Hospital are noted below. How many shelving units will be required to store this year’s inpatient discharge records? Average inpatient discharges = 12,000 Average inpatient record thickness = ¾ inch Shelving units shelf width = 36 inches Number of shelves per unit = 6 a. 41 b. 41.67 c. 42 d. 74 8. Reviewing the health record for missing signatures, missing medical reports and ensuring that all documents belong in the health record is an example of ___ review. a. Quantitative b. Qualitative c. Statistical d. Outcomes 9. The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is ____ review. a. Proactive b. Prospective c. Concurrent d. Retrospective 10. The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principals b. Database development c. Federal and state confidentiality laws d. Human resource management 11. In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility? a. Alphabetic filing system b. Serial numbering system c. Terminal digit filing system d. Unit numbering system 12. In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters? a. Alphabetic filing system b. Serial numbering system c. Unit numbering system d. None of the above 13. A record not completed within the time frame specified in the medical staff rules and regulations is called a: a. Suspended record b. Completed record c. Delinquent record d. Purged record 14. Which of the following should be taken into consideration when designing a health record form? a. Assigning a unique identifying number to the form b. Using a concise title that identifies the form’s purpose c. Including original and revised dates for tracking purposes d. All of the above 15. Which of the following statements describes alphabetical filing? a. File the record alphabetically by first name, followed by the middle initial, and then the last name. b. File the record alphabetically by the last name, followed by the first name, and then the middle initial. c. File the record alphabetically by the last name, followed by the middle initial and then the first name. d. File the record alphabetically by last name only. 16. Which of the following lists of names is in correct order for alphabetical filing? a. Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas b. Carl J. Smith Mary A. Smith Thomas Smith Paul M. Smith c. Smith, A. Mary Smith, J. Carl Smith, M. Paul Smith, Thomas d. Smith, Thomas Smith, Carl J. Smith, Mary A. Smith Paul M. 17. Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long roll? a. Document scanning system b. Microfilm roll c. Microfilm jacket d. Microfiche 18. Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations? a. Deficiency slips b. Master patient indexes c. Outguides d. Requisition slips 19. Which of the following filing methods is considered the most efficient? a. Alphabetical filing b. Alphanumeric filing c. Straight numeric filing d. Terminal digit filing 20. Which of the following indexes is considered to be the authoritative key to locating a health record? a. Disease index b. Master patient index c. Operation index d. Physician index 21. Healthcare organizations are considered to be in compliance with the Medicare Conditions of Participation. This is called: a. Joint accreditation b. Deemed status c. Condition of accreditation d. Compliance status 22. A statement or guideline that directs decision making or behavior is called a: a. Directive b. Procedure c. Policy d. Process 23. If the vice president of marketing requested information regarding the number of cardiac catheterizations performed in 2010, what index would you consult? a. Master patient index b. Physician index c. Disease index d. Operations/procedures index 24. What committee oversees the development and approval of new forms for the health record? a. Quality review committee b. Medical staff committee c. Executive committee d. Forms committee 25. Which entity(ies) have established documentation standards? a. Medicare b. Joint Commission c. American Osteopathic Association d. All of the above 26. What is the term used to describe the process of checking individual data elements, reports, or files against each other to resolve discrepancies in accuracy of data and information? a. Repudiation b. Reconciliation c. Legal health record d. Analysis 27. Critique this statement: Version control is not an issue in the EHR. a. This is a true statement. b. There are issues related to versions of documents such as there must be a flag indicating a previous version. c. There are issues related to versions of documents such as each version should be visible to all users. d. There are issues related to versions of documents which includes the need to delete the old version when a new one is added. 28. Dr. Smith wants to use a lot of free text in his EHR. What should be your response? a. Good idea Dr. Smith. This allows you to customize the documentation for each patient. b. Dr. Smith, we recommend that you do not use any free text in the EHR. c. Dr. Smith, we recommend that you should use only a little free text in the EHR. d. Dr. Smith, we recommend that you use little, if any, free text in the EHR. 29. I am arguing against the use of the copy/paste function in the EHR. Which of the following would be my argument? a. I am unable to identify the author. b. I am unable to print the data out. c. I am concerned about the time that it takes to copy/paste the documentation. d. I am concerned that the users will not know how to perform the copy/paste function. 30. An HIM student has asked you, the HIM director, why the hybrid record is so challenging. What is your response? a. It is because we are focusing on the EHR. b. It is because we have to maintain all of the traditional HIM functions. c. It is because HIM professions do not have the skills to manage the EHR. d. It is because we have to manage both the electronic media as well as the paper. Sample health record number label page. See Numeric Filing project. TERMINAL DIGIT 20-18-13 20-08-13 21-59-42 23-42-83 26-42-06 28-59-85 29-57-51 29-57-53 29-57-55 29-57-67 20-40-99 29-57-89 29-59-66 29-95-91 30-59-70 33-55-05 33-55-26 23-42-34 34-42-92 38-32-02 43-42-00 46-85-92 50-42-99 50-59-81 52-43-01 53-59-45 57-97-29 01-59-40 02-23-02 02-42-76 MIDDLE DIGIT 02-59-55 03-55-17 03-80-30 03-80-31 74-85-03 04-85-77 06-85-84 07-43-06 10-85-87 12-42-17 12-59-46 13-71-20 14-66-20 14-19-20 14-72-20 14-82-20 15-55-24 16-43-03 16-59-95 16-85-90 64-55-00 64-59-44 65-43-21 65-65-65 70-41-00 78-55-14 82-55-22 88-42-11 94-57-29 99-42-27 Terminal Digit Order Answer Key 70-41-00 43-42-00 64-55-00 52-43-01 02-23-02 38-32-02 16-43-03 74-85-03 33-55-05 26-42-06 07-43-06 88-42-11 20-08-13 20-18-13 78-55-14 12-42-17 03-55-17 14-19-20 14-66-20 13-71-20 14-72-20 14-82-20 65-43-21 82-55-22 15-55-24 33-55-26 99-42-27 94-57-29 57-97-29 03-80-30 03-80-31 23-42-34 01-59-40 21-59-42 64-59-44 53-59-45 12-59-46 29-57-51 29-57-53 29-57-55 02-59-55 65-65-65 29-59-66 29-57-67 30-59-70 02-42-76 04-85-77 50-59-81 23-42-83 06-85-84 28-59-85 10-85-87 29-57-89 16-85-90 29-95-91 34-42-92 46-85-92 16-59-95 20-40-99 50-42-99 Middle Digit Order Answer Key 20-08-13 20-18-13 14-19-20 02-23-02 38-32-02 20-40-99 70-41-00 02-42-76 12-42-17 23-42-34 23-42-83 26-42-06 34-42-92 43-42-00 50-42-99 88-42-11 99-42-27 07-43-06 16-43-03 52-43-01 65-43-21 03-55-17 15-55-24 33-55-05 33-55-26 64-55-00 78-55-14 82-55-22 29-57-51 29-57-53 29-57-55 29-57-67 29-57-89 94-57-29 01-59-40 02-59-55 12-59-46 16-59-95 21-59-42 28-59-85 29-59-66 30-59-70 50-59-81 53-59-45 64-59-44 65-65-65 14-66-20 13-71-20 14-72-20 03-80-30 03-80-31 14-82-20 04-85-77 06-85-84 10-85-87 16-85-90 46-85-92 74-85-03 29-95-91 57-97-2

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