1928
Health information management (HIM) has been recognized as an allied health profession since _____.
1928
American Health Information Management
The Association of Record Librarians of North American (ARLNA) was formed in _____. The name has changed many times and is now called the ________________.
to ensure the quality, confidentiality, and availability of health information across diverse organizations, settings, and disciplines.
The underlying purpose of AHIMA is ____________.
Attending Physician
Before 1918, the creation and management of hospital medical records were the sole responsibility of the ___________.
hospital standardization movement
In 1918, the _____________ was inaugurated by the American College of Surgeons (ACS).
Hospital Standardization Program
The purpose of the ____________ was to raise the standards of surgery by establishing minimum quality standards for hospitals.
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
The formal accrediting board for AHIMA is ______________.
Commission on Certification for Health Informatics and Information Management (CCHIIM)
The certifying board for the AHIMA accreditation program is AHIMA's _______________.
education, certification, and lifelong learning
The primary focus of AHIMA is to foster professional development of its members through __________.
Code of Ethics
The _____________ stipulates, that all members of AHIMA are expected to act in an ethical manner and comply with all laws, regulations, and standards governing the practice of health information management.
delegates
AHIMA's members elect the _____________ who serve in the governing bodies of the organization.
Board of Directors
3
AHIMA's _____________ leads the volunteer structure. It manages the property, affairs, and operations of AHIMA. Members of Board serve ____ year terms of office.
Communities of Practice (CoP)
The _____________ make up a virtual network of AHIMA members who communicate via a web-based program by AHIMA.
president
AHIMA's __________ appoints the members of the association's national committees, practice council's, and work-groups.
House of Delegates
The _______________ conducts the official business of the organization and functions as AHIMA's legislative body.
state HIM association
Each ____________ elects representatives to the House of Delegates to serve for a specified term of office.
House of Delegates
The _____________ approves the AHIMA Code of Ethics.
Component State Associations (CSAs)
_________________ provide their members with local access to professional education, networking, and representation. They also communicate relevant national issues and keep members informed of regional affairs that affect HIM.
Chicago
AHIMA's headquarters are located in ___________.
executive director
The ___________ is the individual responsible for overseeing day-to-day operations.
CAHIIM
The ___________ accredits the educational programs in health informatics and information management.
CCHIIM
___________ establishes, implements, and enforces standards and procedures for certification and re-certification of HIM professionals. They provide strategic oversight of all AHIMA certification programs.
AHIMA Foundation
The _________ actively promotes education and research in the HIM field.
individual patient of consumer
The PHR is owned by the ________________.
1. Patient care delivery
2. Patient care management
3. Patient care support processes
4. Financial and other administrative processes
5. Patient self-management
Primary purposes of the health record:
patient care providers
The primary users of health records are ______________.
Individual
________ users depend on the information in health records to perform their job.
1. Patient care delivery personnel (doctors, nurses, therapists, social workers)
2. Patient care delivery consumers (patient and family)
3. Patient care management and support (administrators, quality managers, utilization review managers)
4. Patient care
Examples of individual users of the health record that are directly involved with patient care:
1. Employers
2. Lawyers
3. Law enforcement officials
Other individual users may use the health record as a source of information provided they can demonstrate appropriate authorization granting access.
Examples of other individual users of the health record include:
insitutional
Other organizations, or __________ users, depend on access to healthcare-related information.
1. Healthcare delivery organizations
2. Management and review of care
3. Research organizations
4. Government licensing agencies
5. Policy-making bodies
Examples of institutional users of health record information include:
Centers for Medicare and Medicaid Services (CMS)
The ______________ is a division of the US Department of Health and Human Services.
CMS
________ is responsible for administering the federal Medicare program and the federal portion of the Medicaid program.
Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness.
The 10 quality characteristics in AHIMA's data quality model include:
Data Accuracy
___________ means that the data is correct.
Data Accessibility
___________ means that the data is easily obtainable.
Data Comprehensiveness
___________ means that all the required data elements are included in the health record; in other words, that the health record is complete.
Data Consistency
____________ means that the data are reliable.
Data Currency
___________ means that healthcare data should be up-to-date.
Data Timeliness
____________ refers to data being recorded at or near the time of the event or observation.
Data Definition
__________ means that the data and information documented in the health record are defined.
Data Granularity
_____________ requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data.
Data Precision
___________ describes expected data value.
Data Relevancy
__________ means that the data in the health record is useful.
Privacy
_______ is the rights of individuals to control access to their personal health information.
Confidentiality
_____________ refers to the expectation that the personal information shared by an individual within a healthcare provider during the course of care will be used only for its intended purposes.
Security
________ is the protection of the privacy of individuals and the confidentiality of health records.
Interoperability
____________ standards permit the electronic exchange of patient information within a region or across the nation.
Health record format
____________ refers to the organization of electronic information or paper forms within the individual health record.
Source-oriented
_____________ health record format organized the information according to the patient care department.
Problem-oriented
__________ health record format is a documentation approach in which the physician defines each clinical problem individually and all documentation related to that clinical problem is stored together.
Integrated
__________ health record format organizes all the paper forms in strict chronological order and mixes the forms created by different departments.
hybrid
A health record that is part paper and part electronic is called a ____________ record.
Computerized provider order entry (CPOE)
provides physicians and other providers the ability to place orders via the computer from any number of locations and add decision support capability to enhance patient safety.
documentation of patient care
One primary purpose of the health record is ______________.
electronic health record
The _____________________ refers to a health record available electronically, allowing communication across providers and permitting real-time decision making.
hybrid
When a facility is transitioning from paper to electronic systems and uses components of both electronic and paper medical records, the record is referred to as a ______ record.
clinical and administrative
The health record contains two type of data:
Clinical
________ data document the patient's medical condition, diagnosis, procedures performed as well as the healthcare treatment provided.
Adminstrative
__________ include the graphic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information.
Standards
________________ are statements of expected behavior or reference points against which structures, staff bylaws, rules, and regulations.
Facility-specific
_____________ standards - might be found in facility policies and procedures or medical staff bylaws, rules, and regulations.
Licensure
__________ requirements- before services can be provided, government entities must have meet these.
Certification
Conditions of Participation of Conditions for Coverage
_________ standards- must meet these if they are receiving government reimbursement. These standards are titled ________________.
Accreditation
__________ standards- the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization.
Centers for Medicare and Medicaid Services (CMS)
The Medicare Conditions of Participation are administered by _____________.
deemed
Medicare recognizes some organizations, such as the Joint Commission, as having standards sufficiently covering the related Conditions of Participation. They award them ________ status.
The Joint Commission (TJC)
___________ accredits hospitals (acute, critical access, children's psychiatric, and rehabilitation), ambulatory care organizations, behavioral health organizations, home care including hospital providers, long-term care facilities, clinical laboratories,
American Osteopathic Association (AOA)
________________ first initiated its hospital accreditation to ensure the quality of residency programs for doctors of osteopathy.
Accreditation Association for Ambulatory Care (AAAHC)
____________ has established ambulatory care core standards for all organizations and adjunct standards that only pertain to specific types of services.
Commission on Accreditation of Rehabilitation Facilities (CARF)
______________ accredits rehabilitation programs and services in medical rehabilitation.
National Committee for Quality Assurance (NCQA)
_____________ accredits managed care organizations.
Det Norske Veritas (DNV)
An international accrediting organization that began a hospital accreditation program in the US is ____________. It incorporates international quality management standards and the Medicare Conditions of Participation.
medical history
A complete ___________ documents the patient's current complaints and symptoms and lists his or her past medical, personal, and family history.
physical examination report
The ___________ represents the attending physician's assessment of the patient's current health status after evaluating that patient's condition.
Physican's orders
____________ are the instructions the physician gives to the other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient.
Standing orders
_________ are orders the medical staff or an individual physician have established as routine care for a specific diagnosis or procedure.
verbal
telephone
Physicians may communicate orders ______ or via ____________ when the hospital's medical staff rules allow.
State law
Medical staff rules
_________ and ________ specify which practitioners are allowed to accept and execute verbal and telephone orders.
progress notes
The documentation of clinical observations is included in ____________.
assessment
Many of the nursing staff and allied health professionals' work begins with an ____________ focusing on understanding the patient's condition from the perspective of their specialized body of knowledge.
care plan
A _____________ is a summary of the patient's problems from the nurse or other professional;s perspective with a detailed plan for interventions.
Preoperative
____________ notes are made by the anesthesiologist and surgeon prior to an operative procedure.
consent
The patient must ________ to a procedure after an explanation and an opportunity to ask questions.
Battery
__________ is the unlawful touching of a person without his or her implied or expressed consent.
Implied
__________ consent is assumed when a patient voluntarily submits to treatment.
Expressed
__________ consent is a consent that is either spoken or written.
anesthesia
The __________ report notes any preoperative medications and response to it, the anesthesia administered with dose and method of administration, the patient's vital signs while under anesthesia, and any additional products give to the patient during the p
operative
The __________ report describes the surgical procedures performed on the patient.
recovery room
The ____________ report includes the post-anesthesia note, nurses' notes regarding the patient's condition and surgical site, vital sign, intravenous fluids, and other medical monitoring.
pathology
A _____________ report describes any tissue removed during surgery.
consultation
The _____________ report documents the clinical opinion of a physician other than the primary or attending physician.
discharge summary
The __________ is a concise account of the patient's illness, course of treatment, response to treatment, and conditions at the time of patient discharge for the hospital.
attending physician
The discharge summary if the responsibility of, and must by signed by, the _________.
autopsy
An ________ report is a description of the examination of patient's body after he/she has died.
separate
physician's
A mother's obstetric record is ____________ from the infant's record and actually begins in the _______ office.
mother's
In case of a baby born deceased, all information about the baby and the mother is maintained in the ________ health record.
delivery
The _______ record includes type of delivery; medications administered, including anesthesia; description of the birth process, and any blood loss; evaluation of the placenta and cord; and information about any delivery interventions.
baby
Data about the ______ also will be included in the mother's record, including sex, weight, length, Apgar scores, any abnormal findings, and any treatments given.
Demographics
____________ is the study of the statistical characteristics of human populations.
financial
The _________ information maintained in the acute health record is limited to third party payment information collected from the patient at the time of admission, such as the insurance payer and policy holder information.
consent to treatment
The type of consent that documents the patient's permission for routine services, diagnostic procedures, and medical care is called _____________.
Authorization
_____________ is permission granted by the patient or patient's representative to release information for reasons other than treatment, payment, or healthcare operations.
advance directive
An _______________ is a written document that provides directions about a patient's desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not capable of communicating.
patient's bill of rights
The ____________ includes information such as knowing who is providing treatment, confidentiality, receiving information about treatment, refusing treatment, participating in care planning, and being safe from abusive treatment.
Emergency Care
_____________ documentation includes information about the patient's presenting problem and the diagnostic and therapeutic services provided during the emergency department visit.
Ambulatory Care
____________ includes care provided in physicians' offices, group practices, and clinics, as well as hospital outpatient, neighborhood health, public health, industrial health, and urgent care settings.
problem list
Ambulatory care records contains a __________ which functions to facilitate ongoing patient care management. This describes any significant current and past illnesses and conditions as well as the procedures the patient has undergone.
ambulatory surgery
Medicare requires that _________ include the following: Registration forms, documentation of the patient's informed consent to surgical treatment, significant medical history and physical examination, preoperative studies, operative report, pathology repo
federal
state
The regulations that govern long-term care facilities vary. Most SNFs and NFs are governed by both _______ and _______, including Medicare Conditions of Participation.
Source-oriented
___________ records are grouped together according to their point of origin.
Problem-oriented
A ____________ health record contains a problem list as well as a patient database, an initial care plan, and progress notes.
Subjective, Objective, Assessment, and Plan
A SOAP format for a progress note includes:
Subjective
___________ relates significant information in the patient's words or from the patient's point of view.
Objective
________ includes factual information such as laboratory findings or provider observations.
Assessment
_________ includes professional conclusions.
Plan
_________ any comments or changes in plans.
integrated
The __________ health record is arranged so that the documentation from various sources is intermingled and follows strict chronological (date) order.
Electronic medical record (EMR)
_____________ is an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health record.
Electronic health record (EHR)
________ is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healt
personal health record (PHR)
The _________ is unique in that it is maintained and controlled by each individual and is a compilation of information obtained from healthcare providers as well as through personal discovery.
data sets
Lists of recommended data elements with uniform definitions are called __________.
the Uniform Hospital Discharge Data Set (UHDDS)
The purpose of ______________ is to list and define a set of common, uniform data elements for all health records in an inpatient setting.
Uniform Ambulatory Care Data Set (UACDS)
The goal of the ____________ is to improve data comparison in ambulatory and outpatient care settings.
Minimum Data Set (MDS)
The _________ is the data set used in long term care.
Outcomes and Assessment Information Set (OASIS)
The ___________ is a standardized data set designed to gather and report data about Medicare beneficiaries who are receiving services from a Medicare-certified home health agency.
Healthcare Effectiveness Data and Information Set (HEDIS)
The ___________ is a set of standard performance measures designed to provide healthcare purchases and consumers with the information they need to compare the performance of managed healthcare plans.
National Committee for Quality Assurance (NCQA)
HEDIS is sponsored by ____________.
Data Elements for Emergency Department Systems (DEEDS)
The purpose of ____________ is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.
ORYX
The Joint Commission introduced the _____ initiative to integrate outcomes data and other performance measurement data into its accreditation process.
1. Quality
2. Security
3. Availability
HIM functions are information-centered. This means that they typically involve ensuring information:
MPI
The ____ is the permanent record of every patient ever seen in the healthcare entity. It functions as the primary guide to locating pertinent demographic data about the patient and his/her health record number.
registration
The most common MPI errors occur at the point of ________ when existing MPI information is not located.
duplicate medical record number
A ____________ is assigned when a new patient medical record number is assigned to an individual that has an existing medical record number in the same facility.
overlay
An _______ is when a patient is assigned another patient's medical record number.
overlap
An _______ is when more than one medical record number exists for the same patient within an enterprise at different facilities or in different databases.
1. Deterministic
2. Probabilistic
3. Rules-based
The three types of matching algorithms to identify potential duplicate health record numbers are:
Deterministic
_______ - requires an exact match of combined data elements such as name, birth date, sex, and Social Security number.
Probabilistic
________- based on complex mathematical formulas that analyze facility-specific MPI data to determine precisely matched weight probabilities from attribute values of various data elements.
Rule-based
__________- assigns weights, for significant values, to particular data elements and later uses these weights in comparison of one record to another.
health information exchange (HIE)
A _____________ is frequently used to describe both the sharing of health information electronically among two or more entities and also an organization that provides services to accomplish this information exchange.
medical record number
The health record number is also called the __________. It is a key data element in the MPI because it is the unique personal identifier.
Serial numbering system
_________- a patient receives a unique numerical identifier for each encounter or admission to a healthcare facility.
Unit numbering system
__________- the patient receives a unique health record number at the time of the first encounter.
Serial-unit numbering system
___________ - numbers are assigned in a serial manner, but during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number.
patient registration
The health record number is typically assigned by _________.
1. Alphabetic filing systems
2. Straight numeric filing systems
3. Terminal- digit filing systems
4. Middle-digit filing system
5. Alphanumeric filing system
There are different types of filing systems with paper-based health record:
Alphabetic filing system
___________- records are arranged in alphabetic order.
Straight numeric filing system
__________- records are arranged consecutively in ascending numeric order.
Terminal-digit filing system
__________- the last digit or group of last digits is the primary unit used for filing.
Middle-digit filing system
_________- the primary unit is the middle unit; the secondary unit is the first unit to the left, followed by the last digit.
Alphanumeric filing system
_________- uses a combination of alpha letters and numbers for identification purposes, typically the first two letters of the patient's last name followed by a unique numeric identifier.
purged records
In a paper-based system, ________ are often microfilmed, sent to an off-site storage facility, or scanned.
document imaging system
A __________ scans and indexes an original source document to create a digital picture that can be retrieved via the computer.
requisition
A _________ is a request from a clinical or other area in the organization to check out a specific health record.
Retention
___________ policies and procedures relate to what information must be retained, for how long, and in what form.
Destruction
__________ policies and procedures relate to what information may be destroyed, appropriate destruction methods, and required documentation of destruction.
magnetic degaussing
The preferred method for destroying electronic data is _______.
Record processing
__________ refers to the procedures performed that support the maintenance of each individual patient record in an organized and standard manner.
record reconciliation
When the health records received by the HIM department are compared to a discharge list to make sure they are ready to be processed is called ___________.
assembly (or chart assembly)
In a paper-based system, __________ means that each page in the patient record is organized in a pre-established order.
quantitative analysis
The review of the record for deficiencies, such as missing reports, forms, or required signatures, is referred to as ____________.
Concurrent review
__________ means performing quantitative analysis or record content review periodically during the patient's stay in the hospital.
Retrospective review
__________ is performing quantitative analysis after the patient has left the facility.
deficiency slip
In a paper-based environment, a _______ indicates what reports are missing or require authentication.
delinquent record
When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a ________.
15
30
Generally, an incomplete record is considered delinquent after it has been available to the physician for completion for ___ to ____ days.
corrections
In a paper-based record environment, ________ to health record entries are corrected by drawing a single line through the original entry, writing "error" above the entry, and then the practitioner signs, dates, and times the correction.
addendum
An _________ is a supplement to a signed report that provides additional health information within the health record. It should be documented with the current date and time; writing "addendum" and stating the reason for the addendum, referring back to the
amendment
An ________ is a clarification made to the health information after the original document has been final signed by the procedure. It must be dated, timed, signed, and attached to the original document that is amending.
Access control
__________ is the process that determines who is authorized to access patient information in the health record. It involves determining which individuals or groups should be granted access, what portions of the health record should be available, and what
1. State and federal regulations
2. Statues of limitation
3. Research and educational needs
4. Patient care needs
Record retention in hybrid and electronic record environments is similar to a paper-based environment. Considerations for record retention include:
Retraction
__________ involves removing a document from standard view, removing it from one record, and posting it to another within the electronic document management system. An annotation should be viewable to the clinical staff so that the retracted document can
Resequencing
________ involves moving a document from one place to another within the same episode of care. No annotation of this action is necessary.
Reassignment
___________ (synonymous with misfiles) involves moving the document from one episode of care to a different episode of care within the same patient record. An annotation should be viewable to the clinical staff so that the reassigned document can be consu
Nonrepudiation
________ means to accept. It limits the EHR's user's ability to deny the origination, receipt, or authorization of a data exchange by that user. An example is the use of electronic signatures to assure the authorship of a record entry in which rules built
version control
Healthcare facilities need to have a policy and procedure for _________ starting which versions of the document will be viewable within the health record.
Free-text data
________ is the unstructured narrative data that is the result of a person typing data in a word-processing system. The nature of the data is undefined, unlimited, and unstructured.
voice recognition technology
A method of captured dictated reports in the EHR is through the use of ____________. With this technology, computer software captures the dictation and converts the dictation to text.
patient portal
The _________ is a functionality of the electronic health record that allows patients to access information from protected health information.
Identification, Authentication, Authorization
The three elements of access control in an EHR include:
Indentification
________- the basic building block of access control. It is typically performed through the user name of
Authentication-
________- the act of verifying a claim of identity, or verifying that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information. The most common method is the use of user names and p
Authorization-
____________- the right or permission given to an individual to use a computer resource or to use specific applications and access specific data. It is the permissions given to an individual to perform specific functions such as view, write, edit, delete,
front-end speech recognition
A speech recognition where the doctor watches speech come across the screen and makes the corrections is called _____________.
legal health record
The __________ refers to the health record that is maintained as the business record and is the health record that may be disclosed to authorized users and for evidentiary purposes.
back-end speech recognition
A speech recognition where the transcription listens and reviews on the screen the dictations that has been done and becomes as editor of the document is called ___________.
legal health record
The _______ refers to the health record that is maintained as the business record and is the health record that may be disclosed to authorized users and for evidentiary purposes.
Autonomy
_______ would require the HIM professional to ensure that the patient, and not a spouse or third party, makes the decisions regarding access to his or her health information.
Beneficence
__________ would require the HIM professional to ensure that the information is released only to individuals who need it to do something that will benefit the patient (to an insurance company for payment of a claim).
Nonmaleficence
_______ would require that HIM professional to ensure that the information is not released to someone who does not have authorization to access it and who might harm the patient if access were permitted (a newspaper seeking information about a famous pers
Justice
__________ would require the HIM professional to apply the rules fairly and consistently for all and not to make special exceptions based on personal or organizational perspectives (releasing information more quickly to a favorite physician's office).
Ethics
_________ provides a language and a framework for formally discussing ethical issues.
Privacy
________- the right of an individual to be let alone.
Confidentiality
_________- carries the responsibility for limiting disclosure of private matters.
Security
_____- invloves physical and electronic protections of the integrity, availability, and availability of computer-based information and the resources used to enter, store, process, and communicate it.
Code of Ethics
The AHIMA _______ sets forth values and principles to guide conduct.
Medical identify theft
______________ occurs when someone uses a person's name and sometimes other parts of their identity, without the victim's knowledge or consent, to obtained medical services or goods, or when someone uses the person's identity to obtain money by falsifying
blanket authorization
A ________ is when a patient authorizes the release of information from that point forward, without understanding the implications.
Terminal digit
_____- look at the right portion first. Then look at the middle section. Then look at the section.
Middle digit
______- look at the middle portion first. The look at the left section. Then look at the right section.
Straight number
_________- look at your numbers from left to right.