Are you on your way to becoming a registered health information technician? If you said yes, you are in luck as the quiz below is precisely what you need to refresh your memory on record keeping and what someone in your position is expected to do when it comes to access and details. How about you check it out and see how good you will do.
Organization of the Ameican Health Information Management Association
Establishment of the JCAHO's numerous accreditation programs
Opening of the first imcorporated hosipital, known as Pennsylvania Hospital
Creation of the american College of Surgeons' hospital standardization program
It is stored in the health information department and is used ony by Dr. Day
It is used by Dr. Day and her clinical staff because seh gave them permission to do so
Dr. Day signed a statement regarding its use; the statement is stored with the facility's administration
It is utilized only Dr. Day and the other physicians involved in her group practice
Arrangement according to the source of the information
Association of treatment and therapies with patient problems
Organization of reports in strict chronological date order
Standarized forms as recommended by the JCAHO
Health information management department
Acute care facility's medical staff
Health care facility's governing body
Hospital's administrative offices
Diagnostic index that contains ICD-9-CM codes on Sally Smith
Utilization review committee minutes concerning patient Sally Smith
Sally Smith's emergency department record dated January 1
Emergency department log containing a January 1 entry for Sally Smith
Information from Sally Smith's record included in a hospital statistical report
JCAHO survey of 100 records, including that of Sally Smith
Quality assurance study that contains information from Sally Smith
Malpractice case brought to trial that includes Sally Smith's record as evidence
Drawing a single line through the error
Obliterating the incorrect document
Documenting the reason for the error
Obtaining the supervisor's co-signature
Patient's hospitalization is under 48 hours' duration with minor problems
Circumcised newborn who develops an infection is discharged within 48 hours
Obstetrical patient delivers a healthy female newborn via cesarean section
Expected death of a terminal patient occurs within 48 hours of admission
Analysis after health providers have worked on records, but prior to permanent filing
The assembly of the health record upon receipt from the facility's nursing units
Authentication of incomplete health records after initial analysis has been done
Computerized abstracting of health records after the provider has completed them
At the conclusion of the administration of each radiation therapy session
On a weekly basis, summarizing several radiation therapies administered
By the practitioiner administering the radiation therapy, at least monthly
At the end of the therapeutic radiation threatment for the particular patient
Immediatley upon conclusion of the surgery
Within 24 hours after they surgery is performed
Within 48 hours after the surgery is performed
And authenticated by the patient's surgeon
It requires the attending physician to consider all of the patient's problems
It is easily accepted by physicians, nurses, and allied health professionals
It clearly indicates the goals and methods of the physician in treating the patient
It allows physicians and others to follow the course of any one problem more easily
For 25 years
For 10 years
For 5 years
Permanently
S. Peter Jones
Steven Peter Jones
Stephen Peter Jones
S. Jones
Social security
Family
Unit
Serial-unit
Terminal digit filing
Serial-unit numbering
Unit numbering
Straight numeric filing
Requisition slip
Master patient index
Number index
File shelving
00-00-52, 01-00-52, 02-00-52, 03-00-52
00-00-52, 00-00-53, 00-00-54, 00-00-55
00-00-52, 01-00-53, 02-00-54, 03-00-55
00-01-52, 00-02-53, 00-03-54, 00-04-55
Statute of limitations for the state in which health records are generated
Amount of space available for efficient storage of newer health records
Number of filing personnel available to effectively retrieve or refile records
Equipment used to store records in the health information department
00-00-00, 00-05-00, 00-10-00, 00-15-00
00-00-00, 00-50-00, 01-00-00, 01-50-00
00-00-00, 00-00-05, 00-00-10, 00-00-15
00-00-00, 00-00-50, 00-01-00, 00-01-50
Database, problem list, initial plans, progress notes
Problem list, SOAP notes, nursing notes, graphic sheets
History and physical, problem list, SOAP notes, resume
Initial plans, problem list, SOAP notes, nursing notes
Facility's admitting department
Attendig physician's office
Hospital nursing station
Preadmission testing department
Review of systems
Differential diagnosis
Blood pressure and pulse
The patient's appearance
Provisional diagnosis
Principal diagnosis
Primary diagnosis
Chief diagnosis
Misnumbering of health records
Misfiling of health record folders
Misinterpretation of record content
Misplacement of forms in the record
JCAHO, state licensing regulations, Conditions of Participation
State health department rules, Conditions of Participation, JCAHO
Conditions of Participation, JCAHO, Memo of Understanding
State licensing regulations, JCAHO, Memo of Understanding
Are to be documented at least one daily for each patient in the acute care facility
May or may not contain an admission note focumented by the attending physician
Include a discharge note that is documented at the conclusion of the patient's stay
Should consist of information documented in the history of physical examination
Required authentication of all entries
Use of abbreviations on the face sheet
Potentially compensable events
Consistency in documentation of provider entries
Filed with the mother's record only if the infant was a premature newborn
Separate from the mother's record and contains a few routine forms and reports
Filed with the mother's record if the infant is normal (i.e., healthy newborn)
Separate from them other's record if she experienced no delivery complications
A copy is filled in the patient's health record with the original forwarded to administration
Reference ismade in the health record that an incident report was generated
Documentation of the fall and treatment rendered is recorded inthe patient's health record
The risk manager meets with the patient to discuss this potentially compensable event
Terminial digit
Middle digit
Stright numeric
Serial numeric
Ease in training of employees who file
Increase in health record confidentiality
Ability to monitor file clerk filing activities
Reduction in misfiles of health records
50-63-24
75-63-24
75-61-23
45-52-24
Master patientindex
Computer abstracts
Patient register
Number control log
Aperture cards
Roll film
Microfiche
Microfilm jackets
70%
80%
90%
100%
Coding diagnoses
Medical transcription
Quantitative analysis
Health record tracking
Permanently
For 25 years
For 15 years
For 10 years
Family
Nurse
Patient
Physician
Patient billing/collections
Environmental services
Biomedical maintenance
Clinical laboratory/pathology
Occasional headache
Palpable axillary node
History of cholecystectomy
Pain in right upper quadrant
Spacing needed for typing
Purpose and need for it
Number of copies included
Information to be documented
Review of systems
Present illness
General survey
Chief complaint
Rebound tenderness
Rales and rhonchi
Thrist and dizziness
Negative Romberg sign
Must be authenticated by the physician after being filed in the chart
Can be excluded from the record if they are posted in the nursing unit
May be presigned by the physician prior to dupicating the orders
Need to be signed only if the attending physician alters the orders
Survey of diagnostic and procedural indexes
Review of discharge lists for the past six months
Analysis of health records for deficiencies
Breakdown of records according to entry omissions
Upon the patient's first visit to the emergency department
Each time the patient is seen in the emergency department
When the patient is diagnosed with a different condition
If the patient has changed his or her primary physician
Obtaining a patient database
Documenting the problem list
Recording SOAP progress notes
Writing initial plans for the patient
Patient's progress that has been demonstrated in response to treatment
Diagnostic, therapeutic, and educational plans that are being developed
Documentation of a particular problem in the patient's progress note
Physical assessment conducted on the patient and documented
Serial
Unit
Serial-unit
Terminal digit
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