Health Information Management Quiz! Trivia

In clinical care documentation, any incident not documented means that the care was not given. This is because documentation is an essential part of ensuring that all care provided to a patient is accurately recorded and can be reviewed by healthcare professionals. If an incident or care is not documented, it creates a gap in the patient's medical record, which can lead to confusion, errors, and potential harm to the patient. Therefore, it is crucial for healthcare providers to document all care provided to ensure continuity and quality of care.

A Health Information Manager is responsible for determining appropriate access to and release of information from patient health records. They are trained in the laws and regulations related to patient privacy and confidentiality, ensuring that only authorized individuals have access to the records and that the information is released in accordance with legal requirements. Doctors, administrators, and case managers may have access to patient health records for specific purposes, but the final decision regarding access and release is the responsibility of the Health Information Manager.

Electronic Protected Health Information (ePHI) refers to any health information that is created, received, stored, or transmitted electronically by a healthcare organization. This includes various mediums such as electronic health records, emails, databases, and other electronic systems used to store, transmit, or receive PHI. Therefore, the correct answer is "All of the above," as it encompasses all the options listed - storing, transmitting, and receiving ePHI electronically.

ADR stands for Adverse Drug Reaction. This term refers to any harmful or unintended reaction that occurs after the administration of a drug. These reactions can range from mild side effects to severe allergic reactions or even life-threatening conditions. Adverse drug reactions can occur due to various factors such as individual patient characteristics, drug interactions, dosage errors, or underlying medical conditions. It is important for healthcare professionals to be aware of and monitor for ADRs to ensure patient safety and optimize treatment outcomes.

Digital signatures in Indian healthcare are valid. This means that electronic documents, such as medical records or prescriptions, that are signed using a digital signature are legally recognized and accepted in the Indian healthcare system. Digital signatures provide authentication and integrity to the documents, ensuring that they cannot be tampered with or forged. This allows for secure and efficient electronic communication and storage of healthcare information, improving patient care and reducing administrative burdens.

The correct answer is analyzing. Health Information Management (HIM) involves the process of acquiring, analyzing, and protecting digital and traditional medical information. Analyzing medical information is an important aspect of HIM as it helps in understanding and interpreting patient data, identifying patterns or trends, and deriving meaningful insights for decision-making and improving patient care.

HL 7 stands for Health Level 7. It is a set of international standards for the exchange, integration, sharing, and retrieval of electronic health information. Health Level 7 (HL7) is widely used in the healthcare industry to facilitate interoperability between different healthcare systems and ensure the seamless exchange of patient data.

Data mining is the correct answer because it refers to the process of extracting useful information or patterns from a large database. It involves analyzing and discovering hidden patterns, relationships, and trends within the data, which can then be used for various purposes such as decision making, prediction, and optimization. Data mining techniques include classification, clustering, regression, and association rule mining, among others. Therefore, data mining accurately describes the process of extracting information from a database.

The validity period of a signed consent is 30 days. This means that the consent remains valid for a period of 30 days after it has been signed. After this time, the consent may need to be renewed or obtained again in order to remain valid.

Patient care documents need to be scanned, assigned, and electronically stored in a system that is specifically designed for managing documents. A Document Management System (DMS) is a software solution that allows for the organization, storage, and retrieval of documents in a digital format. This system would be the most appropriate choice for managing patient care documents efficiently and securely.

The correct answer is "exchange". The International Health Terminology Standards Development Organization (IHTSDO) focuses on producing and enhancing the vocabulary used in health information. By emphasizing the term "exchange," it suggests that the organization's goal is to enable the seamless sharing and transfer of health information among different systems and entities. This promotes interoperability and ensures that health information can be effectively communicated and understood by all parties involved.

All verbal orders must be countersigned by a consultant within 24 hours. This means that any verbal orders given by someone must be approved and signed off by a consultant within a day. This is likely done to ensure that all decisions and actions are properly reviewed and authorized by a higher-level professional.

Based on the given answer, it is not acceptable to change demographics of the patient based on the evidence of Insurance policy cards/papers. This implies that the information provided in the insurance policy cards/papers should not be used as a basis for altering the patient's demographics. It is important to note that changing demographics should be done with proper authorization and approval, which is not mentioned as a requirement in this scenario.

When the bed occupancy rate is high, hospital authorities must review the Admission-Discharge-Transfer Protocol. This protocol outlines the procedures and guidelines for admitting, discharging, and transferring patients within the hospital. By reviewing this protocol, hospital authorities can ensure that patients are being admitted, discharged, or transferred in a timely and efficient manner, which can help alleviate the high bed occupancy rate. This review may involve analyzing the current protocol, identifying any bottlenecks or inefficiencies, and making necessary adjustments to improve patient flow and bed availability.

The Drug Controller General of India is responsible for the approval of licenses of specified categories of drugs in India. This regulatory body ensures the safety, efficacy, and quality of drugs available in the market. They regulate the import, manufacture, distribution, and sale of drugs in the country, ensuring that they meet the required standards and guidelines. The Drug Controller General of India plays a crucial role in safeguarding public health by ensuring that only safe and effective drugs are available to the public.

If the digitized health information is unable to exchange across hospitals, then the system is called an EMR (Electronic Medical Record). EMR systems are designed to store and manage patient health information within a single healthcare organization or facility. They are not designed to facilitate the exchange of information between different healthcare organizations. In contrast, EHR (Electronic Health Record) systems are designed to allow the sharing of patient information across different healthcare settings. HIS (Hospital Information System) and RIS (Radiology Information System) are other types of healthcare information systems that may or may not support interoperability between hospitals.

In the case of missing patients, the code that needs to be announced is "Code yellow." This code is commonly used in healthcare facilities to indicate that a patient is missing or has wandered off. By announcing "Code yellow," the staff can quickly mobilize and initiate a search for the missing patient to ensure their safety and well-being.

The determining factor to the official discharge time of an inpatient is the checkout time. This is the time when the patient completes all necessary paperwork, settles any outstanding bills, and officially leaves the hospital. The doctor instructed time may indicate when the doctor recommends the patient to be discharged, but the official discharge time is determined by the checkout process. The final bill payment time is related to the checkout time as it is typically done during the checkout process. Nurse clearance time may be important for ensuring that the patient is medically stable before discharge, but it does not determine the official discharge time.

Data preservation is a strategy used by health care organizations to ensure integration of functions. By preserving data, organizations can ensure that important information is stored and accessible for future use. This allows for seamless coordination and collaboration between different departments and functions within the organization, leading to improved efficiency and effectiveness in delivering health care services. Additionally, data preservation helps in maintaining data integrity and security, ensuring that sensitive patient information is protected and not lost or compromised.

The correct answer is 1968. The International Federation of Health Information Management Associations (IFHIMA) was established in 1968.

SNOMED CT is owned and distributed by the International Health Terminology Standards Development Organization (IHTSDO). This organization is responsible for the development and maintenance of SNOMED CT, which is a comprehensive clinical terminology used for the electronic exchange of health information. The IHTSDO ensures that SNOMED CT remains up to date and meets the evolving needs of the healthcare industry.

The correct answer is healthcare provider. Healthcare providers are responsible for storing and transmitting electronic health records. They are the ones who collect and maintain the health information of patients. This includes storing the records securely and ensuring their proper transmission when needed. The ownership of the medium of storage or transmission of electronic health records lies with the healthcare provider as they are the custodians of this information.

To ensure that a patient is operated on/at the right site, it is important to perform a time-out prior to surgery. This involves a final verification process where the surgical team pauses before starting the procedure to confirm the patient's identity, the correct surgical site, and any specific requirements or concerns. This step helps to prevent wrong-site surgeries and ensures that the surgery is performed on the intended site. Compliance to surgical safety checklist and preparing the correct site at ward are also important aspects of patient safety, but the specific action of performing a time-out prior to surgery is the most direct way to ensure the right site is operated on.

A medication error can be defined as a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. This includes errors in prescribing, dispensing, and documenting medications.

The correct answer is Civil Registration System. In Indian healthcare, CRS refers to the Civil Registration System. This system is responsible for recording vital events such as births, deaths, and marriages. It helps in maintaining accurate demographic data, which is crucial for planning and implementing healthcare policies and programs. The CRS ensures the registration and documentation of these events, which is essential for legal and administrative purposes in the healthcare sector.

The 11th revision of the International Classification of Diseases (ICD-11) is scheduled to be released in 2018. This update will provide the latest version of the internationally recognized system for classifying diseases and health conditions. The ICD-11 will include new codes and categories to reflect advances in medical knowledge and technology, ensuring that healthcare professionals have an up-to-date tool for accurately documenting and reporting diseases and health conditions.

A patient restraint order is typically written when a healthcare professional determines that it is necessary to restrict a patient's movement for their safety or the safety of others. The frequency at which these orders are written depends on the specific circumstances and needs of each patient. However, it is common for healthcare professionals to reassess and rewrite restraint orders every 12 hours to ensure that the patient's condition is continually evaluated and that the restraint is still necessary.

The completion of the medical record, including the final diagnosis, is required within 48 hours following the discharge of the patient. This allows for sufficient time for healthcare professionals to accurately document all relevant information and ensure that the medical record is comprehensive and up to date. A timely completion of the medical record is crucial for continuity of care, effective communication among healthcare providers, and accurate billing and coding processes.

According to e-Pramaan, there are four types of e-Authentication available in India. Unfortunately, without further context or information, it is not possible to provide a more detailed explanation of each type of e-Authentication.

The owner of the patient's medical record varies from country to country. In some countries, the patient is considered the owner and has full control over their medical records. In other countries, the hospital or healthcare provider may be the owner and custodian of the records. Additionally, in some cases, the consultant or specialist who treated the patient may also have ownership rights. The ownership structure depends on the legal and regulatory framework of each country.