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37 Cards in this Set

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Transfer records

A record created whever a patient is transfered from one facility to another.

What does a transfer record contain?

The summary of care while at the facility as well as the reason for transfer.

Cheif complaint

The nature and duration of the symptoms that caused the patient's illness and caused the patient to seek medical attention as stated in the patients own words.

Data quality need to be __________

Consistent

When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a ___________.

Health record matrix

How should corrections to a record be entered properly?

A single line through the error, add a note explaining the error, initial and date the error with the date that the error was discovered, and enter the correct info in chronological order.

All documentation entered in the medical record relating to the patients diagnosis and treatment are considered this type of data _____.

Clinical

Data that have been grouped into meaningful categories according to a classification system are referred to as ___________ data.

Coded

Conducting an inventory of the facility's records, determine the format and location of the record storage, assigning each record a time period for preservation , and destroying records that are no longer needed are all components of:

Retention program

What is the principle function of health records?

Serve as the repository of clinical documentation relevant to the care of individual patients.

The insured party's member number identification number is and example of this type of data:

Financial data

Which part of the problem oriented medical record is used by many facilities that have adopted the whole problem oriented format?

The SOAP form of progress notes.

What materials are required elements in an emergency care record?

Time and means of the patients arrival, treatment rendered, and instructions at discharge.

What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records.

Uniform data sets

What is the unique identifier for their relation database patient table?

Patient number

What is used by a long term care facility to gather information about specific health status factors and include information about specific risk factors in the residents care?

Minimum data set

In a long term care setting, these are problem oriented frameworks for additional patient assessment based on problem identification items or triggered conditions

Resident assessment protocols (RAPs)

Documenting the full depth and breadth of data used in a healthcare an entity requires:

Identifying the needs of data consumers

What is an example of a M:M relationship: patient to hospital admissions or patients to consulting physicians or patients to hospital medical records or primary care physician to patients?

Patient to consulting physician

Mr Smith was admitted to University Hospital by Dr. Collins. Mr Smith's hospital bill will be paid by Blue Cross insurance. upon discharge from the hospital who owns the house record of Mr Smith?

University Hospital

Decision making and authority over data related matters is known as

Data governance

Abbreviations can be a source of patient safety issues due to the misinterpretation and miscommunication. Abbreviations in the health record:

Should have only one meaning

In icd-10-pcs what value is used if there is a character that does not apply to a given code?

- (dash)

The primary responsibility of a coder is to?

Ensure quality of coded data

Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:

Certificate of destruction

What is the data model that is most widely used to illustrate a relational database structure?

Entity relationship diagram ERD

Anywhere hospital has mandated that the Social Security number will be displayed in the xxx - xx - xx xx format for their patients this is an example of the use of a:

Mask

Which of the following is a system in which the patient health record is kept in the same order as the nursing station and in the complete record?

Universal

Data that are collected on large populations of individuals and stored in databases are referred to as:

Aggregate data

The data elements in a patient's automated laboratory results are examples of:

Structured data

According to Joint Commission accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed?

Report of history and physical examination

Why could it be difficult for a health care entity to respond to pulling an entire, legal health record together for authorization request for information?

It can exist in separate or multiple paper-based or electronic systems

Data mapping is used to harmonize data sets or code sets. the code or data set from which the map originates is the:

Source

The process by which a person or entity who offered an EHR entry or document seeks to validate that they are responsible for the data contained within it is called

Authentication

Notes written by physicians or other practitioners as well as dictated and transcribed reports are examples of?

Unstructured clinical information

A significant challenge when handling hybrid records is complicated by the fact that:

The requirements regulations and constrains of EHRs and paper records must be met.

Bartering record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:

Authorship integrity