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HIM-Midterm
CHIMA became the name of the professional association in: - correct answer 2003 The acronym CHIMA represents two separate organizations: - correct answer b. Canadian Health Information Management Association and the Canadian College of Health Information Management The HIM profession is focussed exclusively on the electronic health record - correct answer False Which of the following is not an HIM core competency? a. Access and Privacy b. Biomedical Sciences c. Health Information Analysis d. Management e. Technology - correct answer e. Technology Which method of authentication of entries would be Inappropriate in a hybrid record? a. Initials of a nurse writing a nurses note b. Unique identification code assigned by the computer to each user c. Written signature of the care provider d. None of the above - correct answer a. Initials of a nurse writing a nurses note Abbreviations are never allowed in a health record. - correct answer False Progress Notes are written by: a. Allied Health b. Clinicians
d. Nursing personnel e. A, B and D - correct answer e. A, B and D A record entry that has been modified is known as data: a. Alteration b. Destruction c. Loss d. Risk - correct answer a. Alteration The record of a newborn is filed with that of the mother. - correct answer False For inpatients, the first data item collected of a clinical nature is usually: a. Pre-operative diagnosis b. History and Physical c. Admitting diagnosis d. Consultation report - correct answer c. Admitting diagnosis The medication record will include the physician's order - correct answer False Access to the client record is given to: Select one: a. All care providers b. Physicians and nursing staff only c. The CEO of the organization d. All of the above e. None of the above - correct answer e. None of the above Administrative data includes that which is necessary to identify a person, and typically includes: Select one:
b. It is easier to file loose reports c. It is a legal requirement d. It is the most convenient way for care providers to review information - correct answer d. It is the most convenient way for care providers to review information Decentralized registration has benefits one of which is Select one: a. Changes in registration processes can be done efficiently throughout the organization b. The potential for errors is reduced c. A smaller MPI is created and is easier to maintain d. All of the above e. None of the above - correct answer e. None of the above Accurate Client identification requires: Select one: a. Clearly defined data elements b. Organizational policies and procedures that are audited and enforced c. Rigorous staff training d. Standards for data recording e. All of the above - correct answer e. All of the above Clinical documentation can be: Select one: a. Computer generated b. Handwritten c. Transcribed d. All of the above - correct answer d. All of the above If a facility has both electronic and paper documents, each must be kept so that the legal record is intact.
Select one: True False - correct answer False While doing the final check on a paper record, an HIM notices that there is a missing day of lab results. The report is printed off and filed in chart. The chart can then be filed. Select one: True False - correct answer False Mother's and babe's should share a health record. Select one: True False - correct answer False Which of the following is least likely to be identified as a deficiency? Select one: a. Discrepancy between pre-op and post-op diagnosis b. Missing discharge summary c. Need for authentication of an H&P report d. Xray report on the wrong record. - correct answer a. Discrepancy between pre-op and post-op diagnosis Electronic health records means that there is no need for chart deficiency processes. Select one: True False - correct answer False
Redacting an entry in a record means to delete an error. Select one: True False - correct answer False A key principle of an ADT system is: collect once, use many. Select one: True False - correct answer True The chart order in a paper record is usually determined by a Health Record Committee Select one: True False - correct answer True Authenticate means to prove who wrote/created an entry Select one: True False - correct answer True Verifying that a required document is in the chart and is signed/authenticated is a key step in qualitative analysis. Select one: True False - correct answer False Once a record is destroyed, all reference to that record are obliterated. Select one:
True False - correct answer False You notice on an admission note that Ms. Wool was admitted for disc surgery. Progress notes indicate that surgery was cancelled due to heart irregularities. A document you would expect to find in the record is: Select one: a. Consultation Report b. OR report c. Laboratory Report d. All of the above - correct answer a. Consultation Report A Consultant's Report is: Select one: a. Filed in a separate record b. Required for all surgical interventions c. The opinion of another care provider d. The term used for allied health documentation - correct answer c. The opinion of another care provider Every health record, regardless of type of organization, or the individual's condition will include: Select one: a. CCI codes b. ICD codes c. Notes on services provided d. Client identification e. Reason for encounter f. All of the above g. C and D and E
The unintentional misidentification of an individual is known as Identity Theft Select one: True False - correct answer False Discharge Summary documentation must include: Select one: a. A detailed history of the patient b. A discharge order c. Significant findings during hospitalization d. A and C e. All of the above - correct answer c. Significant findings during hospitalization An eMPI is a combination of different MPIs in a province or region. Select one: True False - correct answer True The content of a terminology is 'fixed'; that is no new terms can be added. Select one: True False - correct answer False The system used to identify and share information on blood samples is: Select one: a. CCI b. ICD c. LOINC d. Snomed CT - correct answer c. LOINC
CCI is designed for exclusive use in acute care facilities. Select one: True False - correct answer False An example of administrative data is: Select one: a. Patient name b. Patient weight c. Date of Birth d. Attending Dr - correct answer d. Attending Dr ICNP describes Nursing diagnoses interventions and outcomes Select one: True False - correct answer True ICD-O is used in Canada to code: Select one: a. Cancer conditions b. Mental health conditions c. Orthopedic conditions d. Rehabilitation conditions - correct answer a. Cancer conditions In a hierarchy, terms are related, but one term is always more general or broad. Select one: True False - correct answer True
True False - correct answer False The framework to effectively exchange information is a: Select one: a. Code b. Classification c. Nomenclature d. All of the above - correct answer c. Nomenclature Characteristics of terminologies include: Select one: a. Definition and granularity b. Concept orientation and permanence c. Consistent views and redundancy d. A and B e. A, B and C - correct answer e. A, B and C The standard for the collection and exchange of information in the EHR is: Select one: a. CCI b. ICD c. LOINC d. Snomed CT - correct answer d. Snomed CT Secondary purposes of the health record include: Select one: a. Clinical decision making
b. Funding c. Health research d. A and B e. All of the above - correct answer e. All of the above A medic alert bracelet is a health record Select one: True False - correct answer True UMLS is a: Select one: a. Mapping system b. Coding System c. Coding System d. Classification system e. Nomenclature - correct answer a. Mapping system Statistical data are: Select one: a. An important resource when evaluating services b. Coded data c. Financial data d. Sent to CIHI for processing - correct answer a. An important resource when evaluating services An example of a non-semantic identifier is: Select one:
Information on eyeglass prescriptions, etc. But given the WHO definition, it might also include: An address A list of immunizations Education level Financial information, etc. Health Information Management - correct answer is a discipline that focuses on health care data and the management of health information regardless of the medium and format. It addresses the nature, structure, and translation of data into usable information. The first Canadian association of health information (or health record) professionals was created - correct answer in 1942 The role of the CHIMA is to: - correct answer. Support continuing education and professional practice of HIM professionals
. Develop strategic partnerships to advance the development and integration of electronic HIM . Advocate for and strengthen the HIM role in health care settings across the continuum of care inpatient is - correct answer Admitted to a facility, provided with a bed, hoteling services, continuing nursing services and receives some care. An outpatient - correct answer receives health care services on a daily basis at a facility and is not admitted. Acute Care - correct answer This is care provided to an inpatient to diagnose and/or treat a condition or injury. Acute care is time limited (usually to a maximum of 30 days)
There are lots of services in acute care. Some examples include: - correct answer Obstetrics General Surgery Orthopedics, etc Ambulatory Care - correct answer Services provided to a person who is treated in an outpatient setting within a facility. The person is not admitted. Examples of ambulatory care include: - correct answer Diabetes clinic appointment Emergency department visit Visit to a lab for blood work Long Term Care - correct answer Long Term Care are services provided in a non- acute care setting to residents with chronic conditions. The length of stay is typically more than 30 days, and may be for years. Typically, the services are less medically intensive, and more nursing and therapeutic supportive care. The care is provided to the elderly, disabled, and mentally handicapped. Levels of Care - correct answer primary secondary tertiary quaternary Primary Care - correct answer The most common care First contact with the health care system Can be for treatment of a minor condition or for preventative care Secondary Care - correct answer Can be in an ambulatory or inpatient setting Care is provided by a specialist Typically, an individual is referred to secondary care.
Ownership - correct answer the health record, whether in paper or electronic format, is the property of the facility that compiles the record The Supreme Court of Canada has ruled that the content belongs to the client and therefore the client has a right to access the record There are 7 seven principles of records management - correct answer 1.Unique identification 2.Specificity of data collection 3.Access and release guidelines 4.Processes for aggregation of data 5.Support evidence-based practice 6.Part of larger health system 7.Processes to protect confidentiality and security The content of the health record has two types of data: - correct answer Administrative data such as the identification of the individual, and health care number; and Clinical information relating to the condition, drugs, history, treatment etc. given to the person Surgical Services - correct answer Reports that are usually required for a surgical case include (in addition to a history and/or consultation report): Consent Form Operative Report Anesthesia Report Recovery Room Record Pathology Report (if a specimen is removed) The Operative report includes - correct answer 1 - The names of the surgeon(s), anesthetist, assistants, date, duration, and name of the procedure 2 - Pre- and post-operative diagnosis are recorded for comparative purposes
3 - A full description of the procedure, including findings and the condition of the client at the end of the surgery 4 - The person's condition throughout the procedure is described Neonatal Records - correct answer The newborn record is a separate record created at the time of delivery. Regardless of the health care setting, the health record typically will include: - correct answer Identification of the individual The reason for the visit Treatments/services performed Notes from any prior visits (if applicable) reverse chronological order - correct answer newest information on top For a paper record, there are three types of organizational style : - correct answer source oriented problem oriented integrated In a source oriented record, - correct answer all information is organized according to the department/speciality that created the documentation. So, all nursing notes are in one section, all physician notes in another, all radiology reports in another. The Problem Oriented Record (POR) format is very complex to establish and to maintain - correct answer Problem Oriented has the documents filed by the number associated with any specific problem as recorded on the Database and Problem List. Notes are written in SOAP format The third format for health records is the integrated model. - correct answer Integrated records are records in which all notes are interfiled based only on the date of the notes. In the integrated model, all the information from any source is filed in strict chronological (or reverse chronological) order.
