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MOT 124

Ch 8-9-10 Test Review

Retention of records, how long are x rays kept? 5 years
How long birth, death, surgical procedure registers are kept? forever
Master patient index is kept? permanent
Employee health records kept? 30 years
Looks like a Ferris wheel, this system can revolve laterally or horizontally. Revolving Shelf
__________ is storing medical records on site allows a facility to maintain security, confidentiality, and timely access to records and is the least expensive. On-Site Storage
___________ storage is where records are no longer under the direct control of the facility’s HIM Off-Site
__________ is a scanned original record in miniature pictures stored on optical disk, also used to convert to computer records. Document/Optical Imaging
__________ is a reproduction of the original paper record into miniature pictures stored on plastic film; reels or sheets. Microfilm/Microfiche
In a file identification the number on the patient that moves with them permanently is called? Unit number
Advantages – Equalizes filing activity throughout the filing sections. Open shelves
This system may use a computer to correlate the medical numbers to file. After MR# is entered the _____________ presents the shelf. revolving shelf
True or False: In a Straight Numeric Filing system folders are placed on the shelf in numeric order using the patient’s medical number. True
This system is beneficial in a small clinic or physician's office where clinical and financial records are combined for claims processing. Family Unit Numbering
Describe an MPI? A unique identification index file card system
A record cannot be retrieved until the relevant file shelf rolls around to the opening. Revolving Shelf
What is the key to locating the health record and a primary goal for identifying each file for all patients who have been seen? MPI
Data taken from the primary source document and used elsewhere is called what? Secondary
True or False: The computerized MPI software is typically one feature of a larger computer system or is interfaced with other computer systems in the health care facility. True
_____________ are part of the MPI Data Elements? Gender/Race/Ethnicity
__________ is a disadvantage to the manual MPI? Patient information is limited
In __________ filing system the patient’s medical record number stay the same, within the facility, throughout the lifetime of the patient? Unit number
What is MPI? Master patient index
Advantages – Limits time looking for file on shelf. Revolving Shelf
True or False: The first two digits in the terminal-digit filing system are called Tertiary digits. True
In the terminal-digit filing system, the last two digits are called the ___________ digits. Primary
In this system of filing, all the family members' records can be kept in one file. Family Unit Numbering
The number that each family member is assigned that is added to the family unit number is called what? a modifier
Data taken directly from the patient or original source is called what? Primary
True or False: When looking for a record in a computer system, the audit trail is used to tract it in the system? True
A patient receives the same number every time they come to the facility. This is what type of system? Unit numbering
A new medical record number is assigned each time a patient has an encounter at the facility. This is an example of what type of system? Serial numbering
The patient receives a new medical record number each time he or she comes into a facility, and the old records are brought forward and filed with the most recent visit. What is this system? Serial-unit numbering
One medical record is assigned to the entire family. What is this system called? Family-unit numbering
This method of filing is time consuming. This is a disadvantage of what system? Serial-unit numbering
Confidentiality can be compromised; divorce, remarriage, and other factors can create complications. This is a disadvantage of what system? Family-unit numbering
An advantage of this system is that each admission is filed in a single folder. Serial numbering
Records are combined for clinical and financial processing of claims. This is an advantage of what system? Family-unit numbering
Mortality refers to ___________? Death
Morbidity refers to ___________? Disease
When records are stored off-site, what’s the biggest advantage? Volume space
It's out of our control is a disadvantage of what? Off-site storage
JCAHO does what? Sets standards for acute care facilities, ambulatory care networks, long term care facilities, and rehabilitation facilities.
Who requires a system that ensures timely access to patient information when requested? JCAHO
True or False: A record review is required by JCAHO quarterly by a multidisciplinary team of health care professionals. True
Why would coding personnel look at a medical record? Identify diagnosis and procedure codes
_________ is a person or a party responsible for the bill. A payer
An Insurance company is an example of what type of payer? third party
Why are surveys so important to the facility? Improve healthcare quality
________ requires appropriate space to provide a safe environment for employees working in the file area. OSHA
OSHA mandates an aisle must be at least ____ feet wide between filing units or shelves. 3
OSHA mandates an Exit aisle must be at least ______ feet wide. 5
OSHA mandates the top of filing units or shelves must be ____ inches from ceiling. 18
Allows access to only one drawer of information at a time is a disadvantage of what filing equipment? File cabinets
Conceals information from public view is an advantage of what filing equipment? File cabinet
A data base record set, if we are trying to get as certain report, what is this? Query
Accommodates file personnel, reducing time spent looking for a file on a shelf is an advantage of what filing equipment? Revolving file system
What is a disadvantage of an open shelf filing system? Files are open to the environment.
A filing method in which the patient's medical record is separated into sets for filing and the first set of numbers are tertiary, the second are secondary, and the last are primary is what system? Terminal digit
The length of time a that a record must be retained is called the ______________________? Record retention schedule
One must do what in order to obtain a report from a database? Query
Increases file space in a small area is an advantage of what filing equipment? Compressible shelves
Color coding of the numerical identification on the end tab of a file folder does what? aids the identification of misfiles
As in Alpha, once they are filed in the permanent file area; the file space becomes depleted rapidly as new files are added to one section. Straight Numeric Filing
True or False: Quality is perceived through the eye of the patient according to the patient's priorities. True
"If it isn't documented..." It didn't happen
Patient’s name, Alias/previous name, Address/Telephone, Date of birth Social security number, Gender/Race/Ethnicity, Medical record number, Patient’s account number are examples of what? MPI Data Elements
____ is the key to locating a health record? MPI
_____ is first collected during the patient registration process? Information for the MPI
Inexpensive, implemented quickly, and accessible regardless of energy supply in facility are what of the MPI system? Advantages
True or False: the amount of information for each patient in the MPI is limited by the size of the index card are advantages of the MPI system. False
Is the container used to store the forms that document the patient’s health information. Physical File Folder
Each time the patient receives health care, the old records are brought forward and filed with the most recent visit, under a new medical record number. Serial-Unit Numbering
Medical record numbers are not shared and are not reused applies to what system? Unit Numbering
Each time a patient has an encounter at the facility a new medical record is assigned applies to what system? Serial Numbering
Space with popular letters,Many alternative spellings of names exist,Problems arise when two patients have the same name are examples of disadvantages of what filing system? Alphabetic Filing
Retrieving all the records for one patient involves going to multiple places is a disadvantage of what system? Serial Numbering
The patient receives a new medical record number each time he/she comes into a facility. Serial-Unit Numbering
Each family member receives his/her own modified modifier number. Family Unit Numbering
This type of system, the patient’s file folders containing the health record for each encounter are not filed in the same folder. Therefore, the Records are not located together on the file shelf applies to what system? Serial Numbering
This type of filing is only used in small offices. Alphabetic Filing
The Folders are placed on the shelf in numeric order using the patient’s medical number. Straight Numeric Filing
Based on the last digits of the six digit ID number Terminal-Digit Filing
Quality is determined by? the person or agency that is evaluating the product or service.
Challenging for some file clerks to learn, misfiles are difficult to locate. Terminal-Digit Filing
Even more challenging to learn than terminal-digit and misfiles are often difficult to locate. Middle-Digit Filing
In the absence of state law, the facility must follow the federal requirements stipulated by the Health Care Financing Administration, which is to save records for ___ years 5
True or False: If the patient is under 21 years of age, 5 years starts before the age of 21. False
Motor vehicle records are kept for ____ years from patient’s last encounter with physician. 10
Emergency Room Registers/Log are retained for how long? Permanently
If facility is sold, the records are managed by the _________? new owner
If facility is closing, the records must be maintained for the duration of the retention schedule where? in an appropriated, secure, confidential location.
How must the facility notify its patient when it is closing. advertisement in newspaper or patient letters
What type of furniture locks/secures information? File Cabinet
The __________ file contains patient’s names and telephone numbers, dates when action or activities should occur, and actions to take. tickler
A record cannot be retrieved until the relevant file shelf rolls around to the opening applies to what type of system? Revolving File System
This type of system allows a facility to maintain security, confidentiality, and timely access to records and is the least expensive. On-site storage
In this type of system, records are no longer under the direct control of the facility’s HIM Off-Site Storage
Original record in miniature pictures stored on optical disk is what? Document/Optical Imaging
A system that helps HIM to keep track of records removed from its usual location is what? Chart Locator Systems
A manual chart locator system uses what? Outguides
In computerized environment, how is information destroyed? by entering a virus into the software
What should be reviewed on a daily basis so the actions are taken on time? tickler file
When files are in the correct placement, color bands will all have the same pattern in what system? Color Coded Systems
Records are always visible to visitors in the file area and they are exposed to potential fire or water damage is a disadvantage of what type of furniture? Open Shelves
A ______ file is used to remind the medical assistant of event or action that will take place at a future date. tickler
How is premature destruction avoided in a computerized system? performing daily back ups
the __________ is a legal document, permanent record, and a tool used to communicate between staff members to deliver services to the patient. medical record
In what system are half the letters solid colors and the other half are solid with a white stripe? Alpha-Z system by the Smead Manufacturing Company
The ______ is not the place to document your opinion or internal office problems. patient’s chart
Data taken when the nurse talks to patient to obtain his/her health information is an example of? primary data
information taken from the primary-source document for use elsewhere; diagnosis, procedure, and physician indices are examples of? secondary data
___________ is a group of elements, collected for a specific purpose. Data Set
True or False: Without a specific requirement for data, some facilities might not include data elements that are helpful to users when performing an analysis. True
What is it called when searching of a database for information, specific elements or a report is done? Query
The result of query, a list from a database is called what? Report
The method for reviewing health care functions to determine their compliance to predetermined standards, requiring action to correct noncompliance and then follow-up review to ascertain whether the correction was effective is what? Quality Assurance
Referring to the process by which a facility reviews its services or products to ensure quality is what? Performance Improvement
The clinical pathway or _________, is the typical care provided to a patient with a specific diagnosis Patient Care Plan
Payers study historical patient treatment by analyzing patient health records to identify “best practices” or a specific plan of treatment that is most likely the best standard is an example of what? Utilization Management
The coordination of the patient’s care within the facility is an example of what? Case Management
__________ referrers to the coordination of efforts within a facility to prevent and control potentially compensable events. Risk Management
_________ is any event that could cause the facility a financial loss ore could lead to litigation. Potentially compensable event
Coding personnel review the patient’s health record to identify the correct __________ and ________ and then assign the appropriate codes diagnoses and procedure(s)
Accurate coding requires a thorough analysis of the complete what? health record
True or False: Submission of false claims is not a crime punishable by law; therefore, coders are educated in the review of records and the appropriate assignment of codes for reimbursement. False
__________ is the common term used to describe the management of the health care facility Administration
Administrators use _____________ to negotiate and evaluate contracts with managed care companies or other vendors such as surgical supply companies and laundry companies health information
__________ is a term used to indicate that a matter must be settled in court; health records or health information is used to support a plaintiff’s or a defendant’s case. Litigation
True or False: Health records can support or validate a claim of physician malpractice. True
The blending of the insurance and provider roles? Managed Care
Created by: kbcanarr