Ch 8-9-10 Test Review
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| Retention of records, how long are x rays kept? | 5 years
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| How long birth, death, surgical procedure registers are kept? | forever
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| Master patient index is kept? | permanent
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| Employee health records kept? | 30 years
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| Looks like a Ferris wheel, this system can revolve laterally or horizontally. | Revolving Shelf
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| __________ 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
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| ___________ storage is where records are no longer under the direct control of the facility’s HIM | Off-Site
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| __________ is a scanned original record in miniature pictures stored on optical disk, also used to convert to computer records. | Document/Optical Imaging
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| __________ is a reproduction of the original paper record into miniature pictures stored on plastic film; reels or sheets. | Microfilm/Microfiche
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| In a file identification the number on the patient that moves with them permanently is called? | Unit number
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| Advantages – Equalizes filing activity throughout the filing sections. | Open shelves
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| This system may use a computer to correlate the medical numbers to file. After MR# is entered the _____________ presents the shelf. | revolving shelf
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| 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
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| 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
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| Describe an MPI? | A unique identification index file card system
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| A record cannot be retrieved until the relevant file shelf rolls around to the opening. | Revolving Shelf
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| 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
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| Data taken from the primary source document and used elsewhere is called what? | Secondary
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| 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
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| _____________ are part of the MPI Data Elements? | Gender/Race/Ethnicity
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| __________ is a disadvantage to the manual MPI? | Patient information is limited
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| In __________ filing system the patient’s medical record number stay the same, within the facility, throughout the lifetime of the patient? | Unit number
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| What is MPI? | Master patient index
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| Advantages – Limits time looking for file on shelf. | Revolving Shelf
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| True or False: The first two digits in the terminal-digit filing system are called Tertiary digits. | True
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| In the terminal-digit filing system, the last two digits are called the ___________ digits. | Primary
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| In this system of filing, all the family members' records can be kept in one file. | Family Unit Numbering
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| The number that each family member is assigned that is added to the family unit number is called what? | a modifier
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| Data taken directly from the patient or original source is called what? | Primary
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| True or False: When looking for a record in a computer system, the audit trail is used to tract it in the system? | True
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| A patient receives the same number every time they come to the facility. This is what type of system? | Unit numbering
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| 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
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| 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
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| One medical record is assigned to the entire family. What is this system called? | Family-unit numbering
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| This method of filing is time consuming. This is a disadvantage of what system? | Serial-unit numbering
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| Confidentiality can be compromised; divorce, remarriage, and other factors can create complications. This is a disadvantage of what system? | Family-unit numbering
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| An advantage of this system is that each admission is filed in a single folder. | Serial numbering
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| Records are combined for clinical and financial processing of claims. This is an advantage of what system? | Family-unit numbering
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| Mortality refers to ___________? | Death
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| Morbidity refers to ___________? | Disease
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| When records are stored off-site, what’s the biggest advantage? | Volume space
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| It's out of our control is a disadvantage of what? | Off-site storage
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| JCAHO does what? | Sets standards for acute care facilities, ambulatory care networks, long term care facilities, and rehabilitation facilities.
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| Who requires a system that ensures timely access to patient information when requested? | JCAHO
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| True or False: A record review is required by JCAHO quarterly by a multidisciplinary team of health care professionals. | True
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| Why would coding personnel look at a medical record? | Identify diagnosis and procedure codes
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| _________ is a person or a party responsible for the bill. | A payer
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| An Insurance company is an example of what type of payer? | third party
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| Why are surveys so important to the facility? | Improve healthcare quality
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| ________ requires appropriate space to provide a safe environment for employees working in the file area. | OSHA
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| OSHA mandates an aisle must be at least ____ feet wide between filing units or shelves. | 3
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| OSHA mandates an Exit aisle must be at least ______ feet wide. | 5
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| OSHA mandates the top of filing units or shelves must be ____ inches from ceiling. | 18
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| Allows access to only one drawer of information at a time is a disadvantage of what filing equipment? | File cabinets
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| Conceals information from public view is an advantage of what filing equipment? | File cabinet
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| A data base record set, if we are trying to get as certain report, what is this? | Query
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| Accommodates file personnel, reducing time spent looking for a file on a shelf is an advantage of what filing equipment? | Revolving file system
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| What is a disadvantage of an open shelf filing system? | Files are open to the environment.
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| 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
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| The length of time a that a record must be retained is called the ______________________? | Record retention schedule
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| One must do what in order to obtain a report from a database? | Query
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| Increases file space in a small area is an advantage of what filing equipment? | Compressible shelves
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| Color coding of the numerical identification on the end tab of a file folder does what? | aids the identification of misfiles
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| 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
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| True or False: Quality is perceived through the eye of the patient according to the patient's priorities. | True
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| "If it isn't documented..." | It didn't happen
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| 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
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| ____ is the key to locating a health record? | MPI
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| _____ is first collected during the patient registration process? | Information for the MPI
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| Inexpensive, implemented quickly, and accessible regardless of energy supply in facility are what of the MPI system? | Advantages
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| 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
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| Is the container used to store the forms that document the patient’s health information. | Physical File Folder
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| 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
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| Medical record numbers are not shared and are not reused applies to what system? | Unit Numbering
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| Each time a patient has an encounter at the facility a new medical record is assigned applies to what system? | Serial Numbering
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| 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
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| Retrieving all the records for one patient involves going to multiple places is a disadvantage of what system? | Serial Numbering
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| The patient receives a new medical record number each time he/she comes into a facility. | Serial-Unit Numbering
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| Each family member receives his/her own modified modifier number. | Family Unit Numbering
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| 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
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| This type of filing is only used in small offices. | Alphabetic Filing
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| The Folders are placed on the shelf in numeric order using the patient’s medical number. | Straight Numeric Filing
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| Based on the last digits of the six digit ID number | Terminal-Digit Filing
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| Quality is determined by? | the person or agency that is evaluating the product or service.
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| Challenging for some file clerks to learn, misfiles are difficult to locate. | Terminal-Digit Filing
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| Even more challenging to learn than terminal-digit and misfiles are often difficult to locate. | Middle-Digit Filing
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| 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
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| True or False: If the patient is under 21 years of age, 5 years starts before the age of 21. | False
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| Motor vehicle records are kept for ____ years from patient’s last encounter with physician. | 10
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| Emergency Room Registers/Log are retained for how long? | Permanently
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| If facility is sold, the records are managed by the _________? | new owner
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| If facility is closing, the records must be maintained for the duration of the retention schedule where? | in an appropriated, secure, confidential location.
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| How must the facility notify its patient when it is closing. | advertisement in newspaper or patient letters
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| What type of furniture locks/secures information? | File Cabinet
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| The __________ file contains patient’s names and telephone numbers, dates when action or activities should occur, and actions to take. | tickler
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| A record cannot be retrieved until the relevant file shelf rolls around to the opening applies to what type of system? | Revolving File System
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| This type of system allows a facility to maintain security, confidentiality, and timely access to records and is the least expensive. | On-site storage
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| In this type of system, records are no longer under the direct control of the facility’s HIM | Off-Site Storage
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| Original record in miniature pictures stored on optical disk is what? | Document/Optical Imaging
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| A system that helps HIM to keep track of records removed from its usual location is what? | Chart Locator Systems
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| A manual chart locator system uses what? | Outguides
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| In computerized environment, how is information destroyed? | by entering a virus into the software
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| What should be reviewed on a daily basis so the actions are taken on time? |
tickler file
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| When files are in the correct placement, color bands will all have the same pattern in what system? | Color Coded Systems
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| 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
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| A ______ file is used to remind the medical assistant of event or action that will take place at a future date. | tickler
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| How is premature destruction avoided in a computerized system? | performing daily back ups
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| the __________ is a legal document, permanent record, and a tool used to communicate between staff members to deliver services to the patient. | medical record
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| 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
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| The ______ is not the place to document your opinion or internal office problems. | patient’s chart
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| Data taken when the nurse talks to patient to obtain his/her health information is an example of? | primary data
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| information taken from the primary-source document for use elsewhere; diagnosis, procedure, and physician indices are examples of? | secondary data
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| ___________ is a group of elements, collected for a specific purpose. | Data Set
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| 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
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| What is it called when searching of a database for information, specific elements or a report is done? | Query
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| The result of query, a list from a database is called what? | Report
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| 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
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| Referring to the process by which a facility reviews its services or products to ensure quality is what? | Performance Improvement
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| The clinical pathway or _________, is the typical care provided to a patient with a specific diagnosis | Patient Care Plan
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| 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
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| The coordination of the patient’s care within the facility is an example of what? | Case Management
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| __________ referrers to the coordination of efforts within a facility to prevent and control potentially compensable events. | Risk Management
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| _________ is any event that could cause the facility a financial loss ore could lead to litigation. | Potentially compensable event
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| Coding personnel review the patient’s health record to identify the correct __________ and ________ and then assign the appropriate codes | diagnoses and procedure(s)
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| Accurate coding requires a thorough analysis of the complete what? | health record
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| 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
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| __________ is the common term used to describe the management of the health care facility | Administration
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| Administrators use _____________ to negotiate and evaluate contracts with managed care companies or other vendors such as surgical supply companies and laundry companies | health information
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| __________ 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
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| True or False: Health records can support or validate a claim of physician malpractice. | True
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| The blending of the insurance and provider roles? | Managed Care
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