Questions and Answers
What is qualitative analysis?
Review of the medical record to ensure that standards are met and to determine accuracy of record documentation.
What is quantitative analysis?
Review of the medical record to determine its completeness and accuracy.
What is the healthcare documentation process?
Process by which the medical record containing the details of a patient's healthcare visit(s) is created and stored.
What is concurrent review?
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What is an electronic health record?
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What is health information exchange?
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What does confidentiality refer to in healthcare?
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What does HIPAA stand for?
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What is microfilm?
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What does security refer to in healthcare?
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Which of the following does NOT apply to medical record documentation?
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What will the electronic health record reduce?
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Which of the following is NOT considered a common documentation error or deficiency?
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Which of the following would NOT be considered a documentation error?
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Implementation of the electronic health record offers many challenges. Which would NOT be considered a critical challenge?
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What is a Progress Note?
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This information is found on the _____ section of the History & Physical exam.
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Determine which report type would ONLY be found in an inpatient medical record.
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The _____ is the name of the U.S. government agency tasked with guiding the nationwide implementation of health information technology.
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One of the benefits to using an encoder is _____
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Medical professionals can use the _____ to identify, match, merge, and cleanse patient records.
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Health information exchange (HIE) is the term used for electronically transferring medical records between facilities around the country.
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One benefit of EHR is that it is much more secure than paper records.
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Another benefit of technology in the medical field is the ability of patients to access medical information through the Internet.
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The enterprise-wide master patient index (EMPI) references all patients in multiple facilities.
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The main function of the medical record is to collect patient data and store it so that it is accessible for all needing access.
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An EHR and a PHR are the same thing.
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CPOE accepts physician orders electronically to replace handwritten or verbal orders and prescriptions.
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Study Notes
Health Information Management Key Concepts
- Qualitative Analysis: Involves reviewing medical records to ensure standards are met and determine accuracy in documentation.
- Quantitative Analysis: Focuses on assessing the completeness and accuracy of medical records.
- Healthcare Documentation Process: Encompasses the creation and storage of medical records detailing patient healthcare visits.
Medical Record Review Types
- Concurrent Review: Conducted while the patient is actively receiving care.
- Progress Note: Documents responses to treatment, diagnosis changes, and progress towards discharge.
Electronic Health Records
- Electronic Health Record (EHR): A digital record that adheres to national interoperability standards, accessible by authorized healthcare personnel across various organizations.
- Health Information Exchange (HIE): Facilitates the electronic transfer of medical records between healthcare facilities nationwide.
Confidentiality and Security
- Confidentiality: Ensures personal information shared with healthcare providers is used solely for intended purposes.
- HIPAA: Mandates security regulations to protect patient rights and the confidentiality of health records.
- Security: Refers to measures that protect patient privacy and the confidentiality of health records.
Record Management Facts
- Microfilm: Can store thousands of images on a long roll, acting as a medium for archiving records.
- Enterprise-wide Master Patient Index (EMPI): Helps medical professionals match, merge, and cleanse patient records across multiple facilities.
Common Documentation Errors
- Common Errors: Late entries and missing operative reports are considered documentation deficiencies.
- Documentation Length: Length does not apply as a factor in medical record documentation.
Advantages of EHR and Technology
- Error Reduction: EHR usage is linked to a reduction in medical errors.
- Patient Access: Enables patients to access medical information online, enhancing their understanding of conditions and treatments.
Regulatory and Implementation Challenges
- Office of the National Coordinator: U.S. agency guiding nationwide health information technology implementation.
- Implementation Challenges: Issues such as data privacy, security, and potential resistance from healthcare personnel.
True/False Statements Summary
- HIE relates to medical record transfer (True).
- EHR is more secure than paper records (False).
- Technology enhances patient understanding of health (True).
- EMPI references patients across facilities (True).
- Main function of medical records is accessibility of patient data (True).
- EHR and Personal Health Record (PHR) are identical (False).
- Computerized Provider Order Entry (CPOE) digitizes physician orders (True).
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Description
Test your knowledge on critical concepts in Health Information Management with these flashcards. Focus on qualitative and quantitative analysis, as well as healthcare documentation processes. Perfect for exam preparation and understanding key terms in the field.
