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Questions and Answers
What is the primary responsibility of a health information professional/health record administrator?
What is the major drawback of alphabetical filing?
What is the primary advantage of numerical filing systems?
In a straight numerical filing system, what determines the order of record filing?
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What is a major concern in the management of health record services?
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Why is it important to have an efficient health record service?
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What happens when alphabetical filing is used and two patients have the same name?
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Why is alphabetical filing not recommended?
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What is the primary consideration in determining the filing system to be used?
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Which of the following is a disadvantage of microfilming?
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What is the primary advantage of image-based storage systems?
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What is the purpose of written policies and procedures in record management?
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Which type of record identification system is suitable for small files?
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What is the primary consideration in choosing a record identification system?
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What is a disadvantage of paper-based storage systems?
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What is an advantage of image-based storage systems over paper-based storage systems?
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What is the primary purpose of assigning a unique identifier to each patient's health record?
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What is the primary concern with using alphabetic identification systems?
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What is the purpose of updating demographic information during a patient's subsequent admission or visit?
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What is the primary function of the Master Patient Index (MPI)?
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What is the consequence of not having a unique identifier for each patient's health record?
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What is the purpose of tracking name changes in patient demographic information?
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What is the primary benefit of using a computerized record system for patient data management?
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What is the final step in the registration process when a patient is discharged?
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Study Notes
Health Record Management
- The health information professional/health record administrator is responsible for establishing systems and procedures to ensure efficient production of health records for patient care, medico-legal purposes, statistics, teaching, and research.
Importance of Departmental Efficiency
- The health record department is judged on the efficient service it provides to the rest of the hospital or clinic.
- Health records must be readily available when required for patient care.
- Departmental efficiency and record control are crucial in health record services management.
Filing Systems
- Alphabetical filing is used when no health record number is assigned, and the patient's name is the only identifier.
- In alphabetical filing, records are filed by patient surname, then given name, and finally middle name or initial.
- Alphabetical filing is time-consuming, prone to errors, and not recommended for facilities with a large patient population and high patient turnover rate.
Numerical Filing Systems
- Numerical filing systems are used when a numerical record identification system is in place.
- There are two main types of numerical filing systems: straight numeric and terminal digit.
- Straight numeric filing involves filing health records in straight numeric sequence.
Record Identification Systems
- Each record must have a unique identifier, either alphabetic or numeric.
- The collection of patient identification data and assignment of a record number should be the first step of every admission or visit.
- Alphabetic identification uses the patient's name to identify and file the patient's health record.
- Accurate spelling of the patient's name is crucial, and a system should be in place to track name changes.
Disadvantages of Alphabetic Identification
- Patient confidentiality may be compromised since the outside of the record is identified only with the patient name, not a number.
Storage Options for Inactive Records
- Original materials can be stored in their original form, but this has drawbacks such as cost, space requirements, deterioration over time, and accessibility concerns.
- Microfilming is an alternative that reduces storage space requirements and is often acceptable as legal evidence, but it has drawbacks such as cost, accessibility, and possible fire hazard.
- Image-based storage systems involve scanning original records and storing digital images on optical disks, allowing for easier and faster retrieval of individual patient records.
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Description
Quiz on the role of health information professionals in managing health records, ensuring efficient production and availability for patient care, research, and more.
