Alliyah Evangelista-
Why is lifelong learning important?
Because the landscape is always changing and information is always added, so there's always something we have to learn.
-
What is HIM?
HIM is the focus of health information documentation regardless of the format.
-
What is the difference between CCHIM and CHIMA?
CCHIM is the organization responsible for deciding what future CHIM's will learn (LOHIM), whereas CHIMA is an organization specifically CHIM's, that support their ongoing learning and events.
-
What are the 4 domains of HI?
- HIM standards
- E-HIM
- Privacy
- Data quality
-
What is the primary purpose for health record documentation?
To increase the quality of direct patient care.
-
What types of information are in a health record?
Administrative (patient identifying info) and Clinical (what happens during their visit/stay)
-
What is the secondary purpose of the health record?
To support the related environment in which the healthcare services are performed (education, legal cases).
-
What are some examples of the primary purpose?
- patient care delivery
- patient care management
- patient care support processes
-
What are some examples of the secondary purpose?
- education
- research
- public health
-policy making and support
-
What is the difference between a standing and a verbal order?
Standing: Written, given clear instructions, no room for misinterpretation
Verbal: given verbally, may be forgotten or misinterpreted
-
Written or spoken permission to proceed with care is classified as?
Verbal consent
-
Which report will describe the findings of tissue that was submitted and analyzed?
Pathology report
-
Name 3 types of demographic information.
- Name
- Address
- Phone #
-
Name 3 types of clinical information.
- Admitting diagnosis
- Medical history
- Labs
-
A report that describes an operative procedure in detail, that also highlights complications that may have occured is the:
Operative Report
-
What might an operative report contain:
- preop diagnosis
- name of provider and assistants
- estimate of blood loss
- name of procedure
- narrative retelling of the procedure
- any complications that may have occured
-
What is the report that gives a concise summary of the patient's illness, the course of treatment, response and conditions upon discharge is called?
Discharge summary
-
What does inpatient mean?
In the hospital, admitted in a room.
-
How can you tell if the record was for an inpatient or outpatient stay?
The length; if it's less than 48hrs it's outpatient and if it's more it's inpatient.
-
What is the unique identifier that belongs to a patient and is used on a health record?
PHIN - Personal Health Identification Member
-
Do you need consent to perform an autopsy?
Yes; the only way you can bypass that is if it was ordered by the government or it says otherwise in the law.
-
What does the health record have to justify?
The patient's treatment
-
This method of numbering records assigns a new medical record number each time the patient visits the hospital is called:
Serial
-
Ensuring that all the required documents are in the chart is called?
Quantitative analysis
-
What is the most important step in the HIM lifecycle?
Health information planning
-
What outlines the definitions, standard formats and acceptable values for data elements?
The data dictionary
-
What is one method provider's use to document a patient's condition?
SOAP
-
Of the SOAP method, give an example of "O".
Labs, vitals, temp.
-
Name the 2 federal laws that govern privacy.
PHIA - Personal Health Information Act
PIPEDA - Personal Information Protection and Electronics Documents Act
-
Policies, disaster recovery plans and emergency procedures are an example of what type of safeguard?
Administrative
-
The right of access to information can be formalized through a ___ process managed by HIM professionals.
access control
-
Data quality and integrity are associated with what step of the lifecycle?
Preservation
-
What must you create when you discover that multiple signatures by the physician are missing?
A deficiency slip
-
What is the first step in the process of disposing of health information?
Create a destruction policy in conjunction with the organization's retention schedule.
-
Write all the steps in the lifecycle in order?
- information management planning
- capture and collection
- preservation
- access, use and dissemination
- maintenance and protection
- disposition
- evaluation
-
Once the legal and regulatory framework is defined, what else should the HIM strategy further define?
- mission
- vision: goals and the future
- guiding principles: values, ethical code
-
List some things that an HIM manager might be responsible for.
- Defining the needs of the organization
- Ensuring timeliness, quality, completeness and the accuracy of the record
- Guaranteeing that practices are put in place and they meet legislative requirements
- Provide appropriate training and tools to further support the organization
