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Comprehensive Review of Health Records and Information Systems

This document offers a comprehensive review and sample questions pertaining to Health Records and Information Systems. It covers essential topics such as the classification of health records, average paper chart length, examples of healthcare data systems, record retention requirements, and Electronic Health Records (EHR) functionalities. Each question explores key concepts in healthcare data management, providing learners with vital insights required for successful examination in the field. Understanding these fundamentals is critical to enhancing patient care and improving healthcare processes.

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Comprehensive Review of Health Records and Information Systems

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  1. Exam 2 Review MIS 4243

  2. Question 1 Health records are classified as primary and secondary records. Which of the following is a primary record? • Insurance claim • Quality improvement report • Aggregate admissions data • Patient history and physical

  3. Question 2 How many pages are in the average inpatient paper chart? • 10 • 25 • 50 • 100

  4. Question 3 The use of a blood pressure monitor is an example of: • E-visit • Telemonitoring • Teleradiology

  5. Question 4 Which healthcare data set is used to measure performance and outcomes? • DEEDS • ORYX • RAI • UCDS

  6. Question 5 There are five types of Health Record Contents. Which type does a personal property list fall under? • Demographics • Legal Documents • Clinical Documents • Public Health Records • Plan of Care Documents

  7. Question 6 Using terminal digit filing, which section of the file room would chart 46-78-01 be found? • 01 • 04 • 46 • 78

  8. Question 7 Order the following charts using middle digit filing: 12-34-56; 12-35-56; 13-34-56; 12-35-57 • 12-34-56; 12-35-56; 12-35-57; 13-34-56 • 12-34-56; 13-34-56; 12-35-56; 12-35-57 • 12-34-56; 12-35-56; 13-34-56; 12-35-57 • 12-35-57; 13-34-56; 12-34-56; 12-35-56

  9. Question 8 _________ numbering is recommended by the Joint Commission. • Family • Serial • Serial-unit • Unit

  10. Question 9 Which of the following is NOT true regarding record retention requirements in healthcare? • Adult patient health records should be retained for 10 years after the most recent visit. • Children’s health records should be retained for 10 years after the child reaches adult age. • Registered birth records are retained permanently. • Registered surgical procedures are retained for 5 years.

  11. Question 10 For this type of paper chart, physician notes would be grouped together in one section, nursing notes in another, and so forth: • Source-oriented • Problem-oriented • Integrated • Mixed

  12. Question 11 What is a nomenclature? • An EHR coding system • A PHI encryption system • A network protocol • A medical protocol

  13. Question 12 ________ is for drug interactions. • HL7 • DUR • Formulary alerts • ABN

  14. Question 13 CPRI identified three key criteria for EHR. Which of the following is NOT one of those criteria? • Capture data at the point of care • Integrate data from multiple sources • Provide decision support • Report on population health

  15. Question 14 As of 2016, what stage of EHR “meaningful use” are healthcare facilities required to be in in order to receive incentive payments? • Advance clinical processes • Data capture and sharing • Improved outcomes

  16. Question 15 Which functional benefit of EHR serves to improve patient health through prevention and disease management? • Health maintenance • Trend analysis • Alerts • Decision support

  17. Question 16 MRI is generally classified as what type of data? • Digital image • Discrete • Text-based • None of the above

  18. Question 17 ___________ is the principal system for a medical office. • HIS • LIS • MPI • Practice management system

  19. Question 18 Which of the following systems would be used to record a PET scan? • LIS • RIS • Pharmacy system • Biomedical system

  20. Question 19 A(n) _________ example is a heart valve; a(n) _________ example is a heart. • Implant; transplant • Transplant; implant

  21. Question 20 A Soundex field would be most valuable for: • LIS • MPI • RIS • HIS

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