Question 1

Data that have been obtained, recorded, and/or reported within a predetermined period satisfy the data quality characteristic of ___________.

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Question 2

Required elements of a record that are missing are called __________.

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Question 3

List the forms that are present, in one way or another, in every acute care health record. What is the most useful way to organize those forms in a record while it is on the nursing unit? Postdischarge? Why do some organizations want the record to be organized differently predischarge and postdischarge?

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Question 4

The data quality characteristic of data being present or existing in its entirety is __________.

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Question 5

An original signature on a report that is then scanned into an electronic document is a __________.

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Question 6

___________ procedures govern the storage of records, including duration, location, security, and access.

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Question 7

TThe representation of diagnoses and procedures as alphanumerical values in order to capture them in the database is called ___________.

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Question 8

In a paper-based record, errors are corrected __________ and writing the correct data near it. It is important not to obscure the erroneous data.

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Question 9

___________ is the process of determining the cause of an error.

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Question 10

What processing problems can occur if an organization implements a universal chart order? How is the issue of record organization resolved in a computer-based record?

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Question 11

Clinicians can evidence supervision of subordinate personnel by ___________ the subordinates' documentation.

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Question 12

You have just checked in all of the records received from the nursing unit. One record that was received is not on your discharge register. What could have happened? How do you determine what to do with the extra record?

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Question 13

What is the purpose of a discharge register? How is it used in postdischarge processing? How else could it be used?

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Question 14

A review of individual user access codes to determine who had access to patient health information and to ensure the access was deemed necessary for patient care is called an ___________.

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Question 15

In a paper environment, records must physically move from the patient care area to the HIM department for processing and storage. Give two examples of how that movement can occur.

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Question 16

Parts of paper records that arrive in the HIM department separately from the main record are often called ______________.

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Question 17

Since the HIM department is primarily concerned with postdischarge processing, of what use is the admission register to this department?

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Question 18

The process of recording elements into a collection device is called _________.

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Question 19

Assignment of ICD-10-CM codes to clinical data while the patient is still being treated is ______________.

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Question 20

In a paper record environment, _______________ refers to the maintenance of the same page order both predischarge and postdischarge.

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Quiz 5: Health Information Management Processing