| 1. What is the national association for HIM professionals? | |
| 2. What is the role of the HIM professional within the healthcare organization? | |
| 3. What are the two credentials available to HIM professionals? | |
- What is the purpose of the patient’s health record?
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- Who uses the patient’s health record?
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- Is the health record a primary or secondary source of information?
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- Can you provide examples of secondary sources of information?
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- What are the three formats for the paper-based health record? Describe these 3 formats.
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- What determines the patient’s level of care?
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- What is the role of the Medical Staff Committee?
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- What is the role of the hospitalist within healthcare?
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- Can you name some regulatory and accrediting agencies that govern the healthcare record?
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- What is the role of Risk Management?
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- What is a critical care access hospital?
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- How does a specialty hospital differ from a rehabilitation hospital?
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- What is an Adult Daycare Center?
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- What services do a skilled nursing facility provide?
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- What is palliative care?
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- What are the two types of data contained within the patient’s health record?
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- Identify two external agencies that govern the patient’s health record?
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- What is the purpose of the Discharge Summary?
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- What are the timeliness requirements of the Discharge Summary?
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- What is the purpose of the History and Physical?
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- What are the timeliness requirements of the History and Physical?
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- What is the purpose of the physician’s order?
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- What is the frequency required of progress notes?
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- What is a pathology report? When is it required?
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- What is an autopsy report? Who signs the consent for an autopsy report?
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- What is informed consent?
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- Who performs a consultation report?
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- When is a transfer summary required?
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- What are data sets? What are their purpose?
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- What healthcare setting uses OASIS?
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- What healthcare setting uses DEEDS?
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- What healthcare setting uses MDS?
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- What healthcare setting uses UHDDS?
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- What are the basic documentation principles?
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- Who governs documentation?
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- What is CDI? What is its goal?
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- When do CDI reviews usually begin and end?
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| 41. What is a hybrid record? | |
| 42. In what record format will you find SOAP notes? | |
| 43. What are the goals of the electronic health record? | |
| 44. Do some medical organizations still use the paper-based record? | |
| 45. What is the role of the HIM professional in regards to the patient healthcare record? | |
| 46. What is CPOE? | |
| 47. What is HIE? | |
| 48. What is meaningful use? | |
| 49. What is SNOMED? What is its purpose within the electronic health record? | |
| 50. What does interoperability mean in regards to the electronic health record? | |
| 51. What is a PHR? | |
| 52. How does the PHR differ from the EHR? | |
| 53. Who controls access to the PHR? | |
| 54. Can you name some functions performed within a HIM department? | |
| 55. What is the MPI? What is its purpose? | |
| 56. How does the MPI affect the functions within a HIM department? | |
| 57. How does a duplicate record result? | |
| 58. What is the unit numbering? | |
| 59. How can paper-based patient health records be filed? | |
| 60. What are the advantages of terminal digit filing? | |
| 61. How are errors in a paper-based record corrected? | |
| 62. How are errors in an electronic health record corrected? | |
| 63. What is an addendum in regards to the health record? | |
| 64. What is an amendment in regards to the health record? | |
| 65. What is the purpose of the Forms/Design Committee? | |
| 66. Why do forms that go into the health record need to be regulated? | |
| 67. What is aggregate data? | |
| 68. What are the four purposes for collecting secondary data? | |
| 69. Who uses secondary data? | |
| 70. What is an index? What three indexes are used in healthcare? | |
| 71. What is a registry? Review the various registries | |
| 72. What is data stewardship? | |
| 73. What is privacy? | |
| 74. What is confidentiality? | |
| 75. What is security? | |
| 76. What is the purpose of a security program? | |
| 77. Identify access security mechanisms used to verify the user. | |
| 78. What is data granularity? | |
| 79. What is data consistency? | |
| 80. What is data accuracy? | |
| 81. What is data integrity? | |
| 82. What is a breach? | |
| 83. What is the procedure if a breach of patient information occurs? | |
| 84. What is the purpose of HL7? | |
| 85. Why do we need standards in terms of data transmission? | |
| 86. What is coding? | |
| 87. Explain the coding process. | |
| 88. What is ICD-10-CM? How is it used? | |
| 89. What is ICD-10-PCS? How is it used? | |
| 90. What is CPT? How is it used? | |
| 91. What is ICD-O-3? How is it used? | |
| 92. What is HCPCS? How is it used? | |
| 93. What is DSM? How is it used? | |
| 94. What is an encoder? | |
| 95. What is CAC? | |
