HIM 101 Final Exam Questions With 100% Correct Answers
The most significant functions of HIM include storage and retrieval of patient
information. Other functions maintained include research and statistics, cancer and/or
trauma registries, birth certificate completion
It is essential to acknowledge the support services maintained by HIM such as answer
record processing, record completion analysis, transcription, release of information,
clinical coding, abstracting, and clinical data analysis
HIM functions are information-based and consist of maintaining information quality,
security, and accessibility.
What determines how those specific functions are performed? - Answer The medium in
which the information is stored.
What is the purpose of the health record system? - Answer To ensure accurate
information is available to authorized users in support of quality patient care.
What is record reconciliation? - Answer Hybrid System, upon patient discharge, receipt
of the health record is checked with a discharge list for completeness.
What are the most basic functions of most HIM departments? Storage and retrieval,
record processing, record completion, transcription, release of information (ROI), and
clinical coding
What is the most important index used by the HIM department? What is it? What is its
function? - Answer Master Patient Index (MPI) and is the permanent record of every
patient ever seen in the healthcare entity. The MPI functions as the primary guide to
locating pertinent demographic data about the patient and his or her health record
number. It is the initial point of documentation of the health record.
,What is an Enterprise Master Patient index (EMPI)? - Answer refers to all patients in two
or more facilities ie integrated healthcare delivery system or health information
exchange (HIE).
What can function as a MPI? - Answer Often the patient registration system aka
registration, admission, discharge, and transfer system R-ADT functions as the MPI
What are some advantages of an electronic system? An-swer ability to access data by
more than one individual at a time, edit checks can be applied against specific fields in
the database to better ensure data accuracy, can be easily cross-referenced (when a
patient has used more than one name during hospital or clinic visits), permits the use of
several search techniques for locating an existing patient's information.
What data elements may be used when searching for a patient's record? Answerm
edical record or billing number, date of birth, or social security number.
Maintenance To maintain the integrity of the MPI several quality control mechanisms
become necessary and include: - Answer Quality - MPI susceptible to errors
misspellings, incorrect demographic data, transposition of numbers and typographical
errors are few. Will cause treatment errors, billing problems and distorting the data
analysis of the organization patient population.
Duplicate, Overlay, and Overlap Medical Record Number Issues Unable to locate patient
information at time of admission and new record is created; Or patient is matched to
incorrect health record
What is an overlay? A patient is given the medical record number of another patient com
mingle that patient medical information with that patient resulting in identifying what
medical information pertains to what patient
What is overlap? -Answer When more than one medical record number exists for the
same patient within an enterprise at different facilities or in different databases. Often
occur in organization with multiple facilities or can occur in the health information
exchanges. Frequently problem arises when there are facility or organization mergers
and an enterprise master person/patient index (EMPI) is created
,Strategies for MPI Integrity-Answer Integrity must be maintained in order to avoid
problems including patient safety, customer service, risk management and legal and
other issues. MPI cleanup process- matching algorithms are utilized in order to locate
and correct these problems. 3 types: are often part of the MPI application: a
DETERMINISTIC algorithm requires an exact match of combined data elements such as
name, birth date, sex, and social security number. The PROBABILISTIC algorithm is
based on complex mathematical formulas that analyse the facility-specific MPI data in
order to determine precisely matched weight probabilities for attribute values of various
data elements. The RULES-BASED algorithm assigns the weights, for significant values,
to particular data elements and later uses these weights in the comparison of one
record to another.
The high quality, error-free MPI management requires continuous maintenance that
includes :
What is first line of defense? Oversight, evaluation and correction of errors.
The front line of defense should be the prevention of problems. Communication back to
the department responsible for the errors is key to providing awareness of the
importance of the MPI and identifying opportunities for training and workflow issues.
HIE Health Information Exchange= sharing of health information electronically among
two or more entities and also an organization that provides services to accomplish this
information exchange.
What is the purpose of an HIE organization? - Answerto increase the availability of
health information to authorized stakeholders in order to improve quality and safety of
healthcare delivery across the continuum.
How they ensure the integrity of patient's identity in health information exchange -
Answer Standardization of health information exchange practices is the most essential
Paper-based identification systems patient id:
Serial numbering System - Answer Patient is assigned a unique numeric identifier for
every visit or admission to a healthcare organization. Disadvantage: details pertaining
to the care and treatment of the patient are filed in separate health records and at
, different locations. Retrieval more difficult. Not as effective.
Unit numbering system-Answer most commonly used for large facilities. The patient is
given a unique number when he is first admitted, and that same number is used when he
comes in for subsequent encounters. Method most commonly used as unique identifier
in EHR environment.
Serial Unit Numbering System - The answer numbers are assigned serially as is done in
the serial numbering system, however during each new patient encounter brought
forward are the previous health records which are filed under the last assigned health
record number.
Where should the process for checking patient records be located? - Answer the
facility's charting policies and procedures
The system in which a health record number is assigned at the first encounter and is
used for all subsequent healthcare encounters is the: - Answer Unit numbering system
The major guide to locating a record in a numerical filing system is the - Answer Master
Patient Index MPI
What type of algorithm(s) may be used to identify duplicate medical record numbers? -
Answer Deterministic, Probabilistic, and Rules Based.
The health record number is assigned by: - Answer Patient registration
Which one of the following is used to locate an electronic health record - Answer Health
record number
John Smith was a patient who was treated within a multi-hospital system and was
assigned three different medical record numbers. Multiple health record numbers are
referred to as: - Answer Duplicates