Standardizing medical terminology to avoid differences in naming various medical conditions and
procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one
purpose of: - Vocabulary Standards
Ensuring the patient information is reliable and the same across the entire patient encounter is: - Data
Consistency
Which health record uses an itemized list of the patient's present and past health problems? - Problem-
Oriented health record
What is the process that allows for connections between two systems? For example, two different code
systems to show equivalent codes allows for data initially captured for one purpose to be translated and
used for another purpose. - Data Mapping
Who must also be notified of a duplicate health record, after the HIM department has merged the
records? - The source of the record, example: Laboratory
What type of analysis compared omitted clinical information received from external providers with the
needed clinical information to make a correct diagnosis? - Gap Analysis
Who provides oversight for the development, review, and control of forms and computer screens? -
Clinical Forms Committee
What index contains a list maintained in diagnosis code number order for patients who are discharged
from a facility during a particular time period? - Disease Index
In a database the LAST_NAME column in a table would be considered a: - Data Element
Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory
reports, and consultation reports are owned: - By the Hospital
,Typically, healthcare facilities should retain the master patient index for how long? - Permanently
Which of the following is the health record component that addresses the patient's current complaints
and symptoms and lists that patient's past medical, personal, and family conditions? - Medical History
What is the information collected during day-to-day operations of a healthcare organization that has
value within an organization? - Information Assets
What is a descriptive list of the data elements to be collected in an information system or database
whose purpose is to ensure consistency of terminology? - Data Dictionary
What is the best definition of system of record (SOR)? - Authoritative source for data about an entity
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
- Laboratory Findings
A patient's gender, phone number, address, next of kin, and insurance policy holder information would
be considered what kind of data? - Administrative Data
What requires that the attributes and values of data be defined at the correct level of detail for the
intended use of the data? - Data Granularity
How is the patient registration department assisted by the HIM department? - Assigns the Health
Record Number
A hospital's EHR defines the expected values of the gender data element as female, male, and unknown.
This type of specificity is known as: - Data Precision
What is the term used to describe expected data values? - Data Precision
, The act of granting approval to a healthcare organization based on whether the organization has met a
set of voluntary standards is called: - Accreditation
What means ensuring the patient data is reliable and the same across the entire patient encounter? -
Data Consistency
What is it when there is a linking of an older version of a code set to a newer version? - Forward
Mapping
A special web page that offers secure access to data is a(n): - Portal
What ethical principle is being followed when a health information management professional ensures
that patient information is only released to those who have a legal right to access it? - Beneficence
The release of information function requires the HIM professional to have knowledge of? - Federal and
State Confidentiality Laws
What is the term used most often to describe the individual within an organization who is responsible
for protecting health information in conjunction with the court system? - Custodian of Records
An individual's right to control access to his or her personal information is known as? - Privacy
The function used to provide access controls, authentication, and audit logging in an HIE is? - Identity
Management
A contract coder, billing companies, consultants, and accounting firms are examples of what? - Business
Associates
What refers to guarding against improper information modification to destruction? - Integrity
Release of birth and death information to public health authorities: - Is a public health activities
disclosure that does not require patient authorization
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller oneclass. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.48. You're not tied to anything after your purchase.