In a manual record tracking system, outguides replace a file that has been checked out of the system. A secondary function of outguides is to
A. serve as a visual check for misfiled records.
B. expedite correct placement of refilled records.
C. enhance the use of file guides.
D. cross-reference a file that has been moved forward to a new number.
Which of the four distinct components of the problem-oriented record contains the medical and social history of the patient?
A. database.
B. problem list.
C. initial plan.
D. progress notes.
As information security officer, you are revising the policies at your rehabilitation facility for handling all patient clinical information. Your best resource for checking out specific accreditation standards and guidelines is the
A. Conditions of Participation for Rehabilitation Facilities
B. Medical Staff Bylaws, Rules, and Regulations
C. Joint Commission manual
D. CARF manual
Which of the following is a type of laser technology that is ideal for health records because it stores data in a permanent capacity, prohibiting users from altering, misfiling, or erasing data?
A. EDI.
B. OCR.
C. WORM.
D. COM.
Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.
A. patient admitted with COPD 1/4/2008 and discharged 1/7/2008
B. Baby Boy Hiltz's born 1/5/2008, maintained normal status, discharged 1/7/2008
C. Baby Boy Hiltz's mother admitted 1/5/2008, C-section delivery, discharged 1/7/2008
D. Baby Boy Doe admitted 1/3/2008, died 1/4/2008
An important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Both technical and procedural methods will bed used with the CPR to control and manage confidential information. An example of a procedural method for protecting data is
A. confidentiality statements signed by all staff.
B. limiting access of certain screens based on the staff's need to know.
C. auditing capability of system to track data access.
D. computer backup systems
As supervisor of the cancer registry, you report the registry's annual caseloads to administration. The most efficient way to retrieve this information would be to use
A. patient abstracts.
B. patient index.
C. accession register.
D. follow-up files.
Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?
A. database.
B. problem list.
C. initial plan.
D. progress notes.
Accreditation by Joint Commission is a voluntary activity for a facility and it is
A. a considered unnecessary by most health care facilities.
B. required for state licensure in all states.
C. conducted in each facility annually.
D. required for reimbursement of certain patient groups.
Which of the following indices might be protected from unauthorized access through t he use of unique identifier codes assigned to members of the medical staff?
A. disease index.
B. procedure index.
C. master patient index.
D. physician index.
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