HIM 2000 HIM Professionals Role Worksheet

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Final Exam Review Worksheet Questions and Concepts 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? 4. What is the purpose of the patient’s health record? 5. Who uses the patient’s health record? 6. Is the health record a primary or secondary source of information? 7. Can you provide examples of secondary sources of information? 8. What are the three formats for the paper-based health record? Describe these 3 formats. 9. What determines the patient’s level of care? 10. What is the role of the Medical Staff Committee? 11. What is the role of the hospitalist within healthcare? 12. Can you name some regulatory and accrediting agencies that govern the healthcare record? 13. What is the role of Risk Management? 14. What is a critical care access hospital? 15. How does a specialty hospital differ from a rehabilitation hospital? 16. What is an Adult Daycare Center? 17. What services do a skilled nursing facility provide? 18. What is palliative care? 19. What are the two types of data contained within the patient’s health record? 20. Identify two external agencies that govern the patient’s health record? 21. What is the purpose of the Discharge Summary? 22. What are the timeliness requirements of the Discharge Summary? 23. What is the purpose of the History and Physical? Page 1 of 4 STUDY NOTES – Include things like where you located this information in your textbook, comments that help you understand the element or concept Final Exam Review Worksheet Questions and Concepts 24. What are the timeliness requirements of the History and Physical? 25. What is the purpose of the physician's order? 26. What is the frequency required of progress notes? 27. What is a pathology report? When is it required? 28. What is an autopsy report? Who signs the consent for an autopsy report? 29. What is informed consent? 30. Who performs a consultation report? 31. When is a transfer summary required? 32. What are data sets? What are their purpose? 33. What healthcare setting uses OASIS? 34. What healthcare setting uses DEEDS? 35. What healthcare setting uses MDS? 36. What healthcare setting uses UHDDS? 37. What are the basic documentation principles? 38. Who governs documentation? 39. What is CDI? What is its goal? 40. When do CDI reviews usually begin and end? 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? Page 2 of 4 STUDY NOTES – Include things like where you located this information in your textbook, comments that help you understand the element or concept Final Exam Review Worksheet Questions and Concepts 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? Page 3 of 4 STUDY NOTES – Include things like where you located this information in your textbook, comments that help you understand the element or concept Final Exam Review Worksheet Questions and Concepts 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? Page 4 of 4 STUDY NOTES – Include things like where you located this information in your textbook, comments that help you understand the element or concept
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Final Exam Review Worksheet

Final exam review Worksheet
Name
Institution of Affiliation
Date

Page 1 of 17

Final Exam Review Worksheet

Questions and Concepts

STUDY NOTES – Include things like where you
located this information in your textbook, comments
that help you understand the element or concept

1. What is the national association for
HIM professionals?

Health Information Management, (HIM) is a certified
organization that deals with the business and medical use
of electronic and paper based clinical information. The
organization provides training and resources that improve
the skills of the medical officers.

2. What is the role of the HIM

The roles of HIM is to capture or record data, analyze the

professional within the healthcare

outcomes and effectively use the data to advance

organization?

healthcare standards. The organization consist of several
certification which includes: General HIM credentials,
coding credentials, data analysis credentials and certified
documentation improvement credentials.

3. What are the two credentials available General HIM credentials
to HIM professionals?
4. What is the purpose of the patient’s
health record?

Coding credentials
Health record to the patient are of much significance.
Personal health record is the data and health facts upheld
by the patient. This data can be copied or printed and
shared using word processor which is compatible. They
ensure the availability of patient information whenever in

Page 2 of 17

Final Exam Review Worksheet

Questions and Concepts

STUDY NOTES – Include things like where you
located this information in your textbook, comments
that help you understand the element or concept
need. The data may include, lab outcomes or information
from other electronic device (Kaelber and Pan 2008).

5. Who uses the patient’s health record?

Insurer with the administration data (showel, 2017).

6. Is the health record a primary or

The roles of HIM is to capture or record data, analyze the

secondary source of information?

outcomes and effectively use the data to advance
healthcare standards. The organization consist of several
certification which includes: General HIM credentials,
coding credentials, data analysis credentials and certified
documentation improvement credentials.

7. Can you provide examples of
secondary sources of information?
8. What are the three formats for the

This includes publication such as book reviews and article
Journal or textbook
These includes, source-based health record, problem

paper-based health record? Describe

based health record and integrated health record. Source

these 3 formats.

based health data involves the use of computerized health
stored data. The data ensures the efficiency of healthcare
which highly depends on reliable, intergraded health
status and history of the patient. The data covers the
important of all stakeholders involved in providing
platform on which the information can be accessed when

Page 3 of 17

Final Exam Review Worksheet

Questions and Concepts

STUDY NOTES – Include things like where you
located this information in your textbook, comments
that help you understand the element or concept
only authorized. Problem based medical records enables
the doctor in recording the data concerning the patient
problem which helps in continuous assessment or
examination of the patient. The Information should be
complete and collected before the start of examining
patient problem. The problems are formulated in the list
based on nursing process and then each problem is
accessed daily with respect to patient status. Integrated
health record is used to offer discrete data from several
sources. The format consist of integrated supported tools
which enables the medical doctor to decide on suitable
test.

9. What determines the patient’s level of The patient’s level of care is determined by the intensity
care?

of illness. These can be custodial care, which is the most
important care provided to the patient in order to meet
daily living activities. This does not require trained
medical staff. Also it can be d...


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