Health Records and Information Mgmt (Ch. 25)

Question 1

A Health record is what type of document?

Answer 1

Legal document

Question 2

Function of the Health Management Department

Answer 2

To maintain the system to store and retrieve clinical info on every patient
-can be maintained in 1 or more forms (hard copy or computerized form)

Question 3

What does Coding involve?

Answer 3

Converting diagnoses and procedures into a numeric classsification system

Question 4

What two federal gov. programs are involved in coding?

Answer 4

• PPS (Prospective Payment System)

- DRGs (Diagnostic Related Groups)

Question 5

Medicare is managed by what government?

Answer 5

Federal Gov.

Question 6

Medicaid is managed by what government?

Answer 6

Runs by theState Gov., funded by federal gov.

Question 7

Coding is used for what regarding Medicare and Medicaid?

Answer 7

reimbursements

Question 8

ICD codes are used for what?

Answer 8

classification system is used to code diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury/disease

Question 9

Helth Record Content includes?

Answer 9

Patient identification, medical history (chief comlaint, present illness or injury, relevant family and social history), report of relevant physical exam, diagnostic and therapeutic orders

Question 10

Image management involves what?

Answer 10

Maintaining a secure electronic system for archiving of digital images
-film uses a computerized tracking system which may utilize bar coding

Question 11

Health Record in Radiology includes what?

Answer 11

• Request for service
• patient demographic info
• specific procedure requested
• physician ordering

Question 12

If a diagnosis, sign, or symptom is not documented, what happens?

Answer 12

There is a delay or failure of payment–which can result in a delay in performing the procedure

Question 13

What is a Radiology Report?

Answer 13

A report in which a radiologist describes what is seen on the radiograph and the implications for the patient

Question 14

Health Records can serve as evidence in court, True or False?

Answer 14

True

Question 15

3 Legal Aspects of Health Records

Answer 15

• They are legal documents
• Records what was done or what was not done to a patient
• Record can be submitted as evidence in court cases

Question 16

If something is not documented, then what is assumed?

Answer 16

It is assumed that an event didn’t take place

Question 17

Health information management departments are identifed as what?

Answer 17

Support Service department

Question 18

HIPPA stands for…

Answer 18

Health Insurance Portability and Accountabilty Act

Question 19

Hospitals have a right to charge a fee to the patient for their medical record.. True or False

Answer 19

True

Question 20

If a patient asks to review their chart during transport or before their exam, what should you do?

Answer 20

This is not allowed..patient could misinterpret info written..tech should refer patient to the physician to discuss the record

Question 21

MQSA stands for what?

Answer 21

Mammography Quality Standards Act

Question 22

How long can a facility keep a mammogram in the permanent record of a patient?

Answer 22

No less than 10 yrs

Question 23

Which record is used in court?

Answer 23

A photocopy of the original record

Question 24

CPT codes are used for what?

Answer 24

Procedural classification