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?
What is the purpose of the patient’s health record?
Who uses the patient’s health record?
Is the health record a primary or secondary source of information?
Can you provide examples of secondary sources of information?
What are the three formats for the paper-based health record? Describe these 3 formats.
What determines the patient’s level of care?
What is the role of the Medical Staff Committee?
What is the role of the hospitalist within healthcare?
Can you name some regulatory and accrediting agencies that govern the healthcare record?
What is the role of Risk Management?
What is a critical care access hospital?
How does a specialty hospital differ from a rehabilitation hospital?
What is an Adult Daycare Center?
What services do a skilled nursing facility provide?
What is palliative care?
What are the two types of data contained within the patient’s health record?
Identify two external agencies that govern the patient’s health record?
What is the purpose of the Discharge Summary?
What are the timeliness requirements of the Discharge Summary?
What is the purpose of the History and Physical?
What are the timeliness requirements of the History and Physical?
What is the purpose of the physician’s order?
What is the frequency required of progress notes?
What is a pathology report? When is it required?
What is an autopsy report? Who signs the consent for an autopsy report?
What is informed consent?
Who performs a consultation report?
When is a transfer summary required?
What are data sets? What are their purpose?
What healthcare setting uses OASIS?
What healthcare setting uses DEEDS?
What healthcare setting uses MDS?
What healthcare setting uses UHDDS?
What are the basic documentation principles?
Who governs documentation?
What is CDI? What is its goal?
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?
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?
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?