Study Aid For Guide To Clinical
Documentation latest Edition Isbn –
9780803666627, All 12 Chapters ||
Complete A+ Guide
Purpose of health record - answer-Ensure continuity of patient care among providers and along
the continuum of care.
Data analytics purpose - answer-It is a means for data analytics for evaluating outcomes,
trending data, and fulfilling administrative reporting requirements.
Quality monitoring - answer-It is a mechanism for monitoring quality-related issues.
Peer review support - answer-Supports peer review activities.
Reimbursement documentation - answer-Provides documentation to substantiate
reimbursement, claim submissions, and the medical necessity of care.
Legal protection - answer-Protects the legal interests of customers, caregivers, and healthcare
organizations.
Biomedical research support - answer-Provides clinical data for biomedical research.
Professional education support - answer-Supports professional education and training for
1
, physicians, nurses, and allied health professionals.
Operational management - answer-Supports operational management of healthcare
organizations.
Public health data - answer-Provides health services data for public health planning and
governmental policymaking.
Ownership of health record - answer-The health record itself belongs to the healthcare facility
or provider that created it.
Patient information ownership - answer-The information in each record belongs to the
individual patient.
Main users of health records - answer-Healthcare providers, allied health professionals,
administrative staff, and supportive staff.
Aggregate data users - answer-Some users, such as researchers or statisticians, don't access
individual patient care records, but aggregate data taken from health record documentation.
Types of individual health record users - answer-Patient care providers and allied health
professionals, patients, families, patients' legal representatives.
HIM professionals' role - answer-HIM professionals must validate the appropriateness of access.
Legal Health Record definition - answer-Documents and data elements that healthcare
providers may include in response to legally permissible requests for patient information.
2
Documentation latest Edition Isbn –
9780803666627, All 12 Chapters ||
Complete A+ Guide
Purpose of health record - answer-Ensure continuity of patient care among providers and along
the continuum of care.
Data analytics purpose - answer-It is a means for data analytics for evaluating outcomes,
trending data, and fulfilling administrative reporting requirements.
Quality monitoring - answer-It is a mechanism for monitoring quality-related issues.
Peer review support - answer-Supports peer review activities.
Reimbursement documentation - answer-Provides documentation to substantiate
reimbursement, claim submissions, and the medical necessity of care.
Legal protection - answer-Protects the legal interests of customers, caregivers, and healthcare
organizations.
Biomedical research support - answer-Provides clinical data for biomedical research.
Professional education support - answer-Supports professional education and training for
1
, physicians, nurses, and allied health professionals.
Operational management - answer-Supports operational management of healthcare
organizations.
Public health data - answer-Provides health services data for public health planning and
governmental policymaking.
Ownership of health record - answer-The health record itself belongs to the healthcare facility
or provider that created it.
Patient information ownership - answer-The information in each record belongs to the
individual patient.
Main users of health records - answer-Healthcare providers, allied health professionals,
administrative staff, and supportive staff.
Aggregate data users - answer-Some users, such as researchers or statisticians, don't access
individual patient care records, but aggregate data taken from health record documentation.
Types of individual health record users - answer-Patient care providers and allied health
professionals, patients, families, patients' legal representatives.
HIM professionals' role - answer-HIM professionals must validate the appropriateness of access.
Legal Health Record definition - answer-Documents and data elements that healthcare
providers may include in response to legally permissible requests for patient information.
2
