CHIMA EXAM PREP - Health Information Management / Health Information Systems / Moving Towards an HER. Questions & Answers, verified.

CHIMA EXAM PREP - Health Information Management / Health Information Systems / Moving Towards an HER. Questions & Answers, verified. Which stage is stated to be the most important stage in the health information lifecycle? a. Maintenance and protection b. Information management planning c. Evaluation d. Capture and collection - -b. Information management planning Which stage of the health information life cycle ensures that necessary safeguards are in place for the appropriate use of patient information? a. Governance and accountability b. Capture and collection c. Disposition d. Access, use and dissemination - -a. Governance and accountability If a healthcare organization plans to exchange health information with other organizations, the data created must meet what international standard? a. CIHI b. EHRS BluePrint Version 2 c. IHE Cross Document Sharing profile d. Heath Level Seven International (HL7) - -d. Heath Level Seven International (HL7) An example of unstructured data is: a. an electrocardiogram b. digital heart sounds c. ultrasound data d. transcribed reports - -d. transcribed reports An example of discrete, structured data is: a. free-text boxes on-line b. nuclear medicine stored as bit mapped c. medication orders d. cardiac catheterizations - -c. medication orders What should be developed for direct charting, voice recognition or transcribed documents to promote the consistent use of language and expression? a. Organization-specific lists of abbreviations, acronyms and symbols b. A staff education program on implications to patient safety of misinterpreted truncated words or characters c. Templates d. Data Dictionary - -c. Templates Acceptable authentication for electronic records includes the author using a/an: a. digital signature or computer key b. template to track changes c. initials with corresponding signature legend d. audit trail - -a. digital signature or computer key Which of the following in NOT an objective component of SOAP a. Patients chief complaint b. Blood Pressure c. Previous lab or diagnostic test results d. Vital Sign Measurements - -a. Patients chief complaint What is the "retraction" as it pertains to health Information? a. Removing a document from one individual's records and posting it to another record b. A late entry that provides additional information about a previous entry c. Deleting duplicate health records within a master patient index (MPI) d. Separating health records that were inadvertently merged within an MPI - -a. Removing a document from one individual's records and posting it to another record What type of data irreversibly disturbs any linkages between the individual and their health information a. Research Data b. Anonymized data c. De-identified data d. Aggregate Data - -b. Anonymized data Which stage of the information lifecyle ensures that HI is kept current and secure? a. Disposition b. Evaluation c. Maintenance and protection d. Preservation - -c. Maintenance and protection Capture and collection phase of the Health Information Lifecycle Define Administrative - -To support strategic and operational planning for an organization and individual programs, evaluate resource use, and assess funding requirements. Capture and collection phase of the Health Information Lifecycle Define Clinical - -To facilitate and promote continuity and quality of care and serve as a communication tool amongst care providers Capture and collection phase of the Health Information Lifecycle Define Education - -To support teaching and continuing education programs for medical and other students, interns, and residents affiliated with a university or other educational institution Capture and collection phase of the Health Information Lifecycle Define Legal Events - -To provide information in cases of litigation, including criminal proceedings, custody battles and appeals for privileges Capture and collection phase of the Health Information Lifecycle Define Professional practice assessments - -To assess the competence of care providers and enable professional regulatory bodies to investigate potential misconduct of their licensed or certified members Capture and collection phase of the Health Information Lifecycle Define Research - -To support clinical and other projects