CHAPTER 4 EXAM HIM QUESTIONS
WITH COMPLETE SOLUTIONS
/.Examine the evolution of the patient health record from simply noting the patient name
and illness to an EHR. Why do you think this evolution was necessary, and what
benefits and challenges do we now face with the EHR? - Answer-✅The patient health
record was initially a brief documentation of the patient's name and illness because
there was likely one care provider who took care of the community and held all the
records. As more providers became involved, communities grew, and medicine
advanced; more details needed to be documented and stored. The development of
quality initiatives, rules, regulations, and standards along with a mobile population
prompted the need for electronic records. The benefits of EHRs include the ability to
treat patients at multiple locations while having all the patient documentation available,
simultaneous viewing of patient documentation for providers and staff, and the ability to
document remotely. There are many more benefits related to aggregating data,
reimbursement, and research. Challenges include privacy and security, data integrity,
system downtime, interoperability, provider acceptance and training, and patient
education
/.The medical staff has been upset by the number of admitting privilege suspensions.
The HIM director has been asked to attend a meeting of the medical staff to address
this issue. What information should be present? - Answer-✅The HIM director should
have the medical staff bylaws with him and explain the areas of the bylaws illustrating
the documentation that is required, the time frame in which documentation is required,
and the consequences (up to and including suspension of admitting privileges) of not
meeting the standards set in the bylaws. The HIM director may also want to have
related accreditation standards as well as state licensure and federal requirements
available showing that they often drive the medical staff bylaws.
/.Patient health records hold a plethora of information. What are three ways patient
health record data can be used aside from direct patient care? - Answer-✅Patient health
record data can be used to determine if a particular clinical service is profitable or not; it
can be used to review what types of conditions are most common in the emergency
department; it can assist with looking for trends in patients who are readmitted to the
hospital; and it can be used to educate providers on the effectiveness of particular
treatments.
/.What is the role of each of the following in the development of standards for health
information: Joint Commission, CMS, state licensure, and medical staff bylaws? -
Answer-✅The Joint Commission promotes voluntary accreditation and develops and
publishes standards to help improve the safety and quality of healthcare in the US. A
large portion of Joint Commission's standards focus on information and documentation.
, CMS includes requirements for records in its Conditions of Participation. The Conditions
of Participation spell out requirements that facilities must meet to be part of CMS
programs.
State licensure has regulations for content of records and information that must be
reported.
The bylaws of individual facilities contain requirements and procedures that must be
followed by the medical staff in consideration of both internal needs and external
requirements.
/.Why is a longitudinal health record valuable, and why is a longitudinal health record in
a hybrid system difficult to achieve? - Answer-✅A longitudinal health record is a birth-to-
death record that acts as an ongoing reference for and about the patient. The problem
with achieving a longitudinal health record with a hybrid system is that the patient has
paper records in multiple settings that cannot be linked.
/.The care provider is ultimately responsible for ensuring the quality of health record
documentation. What is the HIM professional's role in regard to quality documentation?
- Answer-✅Health information managers ensure that providers have the necessary
information, tools and
processes to understand and adhere to the regulations and standards for proper
documentation. HIM professionals audit the records for compliance, inform and educate
the providers on issues, and design processes (automated or manual) to assist
providers.
/.A physician called the unit coordinator to specify the medications needed for her
patient. - Answer-✅d. Orders
/._As a surgeon prepares for surgery, she looks to the patient record for a
comprehensive assessment of the patient - Answer-✅c. History and physical
/.A physical therapist documented which exercises his patient did today including the
level of improvement. - Answer-✅j. Ancillary notes
/.A patient explained how difficult it was for her to see her mother develop dementia at
only age 42. - Answer-✅b. History
/.A 70-year-old patient arrived unconscious in the emergency department following a
heart attack with no family by her side; the physician on duty needs direction in
providing her care. - Answer-✅g. Advance directives
/.An attending physician reviewed the medical record to determine if the patient's blood
pressure was coming down. - Answer-✅f. Nursing notes
/.A patient's family practitioner needs direction in following up on her condition after a
recent brief hospitalization. - Answer-✅i. Discharge summary
WITH COMPLETE SOLUTIONS
/.Examine the evolution of the patient health record from simply noting the patient name
and illness to an EHR. Why do you think this evolution was necessary, and what
benefits and challenges do we now face with the EHR? - Answer-✅The patient health
record was initially a brief documentation of the patient's name and illness because
there was likely one care provider who took care of the community and held all the
records. As more providers became involved, communities grew, and medicine
advanced; more details needed to be documented and stored. The development of
quality initiatives, rules, regulations, and standards along with a mobile population
prompted the need for electronic records. The benefits of EHRs include the ability to
treat patients at multiple locations while having all the patient documentation available,
simultaneous viewing of patient documentation for providers and staff, and the ability to
document remotely. There are many more benefits related to aggregating data,
reimbursement, and research. Challenges include privacy and security, data integrity,
system downtime, interoperability, provider acceptance and training, and patient
education
/.The medical staff has been upset by the number of admitting privilege suspensions.
The HIM director has been asked to attend a meeting of the medical staff to address
this issue. What information should be present? - Answer-✅The HIM director should
have the medical staff bylaws with him and explain the areas of the bylaws illustrating
the documentation that is required, the time frame in which documentation is required,
and the consequences (up to and including suspension of admitting privileges) of not
meeting the standards set in the bylaws. The HIM director may also want to have
related accreditation standards as well as state licensure and federal requirements
available showing that they often drive the medical staff bylaws.
/.Patient health records hold a plethora of information. What are three ways patient
health record data can be used aside from direct patient care? - Answer-✅Patient health
record data can be used to determine if a particular clinical service is profitable or not; it
can be used to review what types of conditions are most common in the emergency
department; it can assist with looking for trends in patients who are readmitted to the
hospital; and it can be used to educate providers on the effectiveness of particular
treatments.
/.What is the role of each of the following in the development of standards for health
information: Joint Commission, CMS, state licensure, and medical staff bylaws? -
Answer-✅The Joint Commission promotes voluntary accreditation and develops and
publishes standards to help improve the safety and quality of healthcare in the US. A
large portion of Joint Commission's standards focus on information and documentation.
, CMS includes requirements for records in its Conditions of Participation. The Conditions
of Participation spell out requirements that facilities must meet to be part of CMS
programs.
State licensure has regulations for content of records and information that must be
reported.
The bylaws of individual facilities contain requirements and procedures that must be
followed by the medical staff in consideration of both internal needs and external
requirements.
/.Why is a longitudinal health record valuable, and why is a longitudinal health record in
a hybrid system difficult to achieve? - Answer-✅A longitudinal health record is a birth-to-
death record that acts as an ongoing reference for and about the patient. The problem
with achieving a longitudinal health record with a hybrid system is that the patient has
paper records in multiple settings that cannot be linked.
/.The care provider is ultimately responsible for ensuring the quality of health record
documentation. What is the HIM professional's role in regard to quality documentation?
- Answer-✅Health information managers ensure that providers have the necessary
information, tools and
processes to understand and adhere to the regulations and standards for proper
documentation. HIM professionals audit the records for compliance, inform and educate
the providers on issues, and design processes (automated or manual) to assist
providers.
/.A physician called the unit coordinator to specify the medications needed for her
patient. - Answer-✅d. Orders
/._As a surgeon prepares for surgery, she looks to the patient record for a
comprehensive assessment of the patient - Answer-✅c. History and physical
/.A physical therapist documented which exercises his patient did today including the
level of improvement. - Answer-✅j. Ancillary notes
/.A patient explained how difficult it was for her to see her mother develop dementia at
only age 42. - Answer-✅b. History
/.A 70-year-old patient arrived unconscious in the emergency department following a
heart attack with no family by her side; the physician on duty needs direction in
providing her care. - Answer-✅g. Advance directives
/.An attending physician reviewed the medical record to determine if the patient's blood
pressure was coming down. - Answer-✅f. Nursing notes
/.A patient's family practitioner needs direction in following up on her condition after a
recent brief hospitalization. - Answer-✅i. Discharge summary
