RHIT Exam Prep 2023 with Complete Solutions

Alphabetic filing method - ANSWER-Used for paper records, no unique identifiers, not commonly used as it takes up storage space. Looks like: John Smith Numeric filing method - ANSWER-Medical record number, straight filing. Looks like: Terminal Digit - ANSWER-Seperates the medical record number into chunks. Looks like: 12 = Primary Unit 34= Secondary Unit 56= Tertiary Unit Middle Digit - ANSWER-Same as trrminal digit but the middle number is the Primary unit. Looks like: 34= Primary Unit 12= Secondary Unit 56= Tertiary Unit Alphanumeric Filing - ANSWER-Most Commonly Used. Looks like: JS (JS for John Smith) Family Numbering - ANSWER-One number identifier for each member of the family and one medical record number. It is most commonly used in pediatric offices and looks like 01-12345, 02-12345 Serial Numbering Identification System - ANSWER-A new medical record number for each admission. This isn't suitable for patient care because other records for that patient have to be tracked down. Unit Identification System - ANSWER-The patient receives a medical record number only once. Serial Unit Identification System - ANSWER-New medical record number for each admission but all previous records are to be merged. Centralized Identification System - ANSWER-All records kept on site Decentralized Identification Systems - ANSWER-The records are not kept on site Color Coding - ANSWER-Each number or letter is assigned a unique color. Chart Tracking System - ANSWER-Used for paper or hybrid records, example: Someone requests a record, they need to fill out a requisition, and that requisition is then slid into the slot that the record came from. This way you know where the record is and who has it. Think of a little receipt or tag hanging out. Audits - ANSWER-Necessary because you can find out if you have the records you say you hve. A report can be ran, which needs to match the records. Loose filing - ANSWER-This is where you pick up a record that may have some nurse notes not in the record and you need to put them in the appropriate area of the record. Record retention and destruction - ANSWER-This needs to follow federal and state standards! Depending on the state, you are required to retain each record for seven years after their last admission. Minors records must be kept until the age of 18 and then seven years after that. Microfilm Storage - ANSWER-"Small Photograph." Three types of microfilm: Roll Microfilm: Small photos are to be rolled. You cannot add to this once you have finished. A new roll will have to be started. Jacket Microfilm: A po ket that protects the small photos. You can add more photos but they cannot be edited if needed. Microfiche: Similar to Jacket microfilm, but it can hold more. Electronic CDs - ANSWER-Needs a backup and can't be added to Electronic Document Imaging - ANSWER-Can add to the record, edit, and delete. This is the most used Method of storage. Administrative Content of the Health Record - ANSWER-This is information that is not needed to treat. It includes a consent to treat, consent to use or disclose PHI, and advance directives. Clinical Content of the Health Record - ANSWER-Information needed to treat. It contains Medical history, diagnosis, physical exam, Clinical Observation, and conclusions including discharge summary and plan. Paper-based source-oriented Health record - ANSWER-Most common, filed according to origin. All nurse notes are together and ll physician notes are together. Problem-Oriented Health Record - ANSWER-List of problems, each diagnosis getting a number and a care plan. Integrated Health Record - ANSWER-Rarely used. Reads like a book, this is documentation as it happens. Quantitative Analysis of the Health Record - ANSWER-A review of the HR to determine its completeness and accuracy quantitative = quanity Qualitative Analysis of the Health Record - ANSWER-Identification of inconsistent or inaccurate documentation, qualitative = quality Master Patient Index - ANSWER-MPI is a list or database created and maintained by a healthcare facility to record the name and ID # of every patient who has been admitted or treated at the facility.