HIM - Chapter 1 questions and answers graded A+ 2023

HIM - Chapter 1Before 1918 who was responsible for the creation and management of hospital medical records? - correct answer The physcians Medical records in the early 20th century contained mostly what? - correct answer Nurses notes The hospital standardization program what inaugurated by who, when? - correct answer The American College of Surgeons in 1918 What was the purpose of the Hospital Standardization program? - correct answer To raise standards of surgery by establishing minimum quality standards for hospitals and to provide complete medical records. A medical record must include what information? - correct answer Patient ID data, complaint, diagnosis, reason for admission, personal and family history, history of the present illness. physical examination, consultations, lab and xray, med/surgical treatment, pathology report, progress notes, final diagnosis, condition on discharge, follow up, and if death, autopsy findings. In a hospital, who gives the orders for the pt? - correct answer The Attending Physician What year was the Association of Record Librarians formed? - correct answer In 1928 HIM professionals understood that for an occupation to be recognized as a profession they needed training. Therefore, the association adopted a formal________. - correct answer Curriculum Accreditation - correct answer Voluntary process of institutional or organizational review in which a body created for this purpose periodically evaluates the quality of the entities work against preestablished criteria. Also, a determination by an accrediting body that an eligible organization, network, or program complies with applicable standards. What is CAHIIM? - correct answer Accredits institutions under the auspices of AHIMA **oversees accreditation** What does the board of registration do? - correct answer Established a criteria for eligibility for registration CCHIIM - correct answer The board of registration that administers the qualifying examinations, oversees AHIMA;s certification process for setting policies and procedures Evolution of AHIMA - correct answer 1928- American association of medical record librarians or north amer (ARLNA) 1944 - American Association of Medical record librarians (AAMRL) 1970 - American medical Record Association (AMRA) 1991- American Health Information management Association (AHIMA) Credentials : Registered Record Administrator is now (RRA) - correct answer RHIA (registered health information administrator) Accredited record Technician is now (ART) - correct answer RHIT (Registered health information technician) The original practice of HIM was based on? - correct answer The hospital standardization program of 1918, which emphasized the need to ensure complete and accurate medical records were compiled and maintained for every patient. What are the 4 Funtions of HIM (paper record) - correct answer 1. Assemble 2. Analysis 3. Coding 4. Abstracting Assemble - correct answer putting records in chorono order by date