C810 questions and answers graded A+ 2023/2024

C8101. What are the three related subsystems of government in the United States and what are their roles? - correct answer Judicial System: Enforces both rights and obligations through the court system Legislative System: Enacts the laws through statutes created by legislative bodies. Administrative System: Controls governmental administrative operations that enact regulations four sources of laws in the United States? - correct answer · Constitutional Law · Common Law · Statutory Law Administrative Law What steps should an organization take to define its legal health record? What special considerations should be taken into account for defining a legal electronic health record? - correct answer HIM professionals and other designated individuals should consider state and federal laws that define health record content and the Federal Rules of Evidence (FRE). What are the three types of advance directives and how do they differ from one another? - correct answer Durable power of attorney for healthcare decisions: Executed by a competent adult, designates another person (proxy) to make healthcare decisions consistent with the individual's wishes on the individual's behalf Living will: Executed by a competent adult, expressing the individual's wishes Do-Not-Resuscitate (DNR): Individual's wish not to receive treatment, specifically cardiopulmonary resuscitation. Who is responsible for ensuring the quality of health record documentation? - correct answer The provider of care is responsible for ensuring entries made in the record are of high quality How does the HIM professional help providers complete health records? - correct answer supports the patient care process by ensuring quality and timely documentation in the patient record Differentiate between quantitative analysis and qualitative analysis. What purpose do they serve? - correct answer Quantitative analysis is a review of the record for completeness and accuracy Qualitative analysis is a more thorough review of the quality and accuracy of the documentation, ensuring it meets standards and regulations. Why is it important for providers wanting a new form to go through the approval process? - correct answer to ensure control of the form, especially as the transition to imaging or computerized systems continues. How will the forms review process, including HIM oversight, change with implementation of electronic health records? - correct answer As health records move toward an electronic format, the forms' design process becomes the process of designing computer views and templates for entry of data, but the principles of control still apply. This transition requires extensive input and expertise from the HIM professional. Why is the MPI considered the key index in the HIM department? - correct answer The master patient index (MPI) is the key locator for records in a numerical filing system because it contains the patient numbers by which the records are filed. What are some of the reasons why incorrect information is obtained? - correct answer · someone other than the patient provided the information, · something was spelled incorrectly, · different names or initials are used for the same patient, · there were clerical mistakes, and there was a difference in language. What are the consequences of a patient having duplicate health record numbers? - correct answer When duplicate records are present in the EHR, data can become conflicted amongst providers, causing poor patient care and incorrect treatment. information and certainty for identification that are critical to the quality and safety of patient care.