HIM 319 Final Study Guide Questions AND Correct Answers
A for Assessment - ✔✔based on findings and observations from
clinicians
ex: problem list, diagnosis
Abstracting (method of data collection) - ✔✔process of reviewing
patient record and collecting pertinent data elements, usually in an
electronic base
Abstracting information from records - ✔✔Registration record -
demographic data
ex. Name
Medical record number
Address / telephone number
DOB
Gender
Marital status
Race
SSN
Insurance Co group number
Insurance Co, address, name of subscriber
,Guarantor, if applicable
Patient relationship to insured
Employer
Occupation
Problem-list -
Summary of all medical and surgical problems, including allergies and
social situations that may have a significant impact on clinical
management
ex. history of child abuse
risk factors such as smoking, alcohol and drug usage
family history of cancer, diabetes, heart disease
Medication List - list of meds patient is taking
ex. Names of meds
Dosages and amounts dispensed
Rx dates and discontinued dates
Problem numbers for which each rx was prescribed
,Patient history questionnaire - lists current and past medical
conditions
Medical history - provider's findings on patient's health status
ex. Chief complaint or reason for visit
Present illness
Past medical history
Social or personal history
Family history
Physical exam report - provider's findings upon examination of the
patient
Immunization and injection records - chronicle the patient's
vaccinations
Progress notes - chronological summary of the patient's illness and tx
at each encounter
S
O
A
P
, Physician orders- instructions the physician gives to other parties to
provide specific meds, svcs, dx tests or tx
ex. Pic
accession number - ✔✔A number assigned to each case as it is
entered in a cancer registry
-it consists of nine-digits
-first four digits represent the year
-the last five digits are approximate chronological order of the
abstracts prepared for that year
accreditation - ✔✔•evaluates an organization using standards that
establish expectations and criteria as a measure of quality
performance
-Accreditation is voluntary but its benefits include:
•Enhancement of public reputation to attract patients and provider
staff
•Satisfaction of program payment requirements (such as Medicare)
through deemed status if the accreditor has deeming authority
•Satisfaction of many state licensure requirements
Accreditation - ✔✔cancer committee is required for accreditation
A for Assessment - ✔✔based on findings and observations from
clinicians
ex: problem list, diagnosis
Abstracting (method of data collection) - ✔✔process of reviewing
patient record and collecting pertinent data elements, usually in an
electronic base
Abstracting information from records - ✔✔Registration record -
demographic data
ex. Name
Medical record number
Address / telephone number
DOB
Gender
Marital status
Race
SSN
Insurance Co group number
Insurance Co, address, name of subscriber
,Guarantor, if applicable
Patient relationship to insured
Employer
Occupation
Problem-list -
Summary of all medical and surgical problems, including allergies and
social situations that may have a significant impact on clinical
management
ex. history of child abuse
risk factors such as smoking, alcohol and drug usage
family history of cancer, diabetes, heart disease
Medication List - list of meds patient is taking
ex. Names of meds
Dosages and amounts dispensed
Rx dates and discontinued dates
Problem numbers for which each rx was prescribed
,Patient history questionnaire - lists current and past medical
conditions
Medical history - provider's findings on patient's health status
ex. Chief complaint or reason for visit
Present illness
Past medical history
Social or personal history
Family history
Physical exam report - provider's findings upon examination of the
patient
Immunization and injection records - chronicle the patient's
vaccinations
Progress notes - chronological summary of the patient's illness and tx
at each encounter
S
O
A
P
, Physician orders- instructions the physician gives to other parties to
provide specific meds, svcs, dx tests or tx
ex. Pic
accession number - ✔✔A number assigned to each case as it is
entered in a cancer registry
-it consists of nine-digits
-first four digits represent the year
-the last five digits are approximate chronological order of the
abstracts prepared for that year
accreditation - ✔✔•evaluates an organization using standards that
establish expectations and criteria as a measure of quality
performance
-Accreditation is voluntary but its benefits include:
•Enhancement of public reputation to attract patients and provider
staff
•Satisfaction of program payment requirements (such as Medicare)
through deemed status if the accreditor has deeming authority
•Satisfaction of many state licensure requirements
Accreditation - ✔✔cancer committee is required for accreditation
