HRSC 206 Patient Record
Fundamentals Exam Study Guide
What is the standard? - Answer What is expected
A series of acknowledged and accepted steps, what is expected and required of
individuals and organizations.
What is a rule? - Answer The way things are/should be done
Description of the way things are, or should be done, guide for conduct and action
What is the best practice? - Answer The best/most efficient way to get things done
Method or technique that is most efficient and effective way of completing task or
course of action
Why are standards required? - Answer -Establishes a framework for improving
communications.
-Define's responsibility for both client and provider
-Compare for performance and benchmark for assessing
-Compare results with those of other organizations
Why are demographic rules important? - Answer The rules provide the guidelines that
are to be followed
What is involved in the registration business process? - Answer Step 1- positivity identify
the patient
Step 2- a search must be carried out to see weather or not they have been see before
Step 3- verify all demographic info
Step 4- register patient into system
What is PPI? - Answer Positive patient identification
Acceptable proof of identity documents include: - Answer -Valid drivers license
-valid passport
-Canadian citizenship card
-Canadian permanent resident card
-Certificate of Indian status card
,-Valid Alberta student ID
-Valid, provincial/territorial healthcare card
-Federal provincial, and territorial, issued identification with photograph
Registration standard #1 - Answer All individuals accessing the Alberta health system
are required to uniquely identify themselves
Registration standard #2 - Answer Only true and accurate data about client is recorded
in registration system. This excludes fetuses, body parts, specimens nonhumans(pets)
Standard #3 - Answer A search of all relevant registration systems will be conducted
prior to completing a registration
Standard #4 - Answer All adult individuals accessing the Alberta health system will
present at least two pieces of original supporting documentation to establish unique
identity. Children under 18 will only present one.
Standard #5 - Answer All client demographic information must be verified with client
before the registration process is completed.
Standard #six - Answer A unique identifier is assigned to all clients in Alberta health
system
Standard #7 - Answer A client registration must include a minimum set of demographic
information, consists of last name, first name, date of birth, gender, unique identifier
Rules for name - Answer -all registrations must include documented name
-before name can be changed or updated individuals are required to provide proof
-Name cannot consist of numeric or special characters
Best practises newborn name - Answer Last: mothers or fathers last name
First: female or male, entered until baby is named
Multiple births: indication of birth order and gender, "twinAfemale, TwinBmale"
One legal name - Answer Entered in both first name and last name field. Eg. "Mauli
mauli"
Preferred name - Answer Clients should be recorded by their documented first, middle,
and last name for consistent identification purposes
Unknown name - Answer Last name: client ID/MRN for client
First name: gender of client
Administrative gender - Answer Recorded as indicated on identification presented at
,time of registration
U and X values for gender - Answer U= unknown
X= does not identify their gender as male or female, or has chosen to not disclose their
gender
DOB - Answer -Date of birth is mandatory data
-Confirmed by supporting documentation
-I required to provide acceptable proof before changing or updating DOB
Unknown DOB - Answer Default value: 1900-01-01
Date of death - Answer -Should be recorded in patient registration system only with
supporting documentation
-Statements from next of kin must be confirmed with acceptable source
!!!!MUST HAVE SUPPORTING SOURCE!!!
Unknown Address - Answer Address line: "unknown"
City: point of encounter city
Country: Canada
Postal code: leave blank or enter postal code of facility
Phone number - Answer -Only numeric characters allowed
-Area code is required
-Phone field should be left blank of client does not have phone
Identifiers - Answer Medical record numbers(MRN)
personal health numbers(PHN)
Unique lifetime identifier (ULI)
Each registration in healthcare systems must include at least one unique identifier
Identify the client - Answer -Positively identify the client who is presenting for services.
-information collected during registration will be used to search for client in EMR/EHR,
as well as linking the correct clinical information to the client.
-standard #1 #4 #5
Searching for client - Answer Conducting a thorough search ensures that correct client
record is selected.
, -standard #3 #4 #5
Combination of demographics attributes should be used when searching for a client: -
Answer Last name+ first name
Last name+ first name+ DOB
Last name+ first name+ DOB+ gender
Last name+ first name (variation of name)
PHN/ULI
Last name+ first name+ postal code
Last name+ first name+ phone#
Verify client information - Answer Verification is required to ensure accuracy of data to
prevent errors in both plant identification, as well as data entry. Correct demographic
data will ensure records are accurately link to EHR.
-Standard #4 #5
Registering client - Answer This complete the registration process and allows client to
proceed for healthcare service
-Standard #2 #4 #6 #7
Homeless client - Answer -Collect as much demographic information as possible
-Registration staff will request supporting documentation(if available)
-A thorough search must be performed
-In case where identity is in doubt, a new record should be created
Identity theft - Answer -for the purpose of providing medical care the client will be
registered using unidentified client standard
-Contact site security personnel if you believe the individual presenting for service is not
the same as the client in the documentation
-notify supervisor
Newborn, born in Alberta - Answer -Alberta ULI should be assigned through Alberta
Healths personal directory (PD) registration system within 24 hours of birth
-newborn should be added to healthcare site registration system as soon as possible
after birth
What is the main purpose of a health record? - Answer Patient care by acting as a
reminder in communication tool
Fundamentals Exam Study Guide
What is the standard? - Answer What is expected
A series of acknowledged and accepted steps, what is expected and required of
individuals and organizations.
What is a rule? - Answer The way things are/should be done
Description of the way things are, or should be done, guide for conduct and action
What is the best practice? - Answer The best/most efficient way to get things done
Method or technique that is most efficient and effective way of completing task or
course of action
Why are standards required? - Answer -Establishes a framework for improving
communications.
-Define's responsibility for both client and provider
-Compare for performance and benchmark for assessing
-Compare results with those of other organizations
Why are demographic rules important? - Answer The rules provide the guidelines that
are to be followed
What is involved in the registration business process? - Answer Step 1- positivity identify
the patient
Step 2- a search must be carried out to see weather or not they have been see before
Step 3- verify all demographic info
Step 4- register patient into system
What is PPI? - Answer Positive patient identification
Acceptable proof of identity documents include: - Answer -Valid drivers license
-valid passport
-Canadian citizenship card
-Canadian permanent resident card
-Certificate of Indian status card
,-Valid Alberta student ID
-Valid, provincial/territorial healthcare card
-Federal provincial, and territorial, issued identification with photograph
Registration standard #1 - Answer All individuals accessing the Alberta health system
are required to uniquely identify themselves
Registration standard #2 - Answer Only true and accurate data about client is recorded
in registration system. This excludes fetuses, body parts, specimens nonhumans(pets)
Standard #3 - Answer A search of all relevant registration systems will be conducted
prior to completing a registration
Standard #4 - Answer All adult individuals accessing the Alberta health system will
present at least two pieces of original supporting documentation to establish unique
identity. Children under 18 will only present one.
Standard #5 - Answer All client demographic information must be verified with client
before the registration process is completed.
Standard #six - Answer A unique identifier is assigned to all clients in Alberta health
system
Standard #7 - Answer A client registration must include a minimum set of demographic
information, consists of last name, first name, date of birth, gender, unique identifier
Rules for name - Answer -all registrations must include documented name
-before name can be changed or updated individuals are required to provide proof
-Name cannot consist of numeric or special characters
Best practises newborn name - Answer Last: mothers or fathers last name
First: female or male, entered until baby is named
Multiple births: indication of birth order and gender, "twinAfemale, TwinBmale"
One legal name - Answer Entered in both first name and last name field. Eg. "Mauli
mauli"
Preferred name - Answer Clients should be recorded by their documented first, middle,
and last name for consistent identification purposes
Unknown name - Answer Last name: client ID/MRN for client
First name: gender of client
Administrative gender - Answer Recorded as indicated on identification presented at
,time of registration
U and X values for gender - Answer U= unknown
X= does not identify their gender as male or female, or has chosen to not disclose their
gender
DOB - Answer -Date of birth is mandatory data
-Confirmed by supporting documentation
-I required to provide acceptable proof before changing or updating DOB
Unknown DOB - Answer Default value: 1900-01-01
Date of death - Answer -Should be recorded in patient registration system only with
supporting documentation
-Statements from next of kin must be confirmed with acceptable source
!!!!MUST HAVE SUPPORTING SOURCE!!!
Unknown Address - Answer Address line: "unknown"
City: point of encounter city
Country: Canada
Postal code: leave blank or enter postal code of facility
Phone number - Answer -Only numeric characters allowed
-Area code is required
-Phone field should be left blank of client does not have phone
Identifiers - Answer Medical record numbers(MRN)
personal health numbers(PHN)
Unique lifetime identifier (ULI)
Each registration in healthcare systems must include at least one unique identifier
Identify the client - Answer -Positively identify the client who is presenting for services.
-information collected during registration will be used to search for client in EMR/EHR,
as well as linking the correct clinical information to the client.
-standard #1 #4 #5
Searching for client - Answer Conducting a thorough search ensures that correct client
record is selected.
, -standard #3 #4 #5
Combination of demographics attributes should be used when searching for a client: -
Answer Last name+ first name
Last name+ first name+ DOB
Last name+ first name+ DOB+ gender
Last name+ first name (variation of name)
PHN/ULI
Last name+ first name+ postal code
Last name+ first name+ phone#
Verify client information - Answer Verification is required to ensure accuracy of data to
prevent errors in both plant identification, as well as data entry. Correct demographic
data will ensure records are accurately link to EHR.
-Standard #4 #5
Registering client - Answer This complete the registration process and allows client to
proceed for healthcare service
-Standard #2 #4 #6 #7
Homeless client - Answer -Collect as much demographic information as possible
-Registration staff will request supporting documentation(if available)
-A thorough search must be performed
-In case where identity is in doubt, a new record should be created
Identity theft - Answer -for the purpose of providing medical care the client will be
registered using unidentified client standard
-Contact site security personnel if you believe the individual presenting for service is not
the same as the client in the documentation
-notify supervisor
Newborn, born in Alberta - Answer -Alberta ULI should be assigned through Alberta
Healths personal directory (PD) registration system within 24 hours of birth
-newborn should be added to healthcare site registration system as soon as possible
after birth
What is the main purpose of a health record? - Answer Patient care by acting as a
reminder in communication tool
