HINM 134 Chapter 3 Vocabulary - Test Solution Manual Fully Solved Latest Update 2025 Already
Passed
1. The process of extracting information from a document to create a brief summary of a patient's
illness, treatment, and outcome. 2. The process of extracting elements of data from a source document
or database and entering them into an automated system. - Answers Abstracting
A late entry added to a health record to provide additional information in conjunction with a previous
entry. The late entry should be timely and bear the current date and reason for the additional
information being added to the health record. - Answers Addendum
Data extracted form individual health records and combined to form de-identified information about
groups of patients that can be compared and analyzed. - Answers Aggregate Data
A system of health record identification and storage that uses the patient's last name as the first
component of identification and hos or her first name and middle name or initial for further definition. -
Answers Alphabetic filingsystem
Both alphabetic and numeric characters are used to sort health records in this system - Answers
Alphanumeric filing system
A clarification made to health care documentation after the original document has been signed; it
should be dated, timed and signed. - Answers Amendment
Review of health record for proper documentation and adherence to regulatory and accreditation
standards - Answers Analysis
The process of ensuring that each page in the health record is organized in a standardized order. -
Answers Assembly
1. A chronological set of computerized records that provides evidence of information system activity
(logins and logouts, file accesses) used to determine security violations. 2. A record that shows who has
accessed a computer system, when it was accessed, and what operations were performed. - Answers
Audit trail
All of the patient's encounters are filed together in a single location. - Answers Centralized unit filing
system
Assigning codes to represent diagnoses and procedures. - Answers Clinical coding
The process in which individual data elements are represented in the computer by a special code to be
used in making comparisons, trending results, and supplying clinical reminders and alerts. - Answers
Clinical decision support (CDS)
, The process of extracting and translating dictated and then transcribed free-text data (or dictated and
then computer -generated discrete data) into ICD-10-CM and CPT evaluation and management codes for
billing and coding purposes. - Answers Computer-assisted coding (CAC)
Screening for medical necessity and tha appropriateness and timeliness of the delivery of medical care
from the time of admission until discharge. - Answers Concurrent review
Edit made to the health record by drawing a single line through the erroneous information and writing
the word "error" above the mistake; the practitioner should sign, date, and time the correction -
Answers Correction
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations
about people, processes, measurements, and conditions - Answers Data
The process of extracting and analyzing large volumes of data from a database for the purpose of
identifying hidden and sometimes subtle relationships or patterns and using those relationships to
predict behaviors. - Answers Data mining
notification when a document or signature is missing that identifies the pertinent document and what
needs to be done (dictated, completed, and signed) - Answers Deficiency slip
An incomplete record not finished or made complete within the time frame determined by the medical
staff of the facility - Answers Delinquent record
information used to identify an individual, such as name, address, gender, age, and other information
linked to a specific person; also known as demographic data. - Answers Demographics
Algorithm that requires exact matches in data elements such as the patient name, date of birth, and
social security number. - Answers Deterministic algorithm
System commonly used when transitioning from paper-based to electronic health record that scans the
paper record and stores it digitally - Answers Document management system
Occurs when the patient has two or more health record numbers issued; the patient's medical
information becomes fragmented with some information under the first number and the remainder
under the second - Answers Duplicate health record
An electronic record of health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed, and consulted by authorized
clinicians and staff across more than one healthcare organization - Answers Electronic Health Record
(EHR)
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the
rules of the coding system. - Answers Encoder
Passed
1. The process of extracting information from a document to create a brief summary of a patient's
illness, treatment, and outcome. 2. The process of extracting elements of data from a source document
or database and entering them into an automated system. - Answers Abstracting
A late entry added to a health record to provide additional information in conjunction with a previous
entry. The late entry should be timely and bear the current date and reason for the additional
information being added to the health record. - Answers Addendum
Data extracted form individual health records and combined to form de-identified information about
groups of patients that can be compared and analyzed. - Answers Aggregate Data
A system of health record identification and storage that uses the patient's last name as the first
component of identification and hos or her first name and middle name or initial for further definition. -
Answers Alphabetic filingsystem
Both alphabetic and numeric characters are used to sort health records in this system - Answers
Alphanumeric filing system
A clarification made to health care documentation after the original document has been signed; it
should be dated, timed and signed. - Answers Amendment
Review of health record for proper documentation and adherence to regulatory and accreditation
standards - Answers Analysis
The process of ensuring that each page in the health record is organized in a standardized order. -
Answers Assembly
1. A chronological set of computerized records that provides evidence of information system activity
(logins and logouts, file accesses) used to determine security violations. 2. A record that shows who has
accessed a computer system, when it was accessed, and what operations were performed. - Answers
Audit trail
All of the patient's encounters are filed together in a single location. - Answers Centralized unit filing
system
Assigning codes to represent diagnoses and procedures. - Answers Clinical coding
The process in which individual data elements are represented in the computer by a special code to be
used in making comparisons, trending results, and supplying clinical reminders and alerts. - Answers
Clinical decision support (CDS)
, The process of extracting and translating dictated and then transcribed free-text data (or dictated and
then computer -generated discrete data) into ICD-10-CM and CPT evaluation and management codes for
billing and coding purposes. - Answers Computer-assisted coding (CAC)
Screening for medical necessity and tha appropriateness and timeliness of the delivery of medical care
from the time of admission until discharge. - Answers Concurrent review
Edit made to the health record by drawing a single line through the erroneous information and writing
the word "error" above the mistake; the practitioner should sign, date, and time the correction -
Answers Correction
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations
about people, processes, measurements, and conditions - Answers Data
The process of extracting and analyzing large volumes of data from a database for the purpose of
identifying hidden and sometimes subtle relationships or patterns and using those relationships to
predict behaviors. - Answers Data mining
notification when a document or signature is missing that identifies the pertinent document and what
needs to be done (dictated, completed, and signed) - Answers Deficiency slip
An incomplete record not finished or made complete within the time frame determined by the medical
staff of the facility - Answers Delinquent record
information used to identify an individual, such as name, address, gender, age, and other information
linked to a specific person; also known as demographic data. - Answers Demographics
Algorithm that requires exact matches in data elements such as the patient name, date of birth, and
social security number. - Answers Deterministic algorithm
System commonly used when transitioning from paper-based to electronic health record that scans the
paper record and stores it digitally - Answers Document management system
Occurs when the patient has two or more health record numbers issued; the patient's medical
information becomes fragmented with some information under the first number and the remainder
under the second - Answers Duplicate health record
An electronic record of health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed, and consulted by authorized
clinicians and staff across more than one healthcare organization - Answers Electronic Health Record
(EHR)
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the
rules of the coding system. - Answers Encoder
