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| the principal repository (storage place) for data and information about the healthcare services provided to a patient |
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| the records of acute care patients who receive services as hospital inpatients |
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| the records used by physicians and physicians' office personnel |
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| the records of patients in long-term facilities |
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| health records in facilities that provide ambulatory behavioral health services |
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| paper based health records, especially in hospital settings |
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| to document and support patient care services |
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| What is the primary function of the health record? |
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| T or F: Data and information mean the same thing |
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| represent the basic facts about people, processes, measurements, conditions, etc. |
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| data is collected and analyzed and converted into a form that can be used for a specific purpose |
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| T or F: Data represents facts |
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| T or F: Information represents meaning |
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| What is gradually replacing paper based documentation systems? |
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| person who typed up dictated reports |
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| The Office of the National Coordinator for Health Information Technology |
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| a sub-Cabinet level post at the Department of Health and Human Services that is coordinating the national effort to convert to EHRs by 2014 |
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What are the primary purposes of the health record?
a) patient care delivery
b) patient care management
c) patient care support processes
d) financial and other administrative processes
e) Patient self-managment
f) all of the above
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Term
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Definition
The health record:
a) helps professionals to make informed decisions about diagnoses and treatments
b) is a tool of communication between different care givers
c) allows healthcare workers to assess and manage risk
d) represents legal evidence of services received by patient
e) all of the above
f) all but d |
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| refers to all the activities related to managing the healthcare services provided to patients |
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| patient care support processes |
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| encompasses the activities related to the handling of the healthcare organization's resources, the analysis of trends, and the communication of information among different clinical departments |
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What is the secondary purpose of a health record? (More than one answer can be chosen)
a) education
b) research
c) regulation
d) policy making
e) public health
f) homeland security
g) all of the above |
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| T or F: One of the primary purposes of a health record is not to assess and document patient expectations and satisfaction |
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| T or F: The primary purose of health care record includes providing reminders to clinicians |
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| T or F: The healthcare record can help assess workload |
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| T or F: The healthcare record cannot give information on how to manage costs |
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| T or F: The healthcare record cannot be used to prepare conferences and presentations because of the confidentiality act |
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| T or F: The health care record can be used in research to develop new products |
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| T or F: Health care records can be used to develop registries and databases |
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