HISM (D033): Chapter 6 Questions and Answers Rated A

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HISM (D033): Chapter 6 Questions and Answers Rated A Healthcare quality indicator system ✔✔An abstracting system that records information about the patient, the care provided to the patient, an... d the healthcare practitioner(s) involved in the care delivered Automated codebook encoder ✔✔An encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index Birth certificate information system ✔✔A state-approved system in which the birth certificate data are entered, after the HIM staff interviews the mother or other parents or guardians and reviews the health record. This software reports births occurring in the healthcare facility to the state health agency Cancer registry information system ✔✔An information system that tracks information (including very detailed information regarding diagnosis and treatment) about the patient's cancer from the time of diagnosis to the patient's death Chart deficiency system ✔✔A system that track and record documentation omission due to deficiency in the health record that comes to the HIM department. Deficiencies can be in paper, imaged, or electronic records depending on the information system used Chart locator system ✔✔A system is designed to identify the current location of the paper health record. This tracking is important because paper records are moved from place to place for patient care, quality reviews, coding, and many other purposes Chart tracking system ✔✔Chart locator system Clinical documentation improvement (CDI) system ✔✔The recognized process assists in identifying ways to improve clinical documentation in the health record Computer-assisted coding (CAC) system ✔✔A software program used to analyze the clinical data found in an electronic health record Dictation system ✔✔Used by the physician to verbally record various medical reports such as history and physical examinations, discharge summaries, radiology reports, autopsy reports, catheterization reports, and other designated reports into the dictation system Disclosure management system ✔✔A system that tracks the disclosures made throughout the healthcare facility for reporting purposes Encoder ✔✔A specialty software used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the h [Show More]

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