Health Information Management Flashcards
6 cards from real Certified Coding Associate Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Information Management flashcards as text
What is the purpose of a master patient index (MPI)?
Answer: To uniquely identify and link all health records for each patient in a facility
The MPI is a database that uniquely identifies each patient and links all encounters and health records associated with that patient.
Which document authorizes a provider to treat a patient and indicates the patient understands the nature of the treatment?
Answer: Informed consent
Informed consent is the process by which a patient is informed about a procedure and voluntarily agrees to undergo it.
How long must hospitals generally retain adult patient health records under most state laws?
Answer: 5–10 years from last treatment or discharge
Most states require adult health records to be retained for a minimum of 5–10 years from the date of last treatment or discharge.
What is the main goal of clinical documentation improvement (CDI)?
Answer: Ensuring documentation accurately reflects the patient's clinical status to support coding and quality reporting
CDI aims to improve the quality and completeness of clinical documentation so that coding accurately reflects the patient's condition and care.
Which of the following is a key component of a health record for inpatient encounters?
Answer: History and physical examination (H&P)
A history and physical examination (H&P) is a required component of the inpatient health record and must be completed within a defined timeframe.
What does the term 'deficiency analysis' mean in health information management?
Answer: Identifying incomplete or missing elements in health records
Deficiency analysis involves reviewing health records to identify incomplete or missing documentation that must be completed by the responsible provider.