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Introduction to Health Information Management
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Avg score: 37% • Most missed: “Occurrence screening/review”
Introduction to Health Information Management
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25 Questions

1. Pathology report

2. A(n) _____ is the review of the medical record to identify potential medical errors.

3. A common deficiency in documentation is a missing physician _____.

4. Vital signs

5. Consultation

6. Health record

7. Report most likely to contain the type of anesthesia used during a procedure

8. Plan

9. A _____ can initially be given verbally but must be followed up by a written report and signed by the physician.

10. Retrospective review

11. Occurrence screening/review

12. Triage nurse

13. One of the first him professionals to review documents in the medical record

14. Descriptive

15. Lungs reveal scattered rhonchi

16. Symptoms

17. Primary data

18. Patient complains of coughing - clear sputum - headache - and chest congestion

19. Privacy

20. Patient demographics

21. Qualitative analysis

22. Objective

23. Incomplete record file

24. Deficiency slip

25. Current review

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