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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. Plan

2. Privacy

3. Deficiency slip

4. Qualitative analysis

5. Subjective

6. Descriptive

7. Alphabetic

8. Symptoms

9. Assessment

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

11. Strength is adequate in all extremities

12. The place in the him department where the deficiency slips are kept.

13. Healthcare documentation process

14. Vital signs

15. Current review

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

17. Patient demographics

18. Retrospective review

19. Health record

20. A(n) _____ is performed to ensure the accuracy of documentation in the medical record.

21. A(n) _____ can identify documentation issues (which can be rectified in a timely manner) while the patient is in the hospital.

22. Physicin order

23. Occurrence screening/review

24. A(n) _____ is used to determine the completeness of the medical record.

25. A medication administration record would be found where?

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