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Health Information Management Chapters 1 – 5

The first professional association for health information managers was established in:
1928
The hospital standardization program was started by the American College of Surgeons in:
1918
The formal approval process for academic programs in health information management is called:
Accreditation
The formal process for conferring a health information management credential is called:
Certification
RHIT
Registered Health Information Technicians
AHIMA
American Health Information Managment Association
Make up a virtual network of AHIMA members who communicate via a web based program managed by AHIMA.
Communities of Practice
functions as the legislative body of AHIMA
AHIMA House of Delegates
Must graduate from approved program to sit for RHIT or RHIA exam
Credentialing
AHIMA foundation was founded in
1962
Principal repository for data and information about health care, who, what, when, where, why and how
Health Records
Basic facts
Data
Data that has been collected and analyzed, has meaning
Information
Who is responsible for management of health records
HIM Professionals
PHR
Personal Health record, maintained by an individual.
What is the primary purpose of a health record?
Make informed decisions about diagnoses and treatment
What is the secondary purpose of a health record?
Related to environment, education, research,regulations, policy making and support.
EHR
Electronic Health Record
Primary users of the health records are
Patient care providers, dentists, dietitians, nurses, physicians,etc
Individual users of health records are
Coding & billing staff, patients, employers, lawyers, law enforcement officials, researchers
IOM
Institute of medicine
Functions of the Health Record
Store patient care documentation
The purposes for which data is collected
Data Application
The processes by which data is collected
Data Collection
The processes by which data is archived, saved for future use
Data warehousing
Processes by which data is translated into information that can be used for designated application
Data Analysis
Right of individuals to control access to their personal health information
Privacy
Expectation that information will be shared only for the intended purpose
Confidentiality
Protection of privacy of individuals and confidentiality of health records
Security
CPOE
CPOE – Computerized physician/provider order entry
Documents medical condition, diagnoses, procedures and treatment
Clinical Data
Demographic and Financial Information Consents and Authorizations – Patients full name, address, phone #, birth date, place of birth, gender, etc.
Administrative Data
Medicare may identify them as a medicare recognized accreditation organization
Deemed Status
accredits a number of different settings, unannounced surveys, standards for documentation, prohibited abbreviation list
Joint Commission
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by:
American Osteopathic Association
Accreditation Association for Ambulatory Healthcare
National Committee for Quality Assurance
Accredits Rehabilitation programs CARF
Commission on Accreditation of Rehabilitation Facilities (CARF)
Addresses uniformity in the content of records
Acute Care Health Record Documentation
Documents demographic information on a patient
Registration Record
Documents patients current and past Health status
Medical History
Contains providers findings based on exam of patient
Physical Exam
What is happening with a patient on a day to day basis
Progress Notes
rules and regulations of the hospital of who can enter info into these notes
Physician Notes
Is assumed when a patient voluntarily submits to treatment
Implied consent
either spoken or written
Expressed Consent
What organization requires authorization granted by patient or representative to release information
Health Insurance Portability and Accountability Act (HIPAA) HIPAA
is used when the permission is for treatment, payment, or healthcare operations tied in with the TPO – treatment, payment & healthcare operations
Consent
written document that provides directions about a patients desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not able to communicate.
Advance Directives
2 Different Types of Advance Directives
Living Will and Durable Power of Attorney for healthcare
Documents presenting problems
Diagnostic and therapeutic services
Emergency Care Documentation
Physician offices, group practices, clinics, hospital outpatient, etc.
Ambulatory Care Documentation
Obstetric/Gynecologic Care Documentation
Pediatric Care Documentation
Specialized Health Record Documentation
Nursing homes, assisted living
Long Term Care Documentation
RAI
Resident Assessment Instrument – RAI
care plan is based on the minimum data set for long term care. Critical component of the health record in long term care.
Resident Assessment Instrument – RAI
provide medical and non-medical services inpatients home
Home Healthcare Documentation
OASIS
Outcomes and Assessment Information Set – OASIS
used for Home Health
Outcomes and Assessment Information Set – OASIS
care provided in patients home, hospitals, long term care facilities, free standing facilities – terminally ill – provide care focuses on symptom management
Hospice Care Documentation
mental health issues
Behavioral Healthcare Documentation
Increase a patients ability to function
Rehabilitation Services Documentation
PAI
Patient assessment instrument – PAI
completed after admission and upon discharge
Patient assessment instrument – PAI
often provide health services to those incarcerated and thus must maintain health records. Prisons, jails, and juvenile detention centers are all examples of correctional facilities.
Correctional Facilities Documentation
Individuals with severe kidney disease requiring renal dialysis may be treated in outpatient settings of healthcare facilities, in independent dialysis centers, while residents of long-term care settings, or even in their own homes (self-dialysis).
End-State Renal Disease Service Documentation
uniformity, who can document, who can receive verbal orders
Basic Documentation Principles
Errors in Paper Records are corrected by? 3 things
1. Draw a single line in ink through incorrect entry
2. Printing the word “error” at top of entry along with signature (or initials).
3. Document date, time, reason for change
CDI
Clinical Documentation Improvement – CDI
Usually nurses review the day after a patient is admitted and continues until discharged
Clinical Documentation Improvement – CDI
Draws attentions to missing information
Query
Formats of the Health Record
Paper or electronic
3 Health records formats
Source Oriented
Problem Oriented
Integrated
grouping together of items. ex – lab records, radiology records
Source Oriented
patients past and present social, psychological and medical problems
Problem Oriented
SOAP Format
subjective, objective, assessment, plan
information in patients words
Subjective
data from lab findings
Objective
made up of the subjective & objective
Assessment
comments and changes
Plan
In chronological order of date. 3rd major paper based health record
Integrated Health Records
single fact or measurement. ex. age, gender, insurance company
Data Element
list of data elements collected in individual health records, definition of the data elements, etc
Data Dictionary
list of recommended data elements with uniform definitions that are relevant for a particular use.
Data Sets
Data Sets are used for –
Research, clinical trials, quality, safety improvement, reimbursement accreditation, exchanging clinical information
Two purposes of Data sets
1. Identify the data elements that should be collected for each patient.
2. to provide uniform definitions for common terms
UHDDS
Uniform Hospital Discharge Data Set
list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases.
The purpose of the UHDDS
UHDDS was adopted when?
In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs.
Who elects the following:
a. AHIMA Board of Directors
b. Members of the Council on Certification
c. Members of the Commission on Accreditation for Health Informatics and Information Management Education
They are elected to their positions by AHIMA members
makes up a virtual network of AHIMA members
AHIMA Communities of Practice
is an arm of AHIMA that promotes education and research in health information management?
AHIMA Foundation
best describes the mission of AHIMA
Community of professionals providing support to members and strengthening the industry and profession
Which professional organization sponsors the CTR certification?
NCRA
Which of the following is a secondary purpose of the health record?
a. Document patient care delivery
b. Assist caregivers in patient care management
c. Aid in billing and reimbursement functions
d. Generate a report to be used in performance improvement
d. Generate a report to be used in performance improvement
Which of the following is an institutional user of the health record?
a. Patient care provider
b. Third-party payer
c. Coding and billing staff
d. Government policy maker
d. Government policy maker
How do patient care managers and support staff use the data documented in the health record?
a. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
b. Communicate vital information among departments and across disciplines and settings
c. Generate patient bills and/or third-party payer claims for reimbursement
d. Determine the extent and effects of occupational hazards
a. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
Which of the definitions below best describes the concept of confidentiality?
a. The right of individuals to control access to their personal health information
b. The protection of healthcare information from damage, loss, and unauthorized alteration
c. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information
c. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
Which of the following statements does not pertain to paper-based health records?
a. They have a built-in access control mechanism
b. They are kept in locked storage areas that are accessible only to authorized staff
c. They are logged out according to the organization’s prescribed procedure
d. They are forwarded to the appropriate service area when needed for patient care purposes
a. They have a built-in access control mechanism
Which of the following is an advantage offered by computer-based clinical decision support tools?
a. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature
b. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends
c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives
d. All of the above
d. All of the above
The hospital where I work is transitioning to an EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as:
a. Integrated health record format
b. A hybrid record
c. A resident record
d. Integrated health record format
b. A hybrid record
Critique this statement: Data and information mean the same thing.
a. This is a true statement.
b. This is false as data is used for administrative purposes and information is used for clinical purposes.
c. This is a false statement as data is raw facts and figures and information is data converted into a meaningful format.
d. This is a true statement as information is raw facts and figures and data is information converted into a meaningful format.
c. This is a false statement as data is raw facts and figures and information is data converted into a meaningful format.
Which of the following statements does not pertain to electronic health records (EHRs)?
a. EHR technologies and systems must not intrude on the patient and provider relationship.
b. EHRs are filed in paper folders.
c. In the United States, a national health information infrastructure is being designed to support EHRs.
d. Clinicians use computer keyboards when documenting in the EHR.
b. EHRs are filed in paper folders
Which of the following is a secondary purpose of the health record?
a. Support for provider reimbursement
b. Support for patient self-management activities
c. Support for research
d. Support for patient care delivery
c. Support for research
Use of the health record by a clinician to facilitate quality patient care is considered:
a. Primary purpose of the health record
b. Patient care support
c. Secondary purpose of the health record
d. Patient care effectiveness
a. Primary purpose of the health record
Use of the health record to monitor bioterrorism activity is considered:
a. Primary purpose of the health record
b. Secondary purpose of the health record
c. Patient use of the health record
d. Healthcare licensing agency function
b. Secondary purpose of the health record
How do accreditation organizations use the health record?
a. Serve as a source for case study information
b. Determine whether the documentation supports the provider’s claim for reimbursement
c. Provide healthcare services
d. Determine whether standards of care are being met
d. Determine whether standards of care are being met
How do research organizations use the health record?
a. To examine results of experimental protocols
b. For reporting of communicable diseases
c. To investigate domestic violence
d. To manage disability insurance benefits
a. To examine results of experimental protocols
Attorneys for healthcare organizations use the health record to:
a. Support claims for medical malpractice
b. Protect the legal interests of the facility and its healthcare providers
c. Plan and market services
d. Locate missing persons
b. Protect the legal interests of the facility and its healthcare providers
Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using?
a. Source-oriented health record
b. Integrated health record
c. Patient-oriented health record
d. Problem-oriented health record
a. Source-oriented health record
Inaccurate data recorded in the health record could:
a. Compromise quality patient care
b. Contribute to incorrect assumptions by policy makers
c. Invalidate research findings
d. All of the above
d. All of the above
The term used to describe expected data values is:
a. Data definition
b. Data currency
c. Data precision
d. Data relevancy
c. Data precision
Protection of healthcare information from damage, loss, and unauthorized alteration is also known as:
a. Privacy
b. Results management
c. Security
d. Data accuracy
c. Security
Since we implemented a new technology, we have eliminated lost orders and problems
with legibility. What technology are we using?
a. Computerized physician/provider order entry
b. Electronic health record
c. Results management
d. Clinical decision support
a. Computerized physician/provider order entry
The paper-based health record format that organizes all forms in chronological order is known as the:
a. Problem-oriented health record
b. Integrated health record
c. Patient-oriented health record
d. Source-oriented health record
b. Integrated health record
Critique this statement: The health record documents services provided by allied health professionals and a patient’s family.
a. This is a true statement.
b. This is a false statement as the health record only document’s physician’s care.
c. This is a false statement as the health record only documents care provided by patient families.
d. This is a false statement as the health record documents the care provided by healthcare professionals.
d. This is a false statement as the health record documents the care provided by healthcare professionals.
An individual’s right to control access to his or her personal information is known as:
a. Security
b. Confidentiality
c. Privacy
d. all of the above
c. Privacy
When all required data elements are included in the health record, the quality characteristic for ______ is met.
a. Data security
b. Data accessibility
c. Data flexibility
d. Data comprehensiveness
d. Data comprehensiveness
Critique this statement: Patient care managers are individual users of health records.
a. This is a true statement.
b. This is a false statement as they do not require patient information to do their job.
c. This is a false statement as they require patient information to do their job.
d. This is a false statement as patient care managers are institutional users.
a. This is a true statement.
Which type of standard is required of hospitals by states prior to providing any healthcare?
a. Accreditation
b. Certification
c. Licensure
d. Medical staff bylaws
c. Licensure
Which of the following clinical data elements is not usually documented in the acute-care health record?
a. Clinical observations
b. Discharge information
c. Medical history
d. Records of immunizations
d. Records of immunizations
Which of the following is not a function of the discharge summary?
a. Providing information about the patient’s insurance coverage
b. Ensuring the continuity of future care
c. Providing information to support the activities of the medical staff review committee
d. Providing concise information that can be used to answer information requests
a. Providing information about the patient’s insurance coverage
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
a. Autopsy report
b. Laboratory findings
c. Pathology report
d. Surgical report
b. Laboratory findings
Which of the following would not be considered clinical data?
a. Progress notes
b. Physician orders
c. Admission diagnosis
d. Name of insurance company
d. Name of insurance company
Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?
a. The Health Information Access and Disclosure Act
b. The Health Insurance Portability and Accountability Act
c. The Patient Self-Determination Act
d. The Social Security Act
b. The Health Insurance Portability and Accountability Act
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?
a. Operative report
b. Anesthesia report
c. Pathology report
d. Laboratory report
a. Operative report
Which of the following materials is not documented in an emergency care record?
a. Patient’s instructions at discharge
b. Time and means of the patient’s arrival
c. Patient’s complete medical history
d. Emergency care administered before arrival at the facility
c. Patient’s complete medical history
Which of the following types of facility is not generally governed by long-term care documentation standards?
a. Subacute care facilities
b. Assisted living facilities
c. Skilled nursing facilities
d. Nursing facilities
b. Assisted living facilities
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
a. Patient assessment instrument
b. Minimum data set for long term care
c. Resident Assessment Protocol
d. Outcomes and Assessment Information Set
d. Outcomes and Assessment Information Set
Which regulations are most commonly applied in end-stage renal disease treatment?
a. Medicare Conditions for Coverage
b. Commission on Accreditation of Rehabilitation Facilities
c. Accreditation Association for Ambulatory Healthcare
d. Joint Commission
a. Medicare Conditions for Coverage
Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?
a. The correction should be dated and signed or initialed.
b. The reason for the change should be noted.
c. The incorrect information should be obliterated.
d. The word error should be noted on the entry.
c. The incorrect information should be obliterated.
Which of the following types of healthcare facilities may seek accreditation from the Joint Commission?
a. Acute care hospitals
b. Psychiatric hospitals
c. Home care providers
d. Ambulatory care organizations
e. All of the above
e. All of the above
The federal Conditions of Participation apply to which type of healthcare organization?
a. Organizations that are accredited
b. Organizations that treat Medicare or Medicaid patients
c. Organizations that provide acute care services
d. Organizations that are subject to the Health Insurance Portability and Accountability Act
b. Organizations that treat Medicare or Medicaid patients
Which of the following is not a traditional health record format?
a. Integrated health record
b. Problem-oriented health record
c. Source-oriented health record
d. Process-oriented health record
d. Process-oriented health record
Which health record format is most commonly used by healthcare settings as they transition to electronic records?
a. Integrated records
b. Problem-oriented records
c. Hybrid records
d. Paper records
c. Hybrid records
Which of the following is an example of administrative information?
a. An admitting diagnosis
b. Blood pressure records
c. Medication records
d. The patient’s address
d. The patient’s address
The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:
a. Subjective
b. Objective
c. Assessment
d. Plan
d. Plan
“Acute allergic reaction” would be documented in which part of a SOAP note?
a. Subjective
b. Objective
c. Assessment
d. Plan
c. Assessment
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?
a. Certification
b. Licensure
c. Accreditation
d. Deemed status
c. Accreditation
Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) _________ paper record.
a. Integrated
b. Source-oriented
c. Problem-oriented
d. Hybrid
a. Integrated
22. Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient’s own words?
a. Present illness
b. Social and personal history
c. Past medical history
d. Chief complaint
d. Chief complaint
Which of the following creates a chronological report of the patient’s condition and response to treatment during a hospital stay?
a. Physical examination
b. Physician order
c. Progress notes
d. Medical history
c. Progress notes
Which of the following determines who can receive and transcribe verbal orders?
a. Accreditation standards
b. Certification regulations
c. Medical staff bylaws
d. Licensure standards
c. Medical staff bylaws
The name of the government agency that has led the development of basic data sets for health records and computer databases is the:
a. Centers for Medicare and Medicaid Services
b. Johns Hopkins University
c. American National Standards Institute
d. National Committee on Vital and Health Statistics
d. National Committee on Vital and Health Statistics
Minimum data set in healthcare are developed to:
a. Recommend common data elements to be collected in health records
b. Mandate all data that must be contained in a health record
c. Define reportable data for federally funded programs
d. Standardize medical vocabulary
a. Recommend common data elements to be collected in health records
Data that are collected from individual records and then combined are referred to as:
a. Statistics
b. Information
c. Aggregate data
d. Standards
c. Aggregate data
The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the:
a. Ambulatory Care Data Set
b. Uniform Hospital Discharge Data Set
c. Minimum Data Set for Long-Term Care
d. Health Plan Employer Data and Information Set
b. Uniform Hospital Discharge Data Set
Both HEDIS and the Joint Commission’s ORYX program are designed to collect data to be used for:
a. Performance improvement programs
b. Billing and claims data processing
c. Developing hospital discharge abstracting systems
d. Developing individual care plans for residents
a. Performance improvement programs
Critique this statement: The continuity care record contains only current clinical information.
a. This is a true statement.
b. This is a false statement as the CCR contains both current and future plans.
c. This is a false statement as the CCR contains both past information.
d. This is a false statement as the CCR contains both future and past clinical information.
d. This is a false statement as the CCR contains both future and past clinical information.
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of:
a. Transaction standards
b. Content and structure standards
c. Vocabulary standards
d. Security standards
c. Vocabulary standards
The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the:
a. Medicare Act
b. Prospective Payment Act
c. Health Insurance Portability and Accountability Act of 1996
d. American Recovery and Reinvestment Act
c. Health Insurance Portability and Accountability Act of 1996
A key technology tool for enabling data is:
a. Content standard
b. Vocabulary standard
c. Extensible markup language
d. Metadata standards
c. Extensible markup language
Most healthcare informatics standards have been implemented by:
a. Federal mandate
b. Consensus
c. State regulation
d. Trade association requirement
b. Consensus
A critical early step in designing an EHR is to develop a ______ in which the characteristics of each data element are defined.
a. Accreditation manual
b. Core content
c. Continuity of care record
d. Data dictionary
d. Data dictionary
According to the UHDDS definition, ethnicity should be recorded on a patient record as:
a. Race of mother
b. Race of father
c. Hispanic, non-Hispanic, unknown
d. Free text descriptor as reported by patient
c. Hispanic, non-Hispanic, unknown
Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?
a. DEEDS
b. UACDS
c. MDS Version 3.0
d. OASIS
a. DEEDS
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on:
a. Reason for admission
b. Reason for encounter
c. Discharge diagnosis
d. Activities of daily living
b. Reason for encounter
In long term care, the resident’s care plan is based on data collected in the:
a. UHDDS
b. OASIS
c. MDS Version 3.0
d. HEDIS
c. MDS Version 3.0
Reimbursement for home health services in dependent of data collected from:
a. HEDIS
b. UHDDS
c. OASIS
d. MDS Version 3.0
c. OASIS
A consumer interested in comparing the performance of health plans should review data from:
a. HEDIS
b. OASIS
c. ORYX
d. UHDDS
a. HEDIS
HEDIS is designed to collect:
a. Administrative data
b. Claims data
c. Health record review data
d. Administrative, claims, and health record review data
d. Administrative, claims, and health record review data
Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for:
a. Government regulations
b. Core data elements
c. Privacy controls
d. Technology requirements
b. Core data elements
A statewide cancer surveillance system is an example of which of the NHII dimensions?
a. Personal
b. Provider
c. Community
d. Payer
c. Community
Providers and health plans need to share information. What standard must they use?
a. X12N
b. LOINC
c. IEEE 1073
d. DICOM
c. IEEE 1073
A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is:
a. X12N
b. LOINC
c. IEEE 1073
d. DICOM
d. DICOM
I work for an outpatient surgery center. What data set should I use?
a. Continuity of Care Record
b. Minimum Data Set
c. Uniform Ambulatory Care Data Set
d. Uniform Hospital Discharge Data Set
c. Uniform Ambulatory Care Data Set
Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?
a. X12N
b. LOINC
c. RxNorm
d. DICOM
d. DICOM
As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for:
a. Developing unique provider identifiers
b. Finalizing the extensible markup language
c. Harmonization of standards from multiple sources
d. Building software systems to support EHR development
b. Finalizing the extensible markup language
ICD-10 is used in the United States for morbidity reporting. True or False
True
The International Classification of Diseases for Oncology Third Edition is a system used for classifying incidences of benign disease. True or False
False
CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services. True or False
True
HCPCS codes are made up of CPT and Level II (national) codes. True or False
True
The APA developed the Diagnostic and Statistical Manual of Mental Disorders as a tool for standardizing the diagnostic process for patients with psychiatric disorders. True or False
True
AHIMA has developed Standards of Ethical Coding. True or False
True
An encoder is a tool that aids coders in assigning diagnostic and procedure codes. True or False
True
I need to confirm the patient’s principal diagnosis for the chart I am coding. How should I do this?
a. Call attending physician
b. Review documents such as the discharge summary
c. Have attending physician certify diagnoses
d. Refer it to a physician advisor
b. Review documents such as the discharge summary
The degree to which codes accurately reflect the patient’s diagnoses and procedures is:
a. Timeliness
b. Completeness
c. Validity
d. Reliability
c. Validity
Standardized vocabulary is needed to:
a. Facilitate the indexing, storage, and destruction of patient information in a EHR
b. Facilitate the indexing, storage, and retrieval of patient information in a EHR
c. Group like diseases together for the purpose of reimbursement
d. Record care provided by nurses
b. Facilitate the indexing, storage, and retrieval of patient information in a EHR
I need to code an ambulatory record but the procedure code I need is not in the CPT manual. How do I code it?
a. ICD-10-CM codes
b. HCPCS level II codes
c. ICD-10-PCS codes
d. ICD-9-CM procedure codes
b. HCPCS level II codes
Which of the following would be an argument for the transition to ICD-10-CM/PCS?
a. Coders have to be retrained
b. MS-DRGS would have to be updated to accommodate the new codes
c. More detail in the code
d. ICD-10-CM contains diagnosis and procedure codes unlike ICD-9-CM
c. More detail in the code
Which of the following is a goal of ICD-10-PCS?
a. Reduce inconsistency due to overlapping of terms
b. Eliminate need to communicate with physicians
c. Assign diagnosis codes
d. Assign diagnosis and procedure codes
a. Reduce inconsistency due to overlapping of terms
Commission for Health Informatics and Information Management – AHIMA Certification Programs
CCHIIM
AHIMA Membership
Active Membership who are credentialed or Student Membership who does not have AHIMA credentials.
Leads the volunteer structure. Responsible for managing the property, affairs and operations of AHIMA.
AHIMA Board of Directors
Strives to be the premiere source for HIM professionals and the leader in advancing the field for the betterment of the HIM profession
AHIMA Foundation
Standard Guide on Content and Structure of Electronic Health Records
E1384
Branch of medical science that deals with classification systems
Nosology
System that lists preferred medical terminology
Nomenclature
World Health Organization
WHO
Mortality
loss of life, death
Morbidity
diseased state or symptom
History & Physical
H&P
Data Elements for Emergency Department Systems – collects data in hospital based emergency departments
DEEDS
Digital Imaging and Communication in Medicine
DICOM
Essential Medical Data Set
EMDS
Uniform Ambulatory Care Data Set
UACDS

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