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HIM final

The HIM department is involved in the ____ process by making the health records of patients enrolled in a research study available to external monitors and auditors.
IRB
Two providers bill for one service provided to one patient
double billing
List the 13 stakeholder outcomes areas listed in Healthy People 2020.
The first professional association for health information managers was established in:
1928
The hospital standardization program was started by ___________________________.
American College of Surgeons
The formal approval process for academic programs in health information management is called which of the following?
Accreditation
Which of the following is the formal process for conferring a health information management credential?
Certification
Which of the following is a traditional HIM role?
Tracking record completion
Which of the following functions governs the HIM profession?
AHIMA House of Delegates
Which of the following make up a virtual network of AHIMA members?
AHIMA Engage
Which of the following is an arm of AHIMA that promotes research in health information management?
AHIMA Foundation
Which of the following best describes the mission of the AHIMA?
Community of professionals providing support to members and strengthening the industry and profession
Which professional organization sponsors the CTR certification?
NCRA
Someone who wishes to sit for the Certified Professional Coder (CPC) certification should contact which organization?
AAPC
In order to qualify for an AHIMA fellowship, what minimal educational level is needed?
Master’s degree
Which of the following qualify for CEUs?
College course
Critique this statement: Once someone has earned the registered health information technician (RHIT) credential, it is a lifetime certification.
This is incorrect as RHITs have to become recertified.
Which group is responsible for AHIMA’s certification exams?
CCHIIM
State College is applying for accreditation of the new HIM program. How long do they have to complete their candidacy?
2 years
The two components of AHIMA’s management structure are which of the following?
Staff and volunteer
An RHIT who graduated from college 6 months ago is joining AHIMA for the first time. What membership is he or she qualified for?
Active
Critique this statement: an RHIT must be at least 65 years old in order to qualify for emeritus membership.
This is a true statement.
The requirement for an HIM professional to comply with all laws, regulations, and standards governing the practice of HIM is in the AHIMA _________.
Code of Ethics
The accountability framework and decision rights to achieve enterprise information management is known as:
Information governance
Prior to hospital standardization, health records were:
essentially worthless
The number of charter members of the ARLNA was:
58
To be recognized as a profession, which of the following did HIM need?
Preliminary training
The emphasis on traditional practice of HIM was to ensure:
complete and accurate health record
Who is responsible for communicating information relevant to national issues and keeping members informed of regional affairs that affect HIM?
AHIMA Component state association
Which group brings together stakeholders to address issues related to the future of the HIM profession and education?
Council for Excellence in Education
Which of the following activities is an information-oriented HIM function?
Data manipulation
Which of the following is the accreditation organization for HIM programs?
CAHIIM
Which of the following is true about the AHIMA certification program?
Candidates must pass an examination before obtaining any of the credentials.
Which of the following classes of AHIMA membership requires that individuals have interest in HIM and will abide by the AHIMA code of ethics?
Active membership
Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA?
Board of Directors
The accreditation program of AHIMA is concerned with which of the following?
Establishing standards for the content of college programs in health information management
Which organization should be contacted regarding the certified healthcare documentation specialist exam?
Association for Healthcare Documentation Integrity
Which of the following makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA?
Engage
Which of the following carries out the operational tasks necessary to support the organization’s mission and goals?
Staff
Members of the AHIMA House of Delegates are:
Elected by members in component state organizations
Who is responsible for final approval of the AHIMA Code of Ethics?
AHIMA House of Delegates
The term used to describe controlling information is ______.
Information governance
Which organization’s goal is centered on health information technology?
HIMSS
An RHIT is going back to earn her bachelor degree so that she can sit for the RHIA exam. What membership category is she qualified for?
Active
A member of the AHIMA Board of Directors is which of the following?
Elected
Which of the following is true about the AHIMA House of Delegates?
They meet virtually throughout the year.
The AHIMA House of Delegates has power over which of the following?
Amendments to AHIMA’s bylaws
The role of the AHIMA chief executive officer is to:
Manage the day-to-day operations
Where should new graduates begin their volunteer experience?
Correct!
CSA
Which step comes first in the accreditation process?
Self-assessment
Sustained professional achievement is required by which of the following?
Fellowship
AHIMA fellowship is conferred for:
Life
Which of the following confers scholarships?
AHIMA Foundation
Which of the following places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers?
Continuum of care
As of 2014, what percent of the U.S. economy was represented by healthcare spending?
17.5
What is the ideal ratio of medical generalist to specialist?
40:60
Registered Nurses are only formally educated at the bachelor’s degree.
false
Which of the following is considered an Allied Health professional?
Licensed Practical Nurses
Occupational Therapists are concerned with a patient’s activities of daily living.
true
Which of the following federal laws created Medicare and Medicaid?
Public Law 89-97 of 1965
Medicare will pay the Medicaid premiums, deductibles, and coinsurance costs for some low-income Medicaid beneficiaries.
false
What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified.
Utilization review
HITECH was a portion of which bill?
American Recovery and Reinvestment Act of 2009
What is the name of the type of beds in a hospital that are defined by those authorized by the state?
Licensed
To qualify as a Critical Access Hospital one of the criteria is to be located in a rural area.
true
One of the functions of the board of directors is to approve the organization and makeup of the clinical staff.
true
The “C” in CIO stands for:
Chief
Health information management departments are considered which of the following?
Ancillary Support Service
Hospital-owned group practices are considered ambulatory care organizations
true
One group of patients that prefer treatment at urgent care centers are those whose insurance carriers treat urgent care centers preferentially when compared with physician offices.
true
Which of the following is the fastest-growing sector to offer services for Medicare recipients?
Home health
Rehabilitation hospitals are categorized as an acute care type of facility in treating patients.
false
Which of the following is a main goal in treating hospice patients?
Minimize the stress and trauma of death
Which of the following is the health profession that focuses on the eyes and related structures?
Optometry
Public Law 89-97 of 1965 created a number of amendments to which Act?
Social Security Act
The Office of the National Coordinator for Health Information Technology was created as part of which Act?
American Recovery and Reinvestment Act
Who has the primary responsibility for setting the overall direction of the hospital?
Board of directors
The medical staff operates according to a pre-determined set of policies called ___________.
Medical staff bylaws
Managed care organizations deliver medical care and manage all aspects of patient care by limiting providers of care, discounting payments to providers of care, or limiting access to care.
true
Two types of practitioners can hold the degree of Doctor of Medicine. They are:
Physician and Surgeon
Which of the following is a surgical specialty?
Anesthesiology
Nurse Practitioners often receive advanced training at the Masters level.
true
Which of the following professionals is not mentioned in this text as requiring licensing by all 50 states?
Health Information Management
Physical Therapists use work and play activities to improve patient’s independent functioning, enhance their development, and prevent or decrease their level of disability.
false
The Social Security Act of 1935 had a healthcare component added by the Republican president, Franklin D. Roosevelt.
false
With the implementation of the Affordable Care Act, U.S. states were given the opportunity to expand Medicaid, though not all have done so.
true
Which of the following persons were intended to be supported by Medicaid in Public Law 89-97 of 1965?
Single-parent families
The average length of stay (LOS) for acute care hospitals is:
25 days or less
The board of directors can also be called the board of trustees.
true
What is the name given to the privileges assigned to physicians to provide clinical services in a hospital?
Clinical
Traditionally physicians alone determine the timely and effective interventions in response to a wide range of problems related to a patient’s treatment, comfort, and safety. Who else are playing a wider role in this function?
Nurses
Long term care patients are referred to as residents of the healthcare facility administering care.
true
What percentage of hospitals offers emergency services?
More than 90%
Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public’s health?
Surgeon General of the United States
Skilled nursing care is defined as skilled nursing observations and:
Technical procedures
Long term care is mainly rehabilitative and supportive rather than curative.
true
Patients in hospice care are expected to live a maximum of ___ days.
180 days
The difference in health insurance coverage between medical and psychiatric care is referred to as:
Non-parity
This type of facility is more homelike and less institutional than in the past
Residential Care Facilities
Cell-based technologies include:
Stem cells for transplant
Name the leading federal agency charged with protecting the public health.
The CDC or Centers for Disease Control
Which of the following is a secondary purpose of the health record?
Educate medical students
Which of the following is an institutional user of the health record?
Government policy maker
How do patient care managers and support staff use the data documented in the health record?
Evaluate the performance of employees
An HIM student asked an HIM director why the hybrid record is so challenging. What is the HIM director’s response?
It is because we have to manage both the electronic and paper media.
What is the process of ensuring that a record is available for every patient seen at the healthcare facility?
Reconcilliation
Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used?
Front-end
Critique this statement: Data and information mean the same thing.
This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.
Which information system will track information provided to a requester?
Release of information
The use of the health record by a clinician to facilitate quality patient care is considered ____________.
A primary purpose of the health record
Why is only the most current version of a document displayed?
To ensure there is no confusion on the correct document
How do accreditation organizations use the health record?
To determine whether standards are being met
How long should the MPI be retained?
Permanently
Deficiencies in a health record include which of the following?
Missing document
Critique this statement: Patient care managers are individual users of health records.
This is a true statement.
Removing health records of patients who have not been treated at the facility for a specific period of time from the storage area to allow space for more current records is called:
Purging records
Which type of microfilm does not allow for a unit record to be maintained?
Roll microfilm
Which of the following is true about document imaging?
Documents can be indexed
Which system records the location of health records removed from the filing system and documents the return of the health records?
Chart tracking system
“Loose” reports are health record forms that:
Are received by the HIM department and added to the health record after it has been processed
Which of the following is the most efficient filing system?
Unit numbering system
Which of the following is the key to the identification and location of a patient’s health record?
MPI
Which of the following numbering system assigns multiple health record numbers, or, one per visit?
Serial
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers but the content is filed under the most recent health record number?
Serial-unit number
Which of the following is part of qualitative analysis review?
Checking that only approved abbreviations are used
Which of the following is true of good forms design for paper forms?
Every form should have a unique identification number
Which of the following best describes the most important function of the health record?
Storing patient care documentation
Who are the primary users of the health record?
Clinical professionals who provide direct patient care
Which of the following elements is typically found in the paper health record?
Patient identification
Which of the following is an example of information
The number of patients discharged has increased 175% over the past year.
How many linear filing inches can a shelving unit hold based on the following data?
Shelving unit shelf width = 36 inches
Number of shelves per unit = 9 shelves
Average record thickness = ½ inch
324
Which of the following assists in locating misfiles in the paper-based filing systems?
Color coding
Which one of the following are included in a list of institutional users of the health record?
Blue Cross and Blue Shield
The services provided by HIM departments in acute care hospitals usually include all the following except:
Medical billing
The patient registration department assists the HIM department in what way?
Assigning the health record number
Which one of the following is an example of virtual HIM?
Employees who code from home
Which of the following HIM tasks is eliminated by the electronic health record system?
Assembly
The master patient index __________________.
Contains basic demographic information about the patient
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
36-45-99
37-45-99
38-45-99
Terminal digit

The annual volume statistics for General Hospital are noted below. How many shelving units will be required to store this year’s inpatient discharge records?

Average inpatient discharges = 12,000
Average inpatient record thickness = ¾ inch
SReviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysishelving units shelf width = 36 inches
Number of shelves per unit = 6

42
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis
Quantitative
The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review?
Retrospective
The release of information function requires the HIM professional to:
Disclose patient identifiable information to a third party
Which system is best suited for a small healthcare facility such as a one-physician practice?
Alphabetic filing system
In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters?
Unit numbering system
A record not completed within the time frame specified in the medical staff rules and regulations is called a ____________.
Delinquent record
Which of the following should be taken into consideration when designing a health record form?
Including original and revised dates
Which of the following statements describes alphabetical filing?
File the record alphabetically by the last name, followed by the first name, and then the middle initial.
Which of the following lists of names is in correct order for alphabetical filing?
Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas
Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip?
Microfilm roll
Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?
Outguides
Which of the following filing methods is considered the most efficient?
Terminal digit filing
Which of the following indexes is key to locating a health record?
Master patient index
Which one of the following is in terminal digit order?
Which one of the following is in terminal digit order?
An addendum to the health record should be dated _____.
The day the addendum was created.
Why should the copy and paste function should not be used in the electronic health record?
The content may contain outdated information
What committee oversees the development and approval of new forms for the health record?
Health information management committee
What is the software that is used for voice recognition known as?
Natural language processing
How can the healthcare facility determine which physician has the best patient outcomes?
Data mining
Critique this statement: Version control is not an issue in the EHR.
There are issues related to versions of documents, such as there must be a flag to indicate a previous version.
Dr. Smith wants to use a lot of free text in his EHR. What should be your response?
Dr. Smith, we recommend that you use little, if any, free text in the EHR.
Which of the following is a secondary purpose of the health record?
Support for research
Which of the following is a disadvantage of alphabetic filing
Uneven expansion in file shelves or cabinets
Which of the terms below represents fixed rules that must be followed?
Standard
Which of the following is a request from a clinical area to charge out a health record?
Requisition
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
216 inches
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.
Concurrent
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record.
Delinquent
In which department or unit does the health record typically begin?
Patient registration
The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:
Purged
Our transcription is performed by a company outside of our organization. What is this called?
Outsourcing
Calculate the number of shelving units required for 35,000 linear filing inches of records if the shelving unit has 7 shelves and is 36 inches wide.
139
Which of the following is an argument against the use of the copy and paste function in the EHR?
Inability to identify the author
Which of the following creates a chronological report of the patient’s condition and response to treatment during a hospital stay?
Progress notes
Which health record format is most commonly used by healthcare settings as they transition to electronic records?
Hybrid records
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?
Accreditation
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?
Chief complaint
Which of the following is an example of administrative information?
Patient’s address
The federal Conditions of Participation apply to which type of healthcare organization?
Organizations that treat Medicare or Medicaid patients
Which of the following materials is documented in an emergency care record?
Time and means of the patient’s arrival
Which of the following statements is true of the process that should be followed in making corrections in paper-based health record entries?
The reason for the change should be noted
Which of the following types of facilities is generally governed by long-term care documentation standards?
Subacute care
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?
Operative report
Which of the following is a function of the discharge summary?
Ensuring the continuity of future care by providing information to healthcare providers.
A patient’s registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record?
Long-term care
Which group focuses on accreditation of rehabilitation programs and services?
CARF
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
Laboratory findings
Which of the following is clinical data?
Physician orders
A healthcare provider organization, when defining its legal health record must ___________.
Assess the legal environment, system limitations, and HIE agreements
Documentation standards have become more detailed and have become focused on ________.
Patient care quality
Written or spoken permission to proceed with care is classified as ___________.
Expressed consent
The Joint Commission places emphasis on ________________.
Appropriate and standardized health record documentation
Which of the following electronic record technological capabilities would allow a paper-based x-ray report to be accessed?
Documents imaging
The Subjective, Objective, Assessment Plan (SOAP) came from the:
Problem-oriented health record
The overall goal of documentation standards is to
Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
What standard does a hospital that participates in the Medicare and Medicaid programs have to comply with that hospitals who do not accept Medicare and Medicaid patients do not?
Conditions of Participation
Which of the following is an example of an acknowledgement?
Notice of privacy practices
The management of health information is a fundamental component of which of the following?
The overall information governance model
What is the general name for Medicare standards impacting healthcare organizations?
Conditions of Participation
Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?
Commission on Accreditation of Rehabilitation Facilities
When correcting erroneous information in a paper health record, which of the following is appropriate?
Add the reason for the change
Patient history questionnaires are most often used in what setting?
Ambulatory care
An RAI/MDS and care plan are found in records of patients in what setting?
Long-term care
Which of the following represents the attending physician’s assessment of the patient’s current health status?
Physical examination
What is the function of a consultation report?
Documents opinions about the patient’s condition from the perspective of a physician not previously involved in the patient’s care
Which of the following represents documentation of the patient’s current and past health status?
Medical history
Which of the following contains the physician’s findings based on an examination of the patient?
Physical exam
Which of the following is usually a component of acute care patient records?
Progress notes
Which of the following is true of many electronic health records?
They are interoperable
When defining the legal health record, what must the healthcare provider do?
Assess the legal environment
The ambulatory surgery record contains information most similar to which records?
Hospital operative records
Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?
Emergency care
Patient Account Information includes
Insurance
Which of the following is an example of a long-term care setting?
Assisted living facility
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Care plan
In what part of the health record would the social and personal history be found?
Medical history
The overall goal of documentation standards is to _____________.
Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
Healthcare provider organizations normally do not have patients sign an acknowledgement addressing the fact that the healthcare provider organization is not responsible for the loss or damage of the patient’s valuables.
false
An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance.
true
CMS does not require healthcare providers to inform their patients about general patient rights afforded to them
false
The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance
true
Auto-authentication is not in compliance with the CMS Interpretive Guidelines for Hospitals.
true
The term ambulatory is the same as the term outpatient
true
Nursing documentation should only be subjective.
false
An increase of healthcare-related identity theft has had no influence on a healthcare provider organization’s decision not to collect Social Security Numbers from patients.
false
Analysis of patient registration information can promote population health management.
true
If data aggregation is the goal of collecting the data, ______ are the best choice.
Classifications
The SNOMED CT _________ includes the semantic tag.
Fully specified name
The ___________ is a core component of SNOMED CT.
Concept
___________ is a nursing terminology.
Clinical Care Classification
Category I CPT includes which of the following?
Surgery
A ___________ is a set of terms representing the system of concepts for the medical field.
Clinical terminology
ICD-10-PCS is a classification of _________.
Inpatient procedures
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders?
American Psychiatric Association
A classification provides clinical data to ______________.
Allow collection and reporting of healthcare statistics
The ___________ is responsible for the development and maintenance of ICD-10-CM.
NCHS
The _________ is a system for classifying the topography and morphology of neoplasm.
ICD-O-3
WHO defines ___________ as a reference classification.
ICF
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________.
Code system
Which of the following is the standard for clinical lab test results under the Meaningful Use program?
LOINC
HCPCS is made up of which code systems?
CPT and HCPCS Level II
If you were looking for a code for a medication taken orally, in which system is it found?
RxNorm
The _______ is responsible for development and maintenance of RxNorm
NLM
One of the two major groups of LOINC content is _________.
Clinical observations
The ___________ is responsible for the publishing and maintaining HCPCS Level II.
CMS
The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.
Common Clinical Data Set
Home health agency process and improvement outcome measures are based on data from the _____.
Outcomes and Assessment Information Set
The standardized HEDIS data elements are collected by
Acute care hospitals
The UHDDS’s core data elements were incorporated into the ___________ prospective payment system.
Acute inpatient
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?
SNOMED CT
LOINC would be found in the UMLS ____________.
Metathesaurus
What is a system of terms that follows pre-established naming conventions.
Nomenclature
Which of the following is a clinical terminology?
CPT
Who drives which clinical terminology, classification, and code system is selected as the standard?
Government regulation
One of the required descriptions for a SNOMED CT concept is _________________.
Preferred term
Category II CPT is used for _______________ .
Performance measurement
Nursing terminologies are ________________.
Used to direct patient care given by nursing staff
The __________ is a component of ICD-10-CM.
Index to External Causes
Which system would be used to classify a state of disability?
ICF
Which system includes ICD-10-CM codes to assist with meeting administrative requirements?
DSM-5
The ___________ is a derived classification of the WHO Family of International Classifications.
ICD-O-3
Which of the following procedure classifications include definitions?
ICD-10-PCS
If you were coding a patient with the diagnosis of congestive heart failure, which classification would you use?
ICD-10-CM
CPT is a terminology and also a ________________.
Code system
Which of the following is one of the parts of the LOINC fully specified name.
Sample type
Which chapter of HCPCS would you find drugs administered intravenously?
J Codes
Which of the following is the standard for healthcare equipment under HIPAA?
HCPCS Level II
Ingredient plus strength plus dose form is known as the
Semantic clinical drug term type
The objective of RxNorm is to normalize names of generic and branded drugs and attach a _________ to that name.
RxNorm concept unique identifier
A list of recommended data elements with uniform definitions is a _______.
Data set
According to CMS, who is qualified to collect the OASIS data?
Registered nurse
The Healthcare Effectiveness Data and Information Set contains standard _______.
Performance measures
The Uniform Hospital Discharge Data Set’s core data elements are collected by ______.
Acute care, short-term stay hospitals
The ___________ established the Common Clinical Data Set.
ONC
The UMLS ___________ contains the terminology, classification and code system standards.
Metathesaurus
The OASIS-C1 data elements originate from a _________.
Medicare-certified home health agency
Which of the following is an example of an electronic data source in healthcare?
Radiology Information System
Which of the following data sets was created to collect uniform data across the United States for inpatient patient stays?
Uniform Hospital Discharge Data Set (UHDDS
Which of the following is a collection of data that is organized in a manner to be accessed, managed, reported, and updated electronically?
Database
Which of the following is the process of execution, implementation, and management of databases within healthcare?
Database life cycle
A/n ___________________ is a list that provides guidance, indication, or other references of information contained in a database?
Index
The ______________ characteristic of quality data is the data being completely free from any errors?
Accuracy
This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation.
Data integrity
Which of the following describes the capability for two or more electronic systems to communicate and exchange information electronically?
Interoperability
The evaluation of data collected based on business needs and strategy is part of _______.
Data stewardship
The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________.
Clinical documentation improvement
What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization?
Form tracking system
What data quality characteristic is met when documenting the specific height of a patient within the health record?
Precision
A/n ________________________ is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider?
Query
This document defines how records and documentation are assembled and authenticated within the hospital
Medical staff bylaws
Which of the following is one of the principles of data stewardship as defined by the National Committee on Vital and Health Statistics (NCVHS)?
Individual’s rights
What concept refers to the process of creating management and oversight of data assets to support the organization’s mission, vision, and values?
Information governance
The process of completing an inventory of all electronic systems that create, transmit, and store health information is known as what?
System characterization
Information is single elements that define a specific characteristic about a patient.
false
Data modeling is the process of creating documentation to document any business decisions made on data collection and storage systems for data.
true
Organization information management is the processes and functions created by an organization to help plan, organize, and coordinate people, processes, technology, and content to manage information systems.
false
The term that refers to an individual’s ability to analyze, assess, and reconstruct a situation to provide a solution is critical thinking.
true
Structured data is data that is entered into a specific format that is capable of being read and analyzed without human intervention.
true
The process of creating paper forms to serve a business need is referred to as form creation.
false
The oversight of the definition of structure of data elements as well as the creation, storage, and transmission of data elements is referred to as data management
true
Data field, definition, data type, and format are all common data elements in what?
Data dictionary
A single or individual fact that represents a patient in healthcare is known as a/n ____________.
Data element
A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a heart attack. The combined data is referred to as?
Information
The data characteristic that refers to promptly entering up-to-date information into the patient’s medical record is which of the following?
Timeliness
AHIMA has created 8 principles to help organizations create ________________ within their organization?
Information governance
Authorship validation is one part of ___________________________?
Data integrity
What is another term for the electronic sharing of patient data between two healthcare systems?
Health information exchange
A patient’s birth date and gender documented in the health record are examples of a data?
Element
Which of the following data sets collect information on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services, and disposition?
Uniform Ambulatory Care Data Set (UACDS
Which of the following creates a visual process to understand the data being collected in two different systems and how it is linked to one another?
Data mapping
What is the term that describes the data that defines and characterizes other data within an electronic system?
Metadata
The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module, and release of information module with the electronic health record. This is an example of what data strategy method?
Data ownership
___________________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations?
Information assets
Safeguards established to support the data is available when and where is it needed under the data quality model is called which of the following?
Accessibility
This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry.
Unstructured data
An example of a clinical documentation improvement tool is computer-assisted coding (CAC).
TRUE
When writing a query for clinical documentation questions, the requestor should specifically state what diagnosis they are evaluating.
false
Interoperability is the capability of two or more systems and software applications to communicate electronically and exchange information.
true
Data warehousing is the process of extracting information stored in structured data formats within a database.
false
A healthcare organization must ensure that data is presented in a way that is appropriate for the purpose of the data.
true
Hospital bylaws define the process for documentation within a health record for all members of the workforce.
true
When documentation is unclear or needs more information in order to proper code the health record, the coder should call the provider, ask them the question, and document the answer in the health record.
false
An example of a standard for forms development is to mandate that the title of the form appear on the top center of the page.
true
Health Level 7
creates standards to support the exchange of information
Institute of Electrical and Electronics Engineers
Creates and develops different standards for hospital systems that need communication between bedside instruments and clinical information systems.
National Council for Prescription Drug Programs
creates standards regarding exchanging prescription information and payment information
Digital Imaging and Communication in Medicine
creates standards for the messaging of digital images
Accountability
create authority over the information governance process within an organization
Transparency
create a clear and open documentation process for the information governance strategy and activities within an organization
Compliance
create a process for ensuring that all the information meetings requirements of appropriate laws, regulations, standards and organization.
Retention
create a process for proper preservation based on requirements from regulations accrediting organizations, and company
Disposition
creates processes for secure and appropriate destruction of information that is no longer needed to be maintained by the organization.
Patient-identifiable data
information such as age and date of birth
Aggregate data
data extracted from individual patient records and combined to form information about groups of patients
Primary data
information about the patient that is documented by the clinicians who provides services to the patient
Secondary data
Data derived from the primary patient record.
Accession registry
list of cases in a cancer registry arranged in the order in which the cases were entered
Disease index
list of diseases and conditions of patients treated in a facility sequenced according to classification code number
Disease registry
central collection of data used to improve the quality of care and measure and effectiveness of a particular aspects of healthcare delivery.
Population-based registry
Registry that includes information from more than one facility in a geopolitical region.
Facility-based registry
registry that includes only cases for a specific facility
Operation index
List of the questions and procedures performed in a facility sequenced according to classification code number.
Physician index
list of patients by physician usually arranged by physician code numbers
Trauma registry
list of patients with severe injuries
Critique this statement: The Medicare Provider Analysis and Review File is made up of patient demographic data collected by acute care and skilled nursing facilities.
MEDPAR is made up of claims data which does include demographic data.
The creation of the National Practitioner Data Bank was mandated by ___________.
the Health Care Quality Improvement Act
The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of ____________________________.
the Healthcare Integrity and Protection Data Bank
The Healthcare Cost and Utilization Project is a major initiative of which organization within the federal government?
The Agency for Healthcare Research and Quality
An accession number is a number assigned to cases as it is entered in a cancer registry.
true
Which of the following is an example of an external user utilizing secondary data?
Federal agencies
Which of the following databases was developed by the National Library of Medicine?
The Medical Literature, Analysis, and Retrieval System Online
A record is considered a primary data source when it ____________________.
contains information about the patient that has been documented by the professionals who provided care to the patient
Secondary data sources consist of ______________.
Registries
A Level I trauma center provides care from initial evaluation through stabilization.
false
A Level III trauma center provides advanced trauma life support prior to the transfer of patients to a higher level trauma center.
false
The main goal of Healthy People 2020 is to focus on promoting vaccine safety in public and private provider settings.
false
Identify the true statement about the health record.
The health record is a primary data source.
Secondary data is generally used ________.
by external users
The state cancer registry desires to become accredited. Who should they contact?
North American Association of Central Cancer Registries
Choose the correct statement regarding population registries.
Population registries may or may not contain follow-up information on patients.
The nature of an injury and its threat to life by body system is shown by the:
Abbreviated Injury Scale
To identify cases to be entered into the trauma registry, where should someone look?
Disease index
Explain what the accession number 16-214 means.
The year that the patient was entered in the registry is 2016 and this was the 214th patient entered in the registry during 2016
Issues related to the efficiency and effectiveness of the healthcare delivery system are addressed by the _____.
Agency for Healthcare Research and Quality
Health information exchange is used primarily for which of the following?
patient care
A physician has a patient with a cancer that is not responding to treatment so he looks for research being conducted on the cancer. Who developed a database that he can use to locate any existing clinical trial?
National Library of Medicine
The content of the health record _______________.
Should facilitate retrieval of data
The length of time health information is retained ______________.
Must account for state retention laws, if they exist
Which type of law defines the rights and duties among people and private businesses?
Private law
Which stage of the litigation process focuses on how strong a case the opposing party has?
Discovery
Which document directs an individual to bring originals or copies of records to court?
Subpoena duces tecum
Errors in the health record should be which of the following?
Corrected by drawing a single line in ink through the incorrect entry
Congress passes laws, which are then developed by federal agencies to provide a blueprint for carrying out these laws. What do the federal agencies develop?
Regulations
In order for Susan to be able to prove negligence, she must be able to prove injury, standard of care, breach of standard of care and which of the following?
Causation
Jeremiah files a medical malpractice lawsuit against Dr. Watson, who performed his surgery. He names no other defendants in the lawsuit. Dr. Watson files a complaint against his assistant surgeon, Dr. Crick. By doing this, Dr. Watson has completed which legal action?
Counterclaim
Joinder
In Lindsay’s lawsuit against her physical therapist, her attorney a) obtained copies of most documents that he requested such as medical records, contracts, e-mail communications, bills, and receipts. However, at trial, Lindsay was surprised to learn that b) several of these documents were not permitted to be considered by the jury as evidence. The concepts associated with a) and b) are which of the following?
Discovery; admissibility
Elizabeth arrived at the nearest urgent care facility after being bitten by her cat, Felix. The physician examined her and gave her a tetanus shot. Based on these facts, a physician-patient relationship has _________.
Been created by implied contract
Alex fell from a tree and was taken to the emergency room. The physician did a physical exam and diagnosed Alex with contusions. In fact, Alex suffered a punctured lung that would have been detected by a radiologic image. In this case, the physician committed which of the following?
Nonfeasance
If a patient is not asked to sign a general consent form when entering the hospital, and later sues the hospital for contact that was offensive, harmful, or not otherwise agreed to, what cause of action has the plaintiff most likely included in his lawsuit?
Battery
A durable power of attorney for healthcare decisions ______________.
Applies when the individual is no longer competent
The maintenance of health records ____________________.
Is governed by Medicare Conditions of Participation for organizations that treat Medicare and Medicaid patients
Disclosure of health information without the patient’s authorization _____________.
May be required by specific state statutes
Metadata are which of the following?
Data about data
Stacie is writing a health record retention policy. She is taking into account the statute of limitations for malpractice and contract actions in her state. A statute of limitations refers to which of the following?
The period of time in which a lawsuit must be filed
The Registered Health Information Technician (RHIT) credential is an example of which of the following?
Certification
Dr. Smith is being sued by a former patient. At issue is whether the care he provided the patient was consistent with that which would be provided by an ordinary and reasonable physician treating a patient in the plaintiff’s condition. The concept in question is whether _____________.
Dr. Smith met the standard of care
Which of the following tyeps of destruction is appropriate for paper health records?
Pulping
A child’s health record should be retained for how long?
The age of majority plus the statute of limitation
Which of the following is a true statement about the legal health record?
It includes PHI stored on any medium
Policies that address how PHI is used inside the organization deal with which of the
Use
What type of negligence would apply when a physician does not order the necessary test?
Nonfeasance
Arbitration
Proceeding in which disputes one submitted to a third party or a panel of experts outside the judicial trial system
Public law
law that involves the government and its relationships with individuals or organizations
Private law
law that involves the government and its relationships with individuals or organizations
Subpoena duces tecum
written documents directing individual to furnish documents and other records to court
Implied consent
permission inferred when a patient voluntary subits to healthcare treatment
Deposition
sworn testimony usually collected before a trial
Authorization
written permission to use or disclose patient-identifiable health information
Defendant
individual or party who is the object of a lawsuit
Statute
law enacted by a legislative body
Administrative law
rules developed by administrative bodies empowered by law to regulate specific activities
Plaintiff
Individual who brings a lawsuit
Breach of contract
failure to meet the conditions specified under a legal agreements
Complaint
process by which a lawsuit is initiated
Discovery
disclosure of pertinent facts or documents to the opposing parties in a legal case
Medical malpractice
professional liability of healthcare providers in the delivery of care to patients
Express contract
spoken or written agreement may be given by a patient to a healthcare provider to permit treatment
Tort
civil wrongdoing
Which of the following is one of the four sources of law?
Judicial decision
District court
court in the lowest tier of the federal court system
US Court of Appeals
court with the power to overturn the final judgements of district courts
US Supreme Court
court with the power to overturn the final judgement of federal state court of appeal
State appellate court
court with the power to overturn the final judgements of state trial courts
State supreme court
generally term used to describe court in the highest tier of state court systems
Trial court
generally term used to describe court in the lowest tier of state court systems
The form and content of the health record are determined in part by which of the following?
The needs of individual healthcare organizations
When a healthcare provider purposely commits a wrongful act that results in injury to a patient, the provider can be held responsible for an intentional tort.
true
The Joint Commission sets the official record retention standards for hospitals and other healthcare facilities.
false
Which of the following spells out the powers of the three branches of the federal government?
US Constitution
Which of the following are laws enacted by a legislative body?
statutes
What is the individual who brings a lawsuit called?
Plaintiff
What is the individual who is the object of a lawsuit called?
Defendant
Which of the following may be a basis of professional liability?
Intentional tort
AHIMA’s record retention guidelines recommend that diagnostic images such as x-rays be maintained for what length of time?
At least 5 years
AHIMA’s record retention guidelines recommend that the master patient index be maintained for what length of time?
Permanently
AHIMA’s record retention guidelines recommend that the health records of adults be maintained for what length of time?
At least 10 years after the most recent encounter
Which of the following should be considered first when establishing health record retention policies?
State retention requirements
The services that a physician is allowed to perform in a healthcare facility is known as which of the following?
Clinical privileges
The physical health record is usually considered the property of which entity?
The organization or provider
In addition to a physician’s order, the do-not-resuscitate order should include which of the following?
Patient consent
A nurse cannot practice without:
Licensure
Amber files a medical malpractice lawsuit against Dr. Mason, who performed her surgery. She names no other defendants in the lawsuit. Dr. Mason files a complaint against Amber. By doing this, Dr. Mason has completed which legal action?
Counterclaim
Which of the following is a true statement about the content of the legal health record?
The legal health record contains metadata
The legal authority to make decisions is known as which of the following?
Jurisdiction
The source of law that is created by legislative bodies is which of the following?
Statute
Which of the following is one of the causes of action?
Breach of contract
Who prohibits specific abbreviations from being used in the health record?
Joint Commission
Which of the following is true of the Health Insurance Portability and Accountability Act (HIPAA)?
Provides a federal floor for healthcare privacy
Under the HIPAA Privacy Rule, which of the following is a covered entity category?
Healthcare clearinghouse
Under the HIPAA Privacy Rule, an impermissible use or disclosure should be presumed to be a breach unless the covered entity or business associate demonstrates that the probability the PHI has been compromised is ___________.
Low
Under usual circumstances, a covered entity must act on a patient’s request to review or copy his or her health information within what time frame?
30 days
The HIPAA Privacy Rule requires that covered entities limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this?
Minimum necessary
Which of the following should be included in a covered entity’s notice of privacy practices?
Description with one example of disclosures made for treatment purposes
Which of the following is true of the notice of privacy practices?
It must be posted in a prominent place
Which of the following statements is true?
An authorization must contain an expiration date or event
In which of the following instances must patient authorization be obtained prior to disclosure?
To the patient’s attorney
Which of the following is true about a facility’s patient directory?
The covered entity must inform the individual of the information to be included in the facility directory.
Which of the following statements about a business associate agreement is true?
It requires the business associate to make available records relating to PHI use and disclosure to the HHS.
How many days does a covered entity have to respond to an individual’s request for access to his or her PHI when the PHI is stored off-site?
60 days
Which of the following statements is true of the notice of privacy practices?
It must be provided to every individual at the first time of contact or service with the covered entity.
Which of the following statements about a facility directory of patients is true?
Disclosures from the directory need not be included in an accounting of disclosures.
In which of the following situations can PHI be disclosed without authorization, as long as there was an opportunity for the individual to agree or object?
Facility directory disclosures
Who of the following would be considered a member of a hospital’s workforce?
A clerk working in the hospital’s registration office
When would PHI loses its status?
After an individual has been deceased more than 50 years
A covered entity may deny an individual’s amendment request for which of the following reasons?
If the PHI in question is not part of the designated record set
Which of the following is a public interest and benefit exception to the authorization requirement?
Judicial and administrative proceedings
The breach notification requirement applies to:
Unsecured PHI only
A subpoena should be accompanied by which of the following?
Patient authorization
In court, hearsay is generally ____________.
Non-admissible
The American Recovery and Reinvestment Act expanded the definition of business associates to include which of the following?
Patient safety organizations
Critique this statement: According to HIPAA, workforce members include students.
This is a true statement
The designated record set includes which of the following?
Billing records
In all cases, a covered entity may deny an individual’s request to restrict the use or disclosure of his or her PHI.
false
Stricter state statutes that provide greater confidentiality of healthcare information take precedence over the provisions of the HIPAA Privacy Rule.
true
A notice of privacy practices should include a statement explaining that individuals may complain to the Secretary of the Department of Health and Human Services if they believe that their privacy rights have been violated.
true
Which of the following is a covered entity under the HIPAA Privacy Rule?
Pharmacy
What types of health records are subject to the HIPAA Privacy Rule?
Health records in any format
What does the acronym PHI stand for?
Protected health information
Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity _______________.
Can deny access to psychotherapy notes
In which of the following situations must a covered entity provide an appeal process for denials to requests from individuals to see their own health information?
When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual
Which of the following statements is true in responding to requests from individuals who wish to access their PHI?
A cost-based fee may be charged for making a copy of the PHI.
How many days does a covered entity have to respond to an individual’s request for access to PHI under HIPAA rules?
30 days
How many days does a covered entity have to respond to an individual’s request for access to his or her PHI when the PHI is stored off-site?
60 days
Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?
Notice of privacy practices
Which of the following statements is true of the notice of privacy practices?
It must be provided to every individual at the first time of contact or service with the covered entity.
Which of the following is unsecured PHI?
PHI that technology has not made unusable, unreadable, or indecipherable to an unauthorized person
Which of the following statements about the directory of patients maintained by a covered entity is true?
Individuals must be given an opportunity to deny permission to place information about them in the directory.
Mary’s PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the physician office’s required action?
It must report the breach to HHS within 60 days after the end of the calendar year in which the breach occurred
PHR vendors that are not part of a covered entity or business associate must report PHI breaches to
The Federal Trade Commission
Which of the following actions by a physician requires the patient’s authorization?
Giving the name of an expectant mother to a baby formula manufacturer
HIPAA administrative requirements include which of the following?
Designating a privacy officer
ARRA and HITECH granted which of the following the ability to bring civil actions in federal district court on behalf of residents believed to have been affected by a HIPAA violation?
State attorneys general
A valid authorization requires which of the following?
An expiration date or event
Which of the following situations is considered a breach of PHI?
A patient’s attorney is sent records not requested by that patient
In which of the following circumstances does the patient have an opportunity to agree or object?
Whether the patient should be in the facility directory
Which of the following rights did HIPAA give patients?
Right to request an amendment of the health record
Which of the following statements is true?
State law preempts HIPAA
Data security includes protecting data availability, privacy, and ________.
Integrity
Within the context of data security, protecting data privacy means defending or safeguarding _________.
Access to information
The greatest threat category to electronic health information is which of the following?
Humans
The first and most fundamental strategy for minimizing security threats is which of the following?
Establish a secure organization
Administrative safeguards include policies and procedures that address which of the following regarding computer resources?
Management
The individual responsible for ensuring that everyone follows the organization’s data security policies and procedures is which of the following?
Chief security officer
An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach?
Access controls
A visitor to the hospital looks at the screen of the admitting clerk’s computer workstation when she leaves her desk to copy some admitting documents. What security mechanism would best have minimized this security breach?
Automatic logoff controls
A laboratory employee forgot his user ID badge at home and uses another lab employee’s badge to access the computer system. What controls should have been in place to minimize this security breach?
Workforce security awareness training
A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach?
Device and media controls
HIPAA requires that policies and procedures be maintained for a minimum of _______.
Six years from date of creation or date when last in effect, whichever is later
A visitor walks through the computer department and picks up a CD from an employee’s desk. What security controls should have been implemented to prevent this security breach?
Facility access controls
Threats to data security are most likely to come from which of the following?
Employees
These are automatic checks that help preserve data confidentiality and integrity.
Application controls
An employee in the physical therapy department arrives early every morning to snoop through the EHR for potential information about neighbors and friends. What security mechanism should have been implemented that could minimize this security breach?
Facility access controls
An employee observes an outside individual putting some computer disks in her purse. The employee does not report this security breach. What security measures should have been in place to minimize this threat?
Security incident procedures
Locks on computer room doors illustrate a type of _________.
Physical control
An admission coordinator consistently enters the wrong patient gender while entering data in the MPI. What security measures should be in place to minimize this security breach
Edit checks
Which of the following statements is true regarding HIPAA security?
HIPAA allows flexibility in the way an institution implements the security standards.
For HIPAA implementation specifications that are addressable, the covered entity _________.
Must conduct a risk assessment to determine if the specification is appropriate to its environment
A user recently opened a file that they thought would help them with their job but it copied files to unsecure ares of the computer. What thpe of malware was activated?
Trojan horse
Training that educates employees on the confidential nature of PHI is known as which of the following?
Awareness
“Something you have” is demonstrated by:
Token
Policies are which type of safeguards?
Administrative
A hospital is looking to use something to act as a buffer between two networks. What should be recommended?
Firewall
The primary reason that healthcare organizations develop business continuity plans is to minimize the effects of which of the following?
Computer downtime
Critique this statement: HIPAA represents an attempt to establish best practices and standards for health information security.
This is a true statement.
A risk analysis is useful to _________.
Identify security threats
Which of the following is true regarding HIPAA security provisions?
Covered entities must retain policies for 6 years after they are no longer used.
Which of the following is a technique that can be used to determine what information access privileges an employee should have?
Context-based
The HIPAA data integrity standard requires that organizations do which of the following?
Keep documented logs of system access and access attempts
Which of the following is required by HIPAA standards?
A written contingency plan
Security controls built into a computer software program to protect information security and integrity are which of the following?
Application controls
This type of control is designed to prevent damage cause by computer hackers.
Network control
Policies and procedures that address the management of computer resources and security are which of the following?
Administrative controls
Safeguarding system access
privacy
Safeguarding data accuracy
integrity
Ensuring system access when needed
availability
Which of the following terms means that data should be complete, accurate, and consistent?
Data integrity
What is the biggest threat to the security of healthcare data?
Employees
What does the term access control mean?
Identifying which data employees should have a right to use
Which of the following is a software program that tracks every access to data in the computer system?
Audit trail
Which of the following is an organization’s planned response to protect its information in the case of a natural disaster?
Business continuity plan
Though the HIPAA Security Rule does not specify audit frequency, how often should an organization’s security policies and procedures be reviewed?
Once a year
Which of the following provide the objective and scope for the HIPAA Security Rule as a whole?
General rules
Which of the following is an example of a physical safeguard that should be provided for in a data security program?
Locking computer rooms
Which of the following best describes information security?
The mechanisms for safeguarding information and information systems
A public key is part of what security measure?
Digital certificates
Which of the following is an example of technical security?
Integrity
Policies were recently rewritten. How long does the facility need to retain the obsolete policies?
Six years
An audit identified that an employee accessed a patient whose name is the same as the employee. This is known as a/an _________.
Trigger
In two computer systems the same data element is different. This is what type of issue?
Data consistency
A radiology information system is which of the following?
Source system
When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence?
Adoption
Which of the following is a fundamental change in how medicine is practiced using health IT?
Clinical transformation
Which of the following is a program that assures there is documented approval for altering an application?
Change control
What health information exchange is a sophisticated structure that enables both receipt of data and the ability to query an exchange for data?
CONNECT
Infusion pumps and robotics are examples of which of the following?
Smart peripherals
What is interoperability?
The ability to share health information with other health IT systems
Revenue cycle management is accomplished through use of which of the following systems?
Patient financial service system
Structured data are which of the following?
Able to be processed by a computer
Ideally, clinical documentation in an EHR should be performed _____________.
At the point of care
The source of drug-drug contraindication information in a computerized provider order entry system is ___________.
Drug knowledge database
Which of the following is an example of clinical decision support?
Workgroup tool
A standard vocabulary is used to achieve what type of interoperability?
Semantic
A way to send secure messages over the Internet is which of the following?
Virtual private network
In order to locate a patient via a health information exchange organization, there must be which of the following?
Identity matching
The systems development life cycle
Ensures all components for a system to achieve its value are in place
A form of clinical decision support that guides a user in appropriate documentation is which of the following?
Template
What is the combination of quality and cost of healthcare?
Value
Computerized provider order entry systems can be used to order narcotics.
true
A clinical data repository supports sophisticated data analytics.
false
An organization’s goals that are supported by health IT can be achieved more quickly and completely if monitoring results is performed.
true
A master patient index is used to locate where patients may have records within a health information exchange organization.
false
Medication reconciliation is very difficult to implement and often one of the last applications within the medication management set of systems.
true
The Logical Observations Identifiers Names and Codes (LOINC) vocabulary is used to encode laboratory orders and results
true
A portal is the same as a personal health record.
false
When a vendor is no longer selling or supporting a health IT product, it is said to be _________________.
Sunset
The nationwide health information network is now called which of the following?
eHealth Exchange
Security functionality provided in a health information exchange is collectively referred to as which of the following?
Identity management
In a health information exchange, patients opt in or opt out of having their data exchanged via a(n)
Consent directive
A person who is able to take advantage of all of the aids offered by health IT is referred to as which of the following?
Power user
Which of the following is a core clinical EHR system?
Results management system
In order for a hospital to generate a claim for reimbursement by a health plan, the EHR must have which of the following components?
Charge capture
What does a form creation system do?
Automates administrative forms processing
Clinical documentation systems that support clinical decision making capture data via ______________.
Structured data templates
EHRs support evidence-based medicine, which refers to which of the following?
Recommendations for care based on research
The standard used in e-prescribing systems to transmit a prescription to a retail pharmacy is which of the following?
SCRIPT
Online transaction processing is conducted in which of the following?
Clinical data repository
Semantic interoperability is achieved by using ____________.
Standard vocabularies
In order for a physiological monitor, such as a device a patient may wear during exercise, to be connected to an EHR, there must be which of the following?
Medical device integration
A registry is which of the following?
Specialized database for a predefined set of data and its processing
Web service architecture does not require an interface.
false
The ASTM International standardized the content of the continuity of care record.
false
The system development lifecycle is repeated when monitoring reveals that the system is no longer producing the desired result.
true
A physician champion is now referred to as a chief medical informatics officer.
false
When almost all applications used in a hospital are acquired from the same vendor, the strategy being deployed is considered best-of-breed.
false
A term that refers to a statistical process of data to reveal new information is which of the following?
Analytics
Information
data processed into usable form
Data
basic facts
Knowledge
understanding to make informed decisions
The Affordable Care Act is a regulation that was issued by CMS, outlining an incentive program for professionals that adopt and successfully demonstrate ________________ of certified EHR technology.
Meaningful Use
Healthcare information is primarily for which of the following?
Provider use in the management of care
To arrive at information, _________ are required.
data
________ data analytics is where health information is captured, reviewed, and used to measure the quality of care provided.
Clinical
What is the first stage of transforming raw data into meaningful analytics?
Data capture
Which of the following may be used to capture the data for storage in a database?
Natural language processing
Which of the following data visualization tool is used when displaying trends?
Graphs
The _________ is a management report of process measures.
Dashboard
Which of the following is where a nurse enters data using a tablet computer when conducting a patient assessment while at the bedside?
Point-of-care charting
__________ is key to the knowledge discovery process.
Data mining
The clinical data ___________ lends itself to data mining as it encompasses multiple sources of data.
Warehouse
Which decision support systems could deliver a reminder to a physician that it is time for the patient’s flu shot?
Clinical
The _______ would be used to help find actionable insights to drive enterprise performance.
Executive information system
A _________ generated scorecard could be used by a manager to monitor readmission rates in order to track trends and identify opportunities for improvement.
Decision support system
The exchange of email communication between the patient and physician on a question regarding medication is an example of ____________ health informatics.
Consumer
According to FDA guidance, a mobile app running on a smart phone to analyze and interpret EKG waveforms to detect heart function irregularities is a ___________.
Medical device
Which access tool is used to view a subset of patient’s health records after logging in to a secure online website?
Patient portal
Which of the following is a type of electronic personal health record that allows access through a portal?
Tethered
Connecting the PHR to the patient’s legal health record protects it under the HIPAA ______.
Privacy Rule
“Why did it happen?” is answered by _______ analytics.
Diagnostic
Free text describing a patient’s chief complaint is an example of _________.
Unstructured data
Tracking and comparing over time the number of medical records coded per hour by individual coder to assess coder productivity is an example of a __________.
Key indicator
Physicians correct misrecognitions at the time of dictation when _______ is used.
Front-end speech recognition technology
___________ is a barrier to health information exchange users.
State law
Which of the following is a benefit of HIE?
Enhanced patient care coordination
A patient portal that allows personal health information to be uploaded for provider access is an example of _______________.
Consumer-mediated exchange
A ________ would be used to define syntax conventions.
Content and structure standard
The ONC’s goal of advancing secure and interoperable health information requires_______.
Sharing information among individuals, providers and the community
What happened?” is answered by _______ analytics.
Descriptive
What is the second stage of transforming raw data into meaningful analytics?
Data provisioning
___________ is a tool used for extracting data from a database.
Data mining
Data from a wearable monitor, such as an exercise-tracking device, is an example of?
Patient-generated health data
The use of a dropdown list to select a patient’s diagnosis is an example of _________.
Structured data
Sharing the contents of a PHR with providers creates an opportunity to ____________.
Improve patient safety
The clinical data ___________ is a central database that focuses on clinical information.
Repository
Which of the following data visualization tool is used to organize quantitative data?
Tables
Which of the following data visualization tool is used to organize quantitative data?
Scorecard
Tracking a _______ can help detect problems and identify opportunities for performance improvement.
Key indicator
Editors correct misrecognitions after the physician completes dictation when _______ is used.
Back-end speech recognition technology
___________ is a possible outcome of point-of-care charting.
Unstructured or structured data
What role in consumer informatics is HIM filling in the following situation: Creation of policies and design workflows for accepting and managing patient-generated health information.
Patient information coordinator
A smart phone app that analyzes and interprets blood pressure readings to detect irregularities is a _________ according to FDA guidance.
Medical device
The problem being solved with the use of DSS is typically _______.
Unstructured
Which system would be used to pull together operational and clinical information in order to uncover a problem with readmissions?
Executive information system
If consumers were looking to interact and receive support from others with similar diseases via electronic means, which tool might they use?
Social media
The eHealth Exchange is a _______________ of exchange partners.
Nationwide community
Scheduling appointments is an example of a patient portal feature having a(n)_______.
Administrative orientation
A _______ accepts data patients’ select from external sources, which is then stored on their computer.
Standalone PHR
When exchanging information about a patient’s problem, a ________ would be used.
Terminology standard
____________ in order to maintain patient identity data integrity.
The data must be accurately entered
A _______ can assist a provider in obtaining a health record on a patient who is visiting from another state, resulting in more informed decisions about the care of the patient.
Query-based exchange
All definitions of HIE mention which of the following?
The capacity exists for different information systems and software applications to exchange data
What is the term used by the insurance industry that refers to the process of paying, denying, and adjusting claims based on patients’ health insurance coverage benefits?
Adjudication
Clinical data is used to identify an individual.
false
________ protects a person from having to pay the full cost of healthcare.
Health insurance
The ______ is the process of patient financial and health information moving into, through, and out of the healthcare facility.
Revenue cycle
What is the term that is used to identify an insurance company that pays for the healthcare of covered individuals?
Third party payer
If a patient is covered by more than one insurance plan, the process of coordination of benefits (COB) takes place.
True
A Chargemaster is a financial management list that contains information about the organization’s charges for healthcare services it provides to patients.
true
______ is a type of incentive to improve clinical performance using the electronic health record resulting in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts.
Pay-for-performance
______ is a specified amount of money paid to a health plan or doctor, used to cover the cost of a health plan member’s healthcare services for a certain length of time.
Capitation
Retrospective utilization review process involves review of utilization information before the patient has been discharge or the care has been completed.
false
A type of prospective review involves ______ which is obtaining approval from a healthcare insurance company before a healthcare service is rendered.
Precertification
What methodology involves payment that combines the professional and technical components of a procedure and disperses payments in a lump sum to be split between the physician and the healthcare facility?
Global payment
The technical component of a service is considered the part of the service supplied by physicians, while the professional component is supplied by the hospital or freestanding surgical center.
false
A prospective payment system is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.
true
Payment method in which the third-party has implemented some provisions to control the costs of healthcare while maintaining quality care.
managed care
A type of healthcare organization that delivers medical care and manages all aspects of the care and payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care.
managed care
An entity that combines the provision of healthcare insurance and delivery of healthcare services, characterized by an organized healthcare delivery system to a geographic area, a set of basic and supplemental health maintenance and treatment services, voluntarily enrolled members, and predetermined fixed, periodic prepayments for members’ coverage.
HMO
A managed care contract coordinated care plan that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan.
preferred provider organization ppo
A federally funded health program to assist with the medical care costs of American 65 years of age and older.
medicare
Medicare prescription drug coverage
medicare part d
A joint federal and state program that helps with medical costs for some people with low incomes.
medicaid
Provides health coverage to eligible children through both Medicaid and individual state programs.
state childrens health insurance program SCHIP
The federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities.
tricare
A federal agency within the Department of of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska Natives.
ihs
Insurance that most employers in the US are required to carry and is used for employees who are injured on the job.
workers compensation
What is a private not-for-profit organization with the mission to improve healthcare quality by accrediting, assessing and reporting on the quality of managed care plans?
NCQA
The Health Maintenance Organization Act of 1973 made it harder for HMOs to grow and attract clients and required all employers that offered traditional health care to their employees to sign up for an HMO if they had more than 35 employees.
false
Medicare enrollees are called ______ and must fall into a benefit category to be eligible for Medicare coverage.
Beneficiaries
People who are enrolled in both Medicare and Medicaid known as _____.
Dual eligible
______ includes verification that the patient is currently covered by the plan on the date of service the services being provided are covered by the plan.
Eligibility
What is a pre-established percentage of eligible expenses after the deductible is met?
Coinsurance
______ is a cost-sharing measure in which the policy holder pays a fixed dollar amount per service.
Copayment
_____ means charging the patient for the remainder of the charges that were not paid by the insurance plan.
Balance bill
Health insurance payers have a variety of reimbursement plans and contract with individual providers and employers for payment meaning the same type of service to two different patients may be paid differently depending on the type of contract or insurance each patient has.
true
What is name of the form that details the way the payer processed the claim for payment?
Explanation of benefits
Many Americans are covered by private insurance plans through their employer, purchased individually, or through a group, such as a professional association.
true
Typically, insurance plans that have very high deductibles or limited covered services is called what?
Private health insurance
Who is responsible for making payment for healthcare claims on behalf of the company?
Third party administrator
In a network HMO the HMO contracts with a network of providers who provide multispecialty group practices
true
In a _____ HMO the physicians are employed by the HMO. Physicians see only members of the HMO and are paid a salary by the HMO.
Staff Model
What type of HMO model contracts with more than one physician, such as a medical group that includes physicians in multiple fields of expertise?
Group Model HMO
______ is where uninsured, eligible Americans are able to purchase federally-regulated and subsidized health insurance.
Health insurance marketplace or exchange
The Health Information and Accountability Act established the hospital-acquired conditions reduction program to encourage hospitals to reduce HAC’s.
false
_____ is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.
Utilization management
What refers to the review that takes place prior to elective procedures or admissions?
Prospective review
Retrospective review involves screening for medical necessity and the appropriateness or timeliness of delivery of medical care from the time of admission until discharge.
false
_____ is a collaboration between healthcare and service providers to aid in the process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet an individual’s and family’s comprehensive health needs.
Case management
A hospital’s _______ represents the average DRG relative weight for a particular hospital.
Case-mix index
In what system are payments for services determined by the resource cost needed to provide them?
RBRVS
The Balance Budget Act (BBA) of 1997 modified how facilities are paid for skilled nursing facility (SNF) services. SNF’s are paid a comprehensive per diem under a PPS, meaning they receive a set amount for each day of service instead of being paid on itemized charges or services.
True
Fraud is when someone intentionally executes or attempts to execute a scheme to obtain money or property of any healthcare benefit program. The key word in the definition is which of the following?
Intentionally
Which of the following is an example of abuse?
A pattern of coding errors
The overutilization or inappropriate utilization of services and misuse of resources, typically not a criminal or intentional act is called which of the following?
waste
The statue that dictates that physicians cannot receive money or other benefits for referring patients to a healthcare facility is known as which of the following?
Anti-Kickback Statute
The Health Insurance Portability and Accountability Act was created through a joint venture between the Department of Health and Human Services and the Depart of Justice in what year?
1996
Overpayments occur in which of the following scenarios?
Payment is billed for non-covered services
Which governmental program has a goal to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries?
RAC
How many basic elements are included in an effective compliance program?
7
Which of the following is the purpose of audits performed by QIOs?
improving patient care
Audit planning includes which of the following?
Establish policies, procedures, and standards of conduct
What is the process of extracting and translating dictated and then transcribed free-text data into ICD and CPT codes for billing and coding purposes?
CAC
The benefits of a coding compliance plan include the following.
Retention of high standard of coding
A complication is defined as which of the following?
A medical condition that arises during an inpatient hospitalization
Which of the following is one of the most widely-used key indicators for a CDI program?
CMI
Which of the following is a type of supportive documentation reflecting objective clinical indicators of a patient illness and refers to the extent of physiological decompensation or organ system loss of function?
SOI
The coder used two separate procedure codes instead of a combination code. This practice known as which of the following?
Unbundling
HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into?
Reasonable diligence
What practice do HIM departments use to protect themselves from RAC identifying coding and billing errors?
Prebilling coding audits
Which of the following is one of the purposes of an audit?
Improving patient care
What is the technology needed for computer-assisted coding?
Natural language processing
Objective clinical indicators about the patient’s illness are known as which of the following?
Severity of illness
Choose the statement that would explain to a physician what a complication is.
Complication is a medical condition that the patient has at the time of the patient’s admission which affects treatment and length of stay.
Critique this statement: Computer-assisted coding eliminates coders.
This is a false statement as coders will be needed but their role will change
Which of the following is a documentation issue?
Copy and paste functionality
Dr. Smith does not understand queries. Which of the following explains it to him?
A query requests additional clarifying documentation.
QIOs frequently conduct audits to determine if healthcare services have been provided in the appropriate setting. Which of the following is an example of the appropriate setting for healthcare services?
A nursing home providing physical therapy for a post-operative hip replacement patient
The focus of RAC audits is patient-care focused.
false
Before an audit can be conducted, an organization must first do which of the following?
Identify the objective of the audit
Which of the following is an example of convenience sampling?
All claims that are readily available to the auditor are audited
Which of the following is a good question for a supervisor of coding to ask when evaluating potential fraud or abuse risk areas in the coding area?
Are the assigned codes supported by the health record documentation?
A study conducted by AHIMA found that credentialed coders who used a CAC were able to reduce the amount of time it took to code a record by 50%.
false
A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria is the definition of which of the following?
Key indicator
One of the most widely-used key indicators for a CDI program to use for monitoring is which of the following?
CMI
HIM professionals are qualified to be CDI specialists.
true
Which of the following is an example of a HAC?
Catheter-associated urinary tract infection
A systematic comparison of the products, services, and outcomes of one organization with those of a similar organization is the definition of which of the following?
Benchmarking
CAC used which of the following processing to review the documentation in the EHR and assign a code number?
NLP
City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital?
$39,375
Fraud is when a healthcare provider or supplier performs an action that directly or indirectly results in unnecessary costs to any healthcare benefit program.
false
The whistleblower provision of the False Claims Act is known as qui tam.
true
This law prohibits a physician from referring patients to a business in which he or she or a member of the physician’s immediate family has financial interests
Stark Law
The Balanced Budget Act excludes healthcare organizations that are convicted for their first offense for
10 years
The three categories that HHS uses to determine the level of effort put into fraud and abuse prevention include which of the following?
Reasonable care, reasonable diligence, willful neglect
The Office of the Inspector General is responsible for which of the following?
Monitoring Medicare and Medicaid programs
The Office of the Inspector General is organized into five divisions: Office of Audit Services, Office of Evaluation and Inspections, Office of Recovery, Office of Investigations, and the Office of Counsel to the Inspector General.
false
Three different types of RAC audits include automated reviews, complex review, and annual reviews.
false
The five levels of the appeal process include redetermination, reconsideration, administrative law judge, appeals council review, and final judicial review.
true
Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following?
Review of validity of hospital diagnosis and procedure coding data completeness
Meaningful Use (MU) does not provide incentives to eligible professionals, hospitals, and critical access hospitals participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology.
false
Meaningful Use Stage 3 focuses on which of the following?
Providers to report infectious diseases, immunizations, cancer and other reportable condition to public health officials
The legal term for “First do no harm” is which of the following?
Nonmaleficence
Beneficence is an ethical principle meaning a patient has the right to choose their course of treatment.
false
An ethical Dilemma occurs when one is faced with a choice between 2 or more situations.
true
What is one assessing when addressing how one views language, communication style, belief systems, customs, attitudes, perception, and values?
Personal cultural competence
A cultural audit is a strategy to define an organizations values, symbols, and routines and identify areas for improvement.
true
What organization was established to help provide equality for minority groups, women, people with disabilities, and veterans?
Equal Employment Opportunity Commission (EEOC)
Ethical Principles and values have been important to the HIM profession since 1942.
false
If a patient receives a _____________ from a healthcare organization it indicated that the patient’s protected health information was involved in a data breach.
Protected Health Breach Notice
Codes are associated with reimbursement rates and therefore, there are inherent incentives to code so the healthcare facilities will receive the lowest reimbursement dollar amount possible.
false
_____ is the fraudulent use of an individual’s identifying information in a healthcare setting.
Medical identity theft
HIM professionals are able to assist patients with the process of finding out what happened in case of medical identity theft and help guide the patient in fixing the errors in the record.
true
What is the committee of the organization tasked with reviewing ethics violations and determining the course of action required to remedy the violations.
Ethics Committee
If a patient notices an unknown item in the explanation of benefits they receive from an insurance company and they do not recognize the service being paid for, the patient should_____.
Contact the insurer and the provider who billed for the services to correct the information
Breach of healthcare ethics is the situation in which ethics are violated, whether it is intentional or accidental.
true
Healthcare providers add documentation after care has been given
retrospective
The minimum necessary standard for ROI
need to know principle
The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps
unbundling
The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that reflect the documentation
upcoding
The committee that oversees the clinical research that is conducted for healthcare, and has the responsibility over the ethical application of research
international review board for the protection of human subjects IRB
The report that provides the foundation for ethical research
Belmont report
Helps control the cost of healthcare by providing services at a fixed cost
managed care
Two providers bill for one service provided to one patient
double billing
A researcher determines what the maximum potential is for society compared to the minimum risk of harm done
beneficence
When more information is needed, or the information needs to be clarified, in regards to coding
query the physician
The right to determine what does or does not happen to him or her, this includes the informed consent process for human research subjects
autonomy
What is the ability to accept and understand the beliefs and values of other people and groups?
Cultural competence
_____ is the perceived or actual difference among people.
Cultural diversity
The classification of people based on national origin or culture is called what?
Ethnicity
The assumption that everyone within a certain group are the same
Stereotyping
Pre-judging a person based on something such as age, education, or religion without reviewing all the information
Prejudice
Prevents a person from having an impartial judgment
bias
Legal and ethical concept that requires healthcare providers to protect health records and other personal and private information from unauthorized use or disclosure
confidentiality
The means to control and protect access of health information and records
security
The right of a patient to control the disclosure of protected health information
privacy
Openness in decision making, honesty in communication and activity and ethical practices that command trust and support collaboration
integritary
Visionary thinking, decisions responsive to membership and mission, and accountability for actions and outcomes
leadership
Appreciation of the value of differing perspective, enjoyable experiences, courteous interaction, and celebration of achievements that advance a common cause
respect
An abiding commitment to innovation, relevance, and continuous improvement in programs, products, and services
quality
A professional code of ethics is adopted by an organization to guide the members in determining right and wrong conduct when performing the duties of their job.
true
Patients trust that the information they share with their healthcare provider will be protected
true
Healthcare consumers are increasingly concerned about security and the potential loss of privacy.
true
Ethical obligation to the _______ include advocating change when patterns or system problems are not in the best interest of the patients and reporting violation of practice standards to the proper authorities.
public
It is not the responsibility of an HIM professional to ensure patient documentation is accurate, timely, and created by authorized parties.
false
Report all healthcare _________ required for external reporting purposes completely and accurately, in accordance with regulatory and documentation standards, and requirement and applicable official coding conventions, rules, and guidelines
data element
According to the Standards of Ethical Coding, Coders apply accurate, complete and consistent coding practices for the production of high-quality healthcare data
true
Healthcare professionals are trained in the ethical issues related to what system because staff may have access to more information than what is needed to do their job
EHR
With an increase in medical identify theft, it is important for HIM professionals to help find and correct fraudulent information within a health record.
TRUE
HIM professionals are not ethically obliged to give back to the HIM community by providing practice opportunities for students.
false
To refuse to participate in or conceal unethical practices or procedures and report such practices is a principle and guidelines to what?
AHIMA Code of Ethics

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