HIT 160-100, Class 1669 Final Review

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Questions from tests on Chapters 1-5, 7, 8,13-16

The services provided by HIM departments in acute care hospitals usually include all the following except ____.
A) medical transcription
B) medical billing
C) clinical coding
D) release of information

B) medical billing

The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the ____.

Patient registration department

The hospital standardization movement was inaugurated by the ___in ____.

American College of Surgeons; 1918

Which of the following tasks might the HIM department not perform in an electronic health record system?
a) document imaging
b) analysis
c) assembly
d) indexing

c) assembly

The master patient index ______.
a) is the most important index maintained by the HIM department.
b) contains basic demographic information about the patient
c) is commonly part of the admission, discharge, and transfer computer system
d) all of the above

d) all of the above

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?
37-45-99
38-45-99
39-45-99

Unit

Source-oriented, problem-oriented, and _____ health record formats are commonly used in paper based record systems.

integrated

True or False: The purpose of ACS is to raise the standards of surgery by establishing minimum quality standards for hospitals.

True

The coding of clinical diagnoses and healthcare procedures and services prior to the patients discharge is ____ review.

concurrent

The release of information function requires the HIM professional to have knowledge of ____.

federal and state confidentiality laws

Joe Schmoe, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health records numbers is ____.

Overlap

The term used to describe a combination of paper-based and electronic health records maintained on the same patient is ____.

hybrid

Which of the following is a listing of patients in alphabetical order?
a) accession register
b) master patient index
c) control log
d) order-entry/order management report

b) master patient index

In alphabetic filing, which of the following names would come first?
a) P. M. Jansen
b) P. Matthew Jansen
c) Paul Matthew Jansen
d) P. Jansen

d) P. Jansen

Father Leo Lyman is indexed immediately before _____.
a) Felix Fernandez
b) Frances L'Monte
c) Louise S. Lyman
d) Lois T. Ruiz-L'Monte

c) Louise S. Lyman

The numbering system in which a patient is assigned a new number with each visit and the patient's older medical records are brought forward to the newest number and location is called ______.

serial-unit

The main advantage of a unit numbering system for filing medical records is _______.

It provides for continuity of care.

Data applications, data collection, ____, and data analysis are the four domains of data quality management.

data warehousing

Statements that define the performance expectations and/or structures or processes that must be in place are called ______.

standards

Which index is considered to be the authoritative key to locating a health record?

Master patient index

What is the acronym HIPAA?

Health Insurance Portability and Accountability Act

A statement or guideline that directs decision making or behavior is called a _____.

policy

______ data is extracted from individual health records and combined to form de-identified information about groups of patients.

Aggregate

If there are not any state retention laws in place, a medical facility should consider what when destroying medical records?

medical staff bylaws

Which entity(ies) have established documentation standards?
a) Medicare
b) Joint Commission
c) National Committee for Quality Assurance
d) all of the above
e) a and b only

e) a and b only

An efficient record management system is conducive to all of the following except:
a) quick retrieval of medical records
b) confidentiality of medical records
c) reduction of misfiles
d) reduction of filing equipment costs

d) reduction of filing equipment costs

According to indexing rules for alphabetic storage, personal names are indexed in the what order?

last name, first name, middle name/initial

True or False: The primary purpose of a health record is patient care management.

True

In 2009, the American Recovery and Reinvestment Act was signed into law. The law provided an economic stimulus package that provides reimbursement incentives for _______.

meaningful users of certified electronic health records

Why is the hybrid record so challenging?

You have to manage both electronic media as well as the paper format simultaneously.

IN a paper-based system, individual health records are organized in a pre-established order. What is this process called?

Assembly

An ____ _____ _____ is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

electronic health record

The ____ published a series of "quality chasm" reports addressing medication errors, poor workflow, and other gaps in health care delivery that should be addressed to ensure quality healthcare.

IOM (Institute of Medicine)

I am a patient. My medical history including information from myself and my physician is stored on the Internet via a secure website. This is an example of the ___.

PHR (personal health record)

All of the items mentioned below are capabilities of an EHR system except:
a) order entry/management
b) patient support
c) reporting and population health management
d) registries

b) patient support

The computer system that may serve as the MPI is the ____.

Patient registration system

We had 550 Medicare patients last month. This statement represents which of the following?
a) information
b) data
c) content of the PHR
d) patient-specific information

b) data

Standards are applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid.

Conditions of Pariticpation

HL7 has developed guidelines that address which aspect of the EHR?

a standard vocabulary

_____ is an earlier name for a Health Information Organization.

RHIO

True or False: HIM functions are information-focused and involve ensuring security, quality, and availability of patient data.

True

The mdeical record number, 44-37-98, is assigned in a terminal digit filing system. What number is the primary unit for filing?

98

True or False: In a paper record, any errors should be completely obliterated.

False

How are documents from other facilities maintained in the EHR?

They are scanned and filed in the EHR.

True or False: A retraction involves moving the document from one episode of care to a different episode of care within the same patient record.

False

In alphabetic filing, which of the following is a reason for cross-referencing?
a) A married woman prefers to use her professional name.
b) Names that sound alike, but are spelled differently.
c) Use of nicknames, I.e. Jim for James, Beth for Elizabeth, etc.
d) all of the above

d) all of the above

In terminal digit filing, the number 25-10-12 would come immediately after:
a) 240912
b) 241012
c) 250911
d) 260912

b) 241012

In middle digit filing, which number would be filed last?
a) 771502
b) 761601
c) 751602
d) 761600

c) 751602

For efficient purging of medical records, color coding of the year the patient was last seen would provide sufficient information for ____.

identification of inactive medical records

What promotes high standards of HIM practice?

The AHIMA Code of Ethics

Which of the following is not a benefit of a HIE?
a) Provides a vehicle for improving quality and safety of patient care.
b) Stimulate consumer education and patients' involvement in their own health care.
c) Allows patient information to freely populate the Internet Explorer with unnecessary safeguards.
d) Helps public health officials meet their commitment to the community(ies) they serve.

c) Allows patient information to freely populate the Internet Explorer with unnecessary safeguards.

____ is scheduled for implementation October 1, 2014.

ICD-10

These are part of the volunteer structure of AHIMA; organized in every state plus Washington, DC and Puerto Rico.

CSAs (Component State Associations)

A credential offered by AHIMA; individuals must pass a certification examination after successfully completing a CAHIIM accredited 2-year program.

RHIT

True or False: The PHR and EHR are synonyms.

False

In an integrated health record, documentation by health professionals is organized how?

Intermixed in chronological order

Which is not a rule in alphabetical filing?
a) Something always comes before nothing.
b) Disregard spaces between words or prefixes.
c) Ignore punctuation and special symbols
d) Titles may be used as the last filing unit after the first name.

a) Something always comes before nothing.

One of the most sought after accreditation distinction by healthcare facilities is offered by the ______.

Joint Commission

Patients Alex Keaton, Jr. and Alec Keaton, Sr. have both been treated at the same hospital. During one hospital encounter for Alec Keaton, Sr., the registration clerk notices Mr. Alex Keaton's demographic information has been entered in Mr. Alec Keaton, Sr.'s record. This is a/an ___ record.

overlay

Step-by-step instructions on how to complete a specific task are called_____.

procedures

A patient receives a unique health record number at the time of the first encounter and keeps the same number for all subsequent encounters is an example of what type of numbering system?

Unit numbering system

A patient receives a unique numerical identifier for each encounter with the healthcare facility is an example of what type of numbering system?

Serial numbering system

The patient receives a unique numerical identifier for each encounter with the healthcare facility, but previous medical records are brought forward and filed under the last assigned number is an example of what type of numbering system?

serial-unit numbering system

The future role of the HIM professional is expected to change due to:
a)advances in technology
b)implementation of new clinical coding system
c) evolution of the EHR
d) all of the above

d) all of the above

True or False: AHIMA's Board of Directors provides members with local access to professional education, networking, and representation, and is a forum for communicating information relevant to national issues and informing members of regional affairs that affect health information management.

False; CSA makes the statement true.

True or False: Health Information Management (HIM) has been recognized as an allied health profession since 1928.

True

________ is the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used for its intended purpose.

Confidentiality

Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered ___ from the database.

information

Which of the following is not covered by Medicare?
a) long-term nursing
b) skilled nursing care
c) hospice nursing care
d) home health care

a) long-term nursing

The increased collection and use of healthcare data was most profoundly influenced in the 1960s by the _____.

development of computers capable of storing and processing large amounts of data

Upon which criterion is Medicaid eligibility based?

Income

What is the name of the federally funded program that pays the medical bills of the spouses and dependents of person on active duty in the uniformed services?

TRICARE

Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop ____.

data sets

What two purposes do data sets serve?

1) to identify data elements to be collected about each patient.
2) to provide uniform data definitions.

____ is the amount charged for a medical insurance policy

Premium

What is the name of the program funded by the federal government to provide medical care to people on public assistance?

Medicaid

The governmental agency most closely involved in the development of healthcare data sets and information standards is the ______.

National Centers for Health Statistics

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______.

UHDDS

Which payment method reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness?

capitation

_____is the type of coding utilized when a CPT/HCPCS codes is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility's coding staff.

Hard-coding

IN the 1980s, which of the following trends necessitated the development of data sets in addition to the UHDDS?
a) inpatient admissions dramatically increased
b) inpatient lengths of stay increased
c) ambulatory services and procedures proliferated
d) ambulatory lengths of stay increased

c) ambulatory services and procedures proliferated

List characteristics of the common healthcare data sets such as UHDDS and UACDS.

1) They define minimum data elements to be collected.
2) They provide a frame work for data collection to which an individual facility can add data items.
3) The federal government recommends, but does not mandate, implementation of most of the data sets.

Define case-mix.

Categories of patients treated

Define complication.

Coexisting condition.

Define principal diagnosis.

Condition established after study to be the reason for hospitalization.

Define comorbidity.

Coexisting condition.

Define present on admission.

Condition present at the time the order for admission was written.

_____ is used as an assessment tool to determine a care plan at the time of admission.

MDS

True or False: Medicare Severity-Diagnosis related groups represent a prospective payment system implemented by CMS to reimburse hospitals a predetermine amount for all outpatient stays.

False; MS-DRGs apply to inpatient stays.

A __________ during the data collection process in long--term care identifies a resident issue or the need for further assessment.

RAP trigger

The _____ data set is mandated for use in facilities that participate in the Medicare and Medicaid programs.

MDS

Which of the following types of hospitals is excluded from the Medicare inpatient prospective payment system?
a) pediatric
b) acute inpatient
c) psychiatric
d) alcohol/drug rehab

a) pediatric
They don't meet the age requirement.

After an episode of emergency care, data is entered into a specialized database for the purpose of developing a health history for the patient. This data is part of _____.

DEEDS

The sum of a hospital's total relative DRG weights for a year was 15,192 and the hospital had 10,471 total discharges for the year. What would be the hospital's case-mix index for that year?

1.45

A corporation is evaluating several health plans for its benefits package. The data set that provides comparison information about health plan performance is ____.

HEDIS

The organization that coordinates the collection of performance data for managed care plans is the _______.

National Committee for Quality Assurance

How many benefit periods are covered by hospital insurance during a Medicare beneficiary's lifetime?

Unlimited

In Outpatient Prospective Payment System (OPPS), which code set is the APC system primarily based on for outpatient procedures and services including devices, drugs, and other items?

CPT and HCPCS codes

The data set designed to organize data for public release about the outcomes of care is ___________.

HEDIS

Data collected to evaluate facility performance in designated core measure areas in order to achieve accreditation is _____.

ORYX

An example of data collected by the JCAHO for the ORYX initiatives is ______.
a) intrahospital mortality data
b) financial data
c) health plan performance data
d) patient demographic data

a) intrahospital mortality data

OASIS data is used to assess the ____ of home health services.

outcomes

The person responsible for the ill, such as a parent or guardian is referred to as the ____.

guarantor

List the key focuses of healthcare information standards development.

1) linking data from disparate computer systems
2) providing common definitions for data elements
3) responding to the information needs of users

The MS-DRG system creates a hosptial's case-mix index based on the relative weights of the MS-DRG. The case-mix can be figured by multiplying the relative weight of each MS-DRG by the number of _____ within that MS-DRG.

discharges

Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called ____ standards.

structure and content

In designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions is the E1384 standard promulgated by the ______.

American Society for Testing and Measurement

The number of days Medicare will cover SNF inpatient care is limited to which of the following:
a) 21
b) 60
c) 30
d) 100

d) 100

In processing a Medicare payment for outpatient radiology exams, a hospital outpatient would receive payment under what?

OPPS (Outpatient Prospective Payment System)

AHIMA strongly opposes the use of ____ as a patient identifier in an electronic environment.

Social Security Number

An example of clinical data representation is an ____.

ICD-9-CM code

What is the primary purpose of the Continuity of Care Record?

To allow healthcare providers to readily access information about a patient's healthcare at any point in time.

The exchange of digitized images such as X rays, CT scans, and MRIs is supported by _____.

DICOM

Activities of daily living (ADL) are components of ______.

MDS and OASIS

The key data element for linking data about an individual who is seen in a variety of care settings is the ____.

unique patient identifier

The best resource to use in defining the structure of an EHR is the ____.

HL7 Functional Model

The ____ mandated the development of standards for electronic medical records.

Health Insurance Portability and Accountability Act of 1996

Messaging standards for electronic data interchange in healthcare have been developed by ____.

HL7

A recent breakthrough in the development of a universal language to aid storage and transmission of Web-based data is ____.

XML

As a health information professional, you've become involved in developing an HIE in your region. the agency that would provide the best resources for HIE development is ___.

ONC (Office of the National Coordinator of Health Information Technology)

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the ___.

Uniform Hospital Discharge Data Set (UHDDS)

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on ___.

reason for encounter.

Reimbursement for home health services is dependent of data collected from ____.

OASIS (Outcomes and Assessment Information Set)

Data that are collected on large populations of individuals and stored in databases are referred to as ___.

aggregate data

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures is one purpose of ____.

vocabulary standards

True or False: Most healthcare informatics standards have been implemented by state regulations.

True

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for _____.

performance improvement programs

Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. this successful transmission is dependent on what standards?

LOINC (Logical Observations, Identifiers, Names, and Codes)

two official HHS advisory committees established as a result of ARRA are ___ and ___.

HIT Policy; HIT Standards

The HIPAA provides a federal floor for ____ ____.

healthcare privacy

The content of the health record is defined by what three things?

state licensing rules and laws,
accrediting body standards, and
medical staff bylaws

The length of time health information is retained is determined by what?

state retention laws,
accrediting body standards, and
needs of the healthcare facility

What type of law defines the rights and duties among people and private businesses?

private law

Law enacted by a legislative body is called a ____.

statute

An individual who brings a lawsuit is called the ____.

Plaintiff

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 corrected by ____.
a) drawing a single line in ink through the incorrect entry
b) printing the word "error" at the top of the entry
c) date, time, reason for change, and signature and title of person making the correction
d) all of the above

d) all of the above

The physical health record is usually considered the property of _____.

the organization or provider that maintains and stores the record

Under the HIPAA privacy rule, the term covered entities refers to whom?

healthcare providers, healthcare clearinghouses, and health plans

Under the HIPAA privacy rule, ___ are excluded from the privacy protection rules.
a) paper records
b) electronic records
c) oral communications
d) none of the above

d) none of the above

Under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within how many days?

30

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 an example of?

minimum necessary

Which of the following does not have to be included in a covered entity's notice of privacy practice?
a) Description with one example of disclosures made for treatment, payment, and healthcare operations
b) Description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization
c) Statement of individual's rights with respect o PHI and how the individual can exercise these rights
d) Signature of the patient and date the notice was given to the patient

d) Signature of the patient and date the notice was given tot he patient

Which of the following is not true of the notice of privacy practices?
a) it must be made available at the site where the individual is treated
b) it must be posted in a prominent place
c) its content that cannot be changed
d) it must be prominently posted on the covered entity's web site if the entity has one

c) its content that cannot be changed

True or False: A consent for use and disclosure of information must be obtained from every patient.

False

In what instances can PHI be used without patient authorization?

release to an insurance company for payment, release to another healthcare provider for treatment, and release to public health authorities as required by law

True or False: The covered entity must inform the individual that certain information is maintained in a facility patient directory and to whom this information may be disclosed.

True

Which of the following is not true about a BA (business associate) agreement?
a) It prohibits the BA from using or disclosing PHI for any purpose other than that described in the contract with the covered entity.
b) It allows the BA to maintain PHI indefinitely after termination of the contract
c) It prohibits the BA from using or disclosing PHI in any way that would violate the HIPAA privacy rule
d) It requires the BA to make available all of its books and records relating to PHI use and disclosure to the HHS or its agents

b) It allows the business associate to maintain PHI indefinitely after termination of the contract

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