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AHIMA

AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION

CCS

CERTIFIED CODING SPECIALIST

AOA

AMERICAN OSTEOPATHIC ASSOCIATION

NCQA

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

ARLNA

ASSOCIATION OF RECORD LIBRARIANS OF NORTH AMERICA

HIM

HEALTH INFORMATION MANAGEMENT

MDS

MINIMUM DATA SET

MRN

MEDICAL RECORD NUMBER

RHIT

REGISTERED HEALTH INFORMATION TECHNICIAN

MPI

MASTER PATIENT INDEX

TJC

THE JOINT COMMISSION

CMS

CENTERS FOR MEDICARE AND MEDICAID SERVICES

HIT

HEALTH INFORMATION TECHNICIAN

PHR

PERSONAL HEALTH RECORD

RHIA

REGISTERED HEALTH INFORMATION ADMINISTRATOR

CAHIIM

COMMISSION ON ACCREDITATION FOR HEALTH INFORMATICS AND INFORMATION MANAGEMENT EDUCATION

CCHIIM

COMMISSION ON CERTIFICATION FOR HEALTH INFORMATICS AND INFORMATION MANAGEMENT

EHR

ELECTRONIC HEALTH RECORD

POHR

PROBLEM ORIENTED HEALTH RECORD

OASIS

OUTCOMES AND ASSESSMENT INFORMATION SET

CARF

COMMISSION IN ACCREDITATION OF REHABILITATION FACILITIES

RAI

RESIDENT ASSESSMENT INSTRUCTION

PAI

PATIENT ASSESSMENT INSTRUCTION

CPR

COMPUTER BASED PATIENT RECORD

CIO

CHIEF INFORMATION OFFICER

CEO

CHIEF EXECUTIVE OFFICER

LOS

LENGTH OF STAY

IMPLIED CONSENT

ASSUMED

EXPRESSED CONSENT

WRITTEN OR SPOKEN

LICENSED BED COUNT

ACTUAL NUMBER

BED COUNT

ACTUAL STAFFED

PAPER RECORD WEAKNESSES

- SINGLE USER
- DAMAGE
- DOESN'T TRAVEL
- POSSIBLY INCOMPLETE
- PENMANSHIP
- ORGANIZATION

E-RECORD STRENGTHS

- MULTIPLE USERS
- TRAVELS
- COST SAVINGS
- INFO. IMMEDIATELY AVAILABLE
- CLIENT ALERTS
- FLEXIBLE TO USER NEEDS

E- RECORD WEAKNESSES

- IMPLEMENTATION COSTS
- LEARNING CURVE
- STANDARDS?

ADDENDUM

AN ADDITION TO A MEDICAL RECORD THAT DOESN'T CHANGE ANY PRE-EXISTING CONTENT

AMENDMENT

ACTUAL CHANGE TO THE MEDICAL RECORD

AHIMA MEMBERSHIP CATEGORIES

- STUDENT
- ACTIVE
- NEW GRAD.
- SENIOR*

CONCURRENT REVIEW

OCCURS DURING ADMINISTRATION OF SERVICES

RETROSPECTIVE REVIEW

OCCURS AFTER MEDICAL SERVICES HAVE BEEN PROVIDED

HIM HAS BEEN RECOGNIZED AS AN ALLIED HEALTH PROFESSION SINCE:

1928

THE HOSPITAL STANDARDIZATION MOVEMENT WAS INAUGURATED BY THE:

AMERICAN COLLEGE OF SURGEONS

THROUGHOUT THE YEARS, HIM ROLES HAVE:

BROADENED IN SCOPE

THE TRADITIONAL MODEL OF HIM PRACTICE WAS:

DEPARTMENT BASED

THE NEW MODEL OF HIM PRACTICE IS:

INFORMATION BASED

WHAT EVOLVING ROLE OVERSEES THE PROCESS THAT BEGINS AT THE TIME OF DOCUMENTATION THROUGH BILLING?

REVENUE CYCLE MANAGEMENT

THE ORGANIZATION THAT ACCREDITS HIM PROGRAMS IS?

CAHIIM

WHAT EVOLVING ROLE ASSESSES QUALITY IN HEALTH RECORD BANKING

HEALTH RECORD REVIEWER

THE PRIMARY FOCUS OF AHIMA?

FOSTER PROFESSIONAL DEVELOPMENT OF ITS MEMBERS

ACTIVE MEMBERS OF AHIMA INCLUDE THOSE WHO:

ARE SENIOR MEMBERS

WHICH OF THE FOLLOWING FUNCTIONS AS THE LEGISLATIVE BODY OF AHIMA?

HOUSE OF DELEGATES

WHICH OF THE FOLLOWING PROMOTES EDUCATION AND RESEARCH?

AHIMA FOUNDATION

THE VIRTUAL NETWORK USED BY AHIMA MEMBERS IS?

COMMUNITIES OF PRACTICE

WE HAD 324 MEDICARE PATIENTS LAST MONTH. THIS STATEMENT REPRESENTS WHICH OF THE FOLLOWING?

DATA.

I'M A PATIENT. MY MEDICAL HISTORY INCLUDING INFORMATION FROM MYSELF AND MY PHYSICIANS IS STORED ON THE INTERNET. THIS IS AN EXAMPLE OF WHAT?

PHR

WHICH OF THE FOLLOWING IS AN EXAMPLE OF A PRIMARY PURPOSE OF THE MEDICAL RECORD?

PATIENT CARE MANAGEMENT

EXAMPLES OF PATIENT CARE DELIVERY USAGE OF THE MEDICAL RECORD INCLUDE WHICH OF THE FOLLOWING USES?

COMMUNICATION BETWEEN CAREGIVERS

THE PHR AND EHR ARE SYNONYMS.

PHR IS PATIENT AND EHR IS PHYSICIAN.

THE HEALTH RECORD IS THE PRINCIPLE REPOSITORY FOR DATA AND INFORMATION ABOUT THE HEALTHCARE SERVICES PROVIDED TO INDIVIDUAL PATIENTS.

TRUE

THE LAB TEST 'HEMOGLOBIN: 14.6GM/110ML' IS CONSIDERED INFORMATION.

FALSE.

ALL THE PRIMARY PURPOSES OF THE HEALTH RECORD ARE ASSOCIATED DIRECTLY WITH THE PROVISION OF PATIENT CARE.

FALSE

SUBMITTING HEALTH RECORD DOCUMENTATION TO A THIRD PARTY PAYER FOR THE PURPOSE OF SUBSTANTIATING A PATIENT BILL IS CONSIDERED A SECONDARY PURPOSE OF THE HEALTH RECORD.

FALSE.

USE OF THE HEALTH RECORD TO STUDY THE EFFECTIVENESS OF A GIVEN DRUG IS CONSIDERED A PRIMARY USE OF THE HEALTH RECORD.

FALSE.

WHICH OF THE FOLLOWING USERS OF THE HEALTH RECORD IS AN INSTITUTIONAL USER?

THIRD PARTY PAYER

WHICH OF THE FOLLOWING USERS WOULD UTILIZE AGGREGATE DATA?

PATIENT CARE MANAGERS AND SUPPORT STAFF

I WORK FOR AN ORGANIZATION THAT UTILIZES HEALTH RECORD DATA TO PROVE OR DISPROVE HYPOTHESES RELATED TO DISEASE. I WORK FOR:

RESEARCH ORGANIZATION

A USER OF HEALTH RECORDS INCLUDES ONLY CARE PROVIDERS WHO DOCUMENT IN THE HEALTH RECORD OR REFER TO IT FOR PATIENT CARE.

FALSE

I WORK FOR CMS. HOW WOULD I USE A HEALTH RECORD?

MAKE DECISIONS ON HEALTHCARE REIMBURSEMENT.

A PHYSICAL THERAPIST DOCUMENTING IN THE HEALTH RECORD IS AN INSTITUTIONAL HEALTH RECORD WORKER.

FALSE

AN AUDITOR WHO IS EMPLOYED BY MEDICARE IS REVIEWING A HEALTH RECORD FOR A MORTALITY STUDY. THEIS AUDITOR IS AN INDIVIDUAL HEALTH RECORD USER.

FALSE

CMS USES DATA TO ACCREDIT HOSPITALS.

FALSE

RESEARCH ORGANIZATIONS DEVELOP AND TEST EXPERIMENTAL PATIENT CARE PROTOCOLS.

TRUE

PATIENTS DO NOT HAVE THE RIGHT TO ADD MISSING INFORMATION TO THE HEALTH RECORD.

FALSE

A PHYSICIAN JUST RECEIVED NOTIFICATION FROM AN EHR SYSTEM THAT A PATIENT'S LAB TEST HAD A DANGEROUSLY HIGH VALUE. THIS IS AN EXAMPLE OF WHAT KIND OF CLINICAL TOOL?

CLINICAL DECISION SUPPORT

I JUST TOLD MY PHYSICIAN SOMETHING EMBARRASSING ABOUT MYSELF. I TOLD HIM BECAUSE I EXPECT HIM TO USE THE INFORMATION FOR MY CARE ONLY. THIS CONCEPT IS CALLED:

CONFIDENTIALITY

SOMEONE SUGGESTED THAT WE COLLECT A PATIENT'S EYE COLOR. THIS WAS NOT IMPLEMENTED. WHAT QUALITY CHARACTERISTIC WOULD BE THE JUSTIFICATION FOR NOT COLLECTING THIS INFORMATION?

RELEVANCY

IT WAS SUGGESTED THAT WE ENTER THE PATIENT'S AGE MANUALLY IN ALL OF OUR INFORMATION SYSTEMS. WHAT QUALITY CHARACTERISTIC WOULD BE THE JUSTIFICATION FOR NOT DOING THIS, BUT RATHER SHARING INFORMATION BETWEEN SYSTEMS?

CONSISTENCY

ACCORDING OF THE AHIMA DATA QUALITY MODEL, WHAT IS THE TERM USED TO DESCRIBE HOW DATA IS TRANSLATED INTO INFORMATION?

DATA ANALYSIS

DATA GRANULARITY

CHARACTERISTICS OF DATA WHOSE VALUES ARE DEFINED AT THE APPROPRIATE LEVEL OF DETAIL

SECURITY

A PROGRAM DESIGNED TO PROTECT PATIENT PRIVACY AND TO PREVENT UNAUTHORIZED ACCESS, ALTERATION, OR DESTRUCTION OF HEALTH RECORDS.

PRIVACY

AN INDIVIDUAL'S RIGHT TO CONTROL ACCESS TO HIS OR HER PERSONAL INFORMATION

DATA COMPREHENSIVENESS

A CHARACTERISTIC OF DATA THAT INCLUDES EVERY REQUIRED DATA ELEMENT

DATA RELEVANCY

A CHARACTERISTIC OF DATA WHERE THE DATA IS USEFUL.

WHICH TWO MAJOR TYPES OF DATA ARE CONTAINED IN THE HEALTH RECORD?

ADMINISTRATIVE AND CLINICAL

WHICH OF THE FOLLOWING TERMS REFERS TO STATE OF COUNTRY REGULATIONS THAT HEALTHCARE FACILITIES MUST MEET TO BE PERMITTED TO PROVIDE CARE?

LICENSURE

WHICH OF THE FOLLOWING WOULD NOT BE FOUND IN A MEDICAL HISTORY?

VITAL SIGNS

AN ATTENDING PHYSICIAN REQUESTS THE ADVICE OF ANOTHER PHYSICIAN WHO THEN REVIEWS THE HEALTH RECORD AND EXAMINES THE PATIENT. THE SECOND PHYSICIAN RECORDS IMPRESSIONS IN WHAT TYPE OF REPORT?

CONSULTATION REPORT

WHICH SPECIALIZED TYPE OF PROGRESS NOTE PROVIDES HEALTHCARE PROFESSIONALS IMPRESSIONS OF PATIENT PROBLEMS WITH DETAILED TREATMENT ACTION STEPS?

CARE PLAN

WRITTEN OR SPOKEN PERMISSION TO PROCEED WITH CARE IS CLASSIFIED AS:

EXPRESSED CONSENT

WHICH OF THE FOLLOWING REPORTS PROVIDES INFORMATION ON TISSUE REMOVED DURING A PROCEDURE?

LAB REPORT

SLEEPING PATTERNS, HEAD AND CHEST MEASUREMENTS, FEEDING AND ELIMINATION STATUS, WEIGHT, AND APGAR SCORES ARE RECORDED IN WHICH OF THE FOLLOWING RECORDS?

NEWBORN

WHICH OF THE FOLLOWING ISN'T CONSIDERED PATIENT DEMOGRAPHIC INFORMATION?

ADMITTING DIAGNOSIS

WHICH OF THE FOLLOWING ADMINISTRATIVE DOCUMENTS NAMES THE PATIENT'S CHOICE OF LEGAL REPRESENTATIVE FOR HEALTHCARE PURPOSES?

ADVANCE DIRECTIVE

WHICH TYPE OF HEALTH RECORD CONTAINS INFORMATION ABOUT CARE PROVIDED PRIOR TO ARRIVAL AT A HEALTHCARE SETTING AND DOCUMENTATIONS OF CARE PROVIDED TO STABILIZE THE PATIENT?

EMERGENCY CARE

PATIENT HISTORY QUESTIONNAIRES, PROBLEM LISTS, DIAGNOSTIC TESTS RESULTS, AND IMMUNIZATION RECORDS ARE COMMONLY FOUND IN WHICH TYPE OF RECORD?

AMBULATORY CARE

THE AMBULATORY SURGERY RECORD CONTAINS INFORMATION MOST SIMILAR TO:

HOSPITAL OPERATIVE RECORDS

WHICH STANDARDIZED TOOL IS USED TO ASSESS MEDICARE CERTIFIED REHABILITATION FACILITIES?

PATIENT ASSESSMENT INSTRUMENT

INTERDISCIPLINARY CARE PLANS ARE AN IMPORTANT PART OF WHICH TYPE OF HEALTH RECORD?

HOSPICE CARE

PORTIONS OF A TREATMENT RECORD MAY BE MAINTAINED IN A PATIENT'S HOME IN WHICH TWO TYPES OF SETTINGS?

HOME HEALTH AND END STAGE RENAL DISEASE

A PATIENT'S LEGAL STATUS, COMPLAINTS OF OTHERS REGARDING THE PATIENT, AND REPORTS OF RESTRAINTS OR SECLUSION WOULD BE FOUND MOST FREQUENTLY IN WHICH TYPE OF HEALTH RECORD?

BEHAVOIRAL HEALTH

PAPER RECORDS MY REQUIRE THINNING IN WHICH TWO SETTINGS?

LONG TERM CARE AND CORRECTIONAL SERVICES

A GROWTH AND DEVELOPMENT RECORD MAY BE FOUND IN WHAT TYPE OF RECORD?

PEDIATRIC

THE DOCUMENT THAT INDICATES CONSENT AND PAST MEDICAL CONDITIONS IS?

PROBLEM LIST

WHICH OF THE FOLLOWING IS AN ACCREDITING ORGANIZATION?

DNV

AN ACCREDITING ORGANIZATION IS AWARDED DEEMED STATUS BY MEDICARE. THIS MEANS THAT FACILITIES RECEIVING ACCREDITATION UNDER ITS GUIDELINES DO NOT NEED TO:

UNDERGO MEDICARE CERTIFICATION SURVEYS

WHICH GROUP FOCUSES ON ACCREDITATION OF MANAGED CARE AND PREFERRED PROVIDER ORGANIZATIONS?

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

WHICH OF THE FOLLOWING REGULATIONS WOULD MOST LIKELY CONTAIN INFORMATION ON WHO IS AUTHORIZED TO ENTER DOCUMENTATION IN A PATIENT'S RECORD?

FACILITY RULES AND REGULATIONS

WHICH OF THE FOLLOWING GROUPS HAS INSTITUTED A HEALTH RECORD PROHIBITED ABBREVIATION LIST?

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

WHICH TYPE OF HEALTH RECORD INCLUDES BOTH PAPER AND COMPUTERIZED COMPONENTS?

HYBRID

WHICH OF THE FOLLOWING IS A DISADVANTAGE OF AN EHR OVER A PAPER BASED RECORD?

REQUIRES PROPERTY AND SECURITY MEASURES

IN AN INTEGRATED HEALTH RECORD, DOCUMENTATION BY HEALTH PROFESSIONALS IS ORGANIZED:

INTERMIXED IN DATE SEQUENCE

THE PATIENT INDICATES THAT HER PAIN IS WORSE. IN WHICH PART OF SOAP NOTE WOULD THIS INFORMATION BE RECORDED?

SUBJECTIVE.

WHICH OF THE FOLLOWING ELECTRONIC RECORD TECHNOLOGICAL CAPABILITIES WOULD ALLOW AN X-RAY TO BE SENT TO A PHYSICIAN IN ANOTHER STATE?

IMAGE PROCESSING

WHICH OF THE FOLLOWING IS TRUE OF PAPER BASED RECORDS?

THEY ARE SUSCEPTIBLE TO DAMAGE FROM FIRE OR FLOODS.

A DEFINITION OF WHAT CONSTITUTES A RECORD, RECORDING WHERE EACH COMPONENT IS LOCATED, AND NOTHING DATES OF FORMAT CHANGES ARE PARTICULARLY IMPORTANT IN:

HYBRID RECORDS

IN A PROBLEM ORIENTED HEALTH RECORD, PROBLEMS ARE ORGANIZED BY:

NUMBER

HEALTH LEVEL SEVEN HAS DEVELOPED GUIDELINES THAT ADDRESS WHICH ASPECT OF THE ELECTRONIC RECORD?

DEFINITIONS OF FUNCTIONS.

WHICH TYPE OF DATA INPUT MECHANISM IS COMMONLY USED IN BOTH PAPER AND ELECTRONIC ENVIRONMENTS?

TRANSCRIPTION

THE SYSTEM IN WHICH A HEALTH RECORD NUMBER IS ASSIGNED AT THE FIRST ENCOUNTER AND THEN USED FOR ALL SUBSEQUENT HEALTHCARE ENCOUNTERS IS THE:

UNIT NUMBERING SYSTEM.

THE PRIMARY GUIDE TO LOCATING A RECORD IN A NUMERICAL FILING SYSTEM IS THE:

MASTER PATIENT INDEX

ALL FORMS SHOULD:

CONTAIN A UNIQUE IDENTIFIER

THE HEALTH RECORD NUMBER IS TYPICALLY ASSIGNED BY:

PATIENT REGISTRATION

WHICH OF THE FOLLOWING IS USED TO LOCATED AN ELECTRONIC HEALTH RECORD?

HEALTH RECORD NUMBER

JOHN SMITH, TREATED AS A PATIENT AT A MULTI-HOSPITAL SYSTEM, HAS THREE MEDICAL RECORD NUMBERS. THE TERM USED TO DESCRIBE MULTIPLE HEALTH RECORD NUMBERS IS:

DUPLICATES

WHICH OF THE FOLLOWING SHOULD BE PART OF A COMPREHENSIVE MPI MAINTENENCE PROGRAM?

ADVANCED PERSON SEARCH

WHICH OF THE FOLLOWING IS TRUE ABOUT THE SOCIAL SECURITY NUMBER?

BOTH SSA AND AHIMA OPPOSE USING IT AS PATIENT NUMBER. STUPID.

THE MOST COMMON NUMBERING SYSTEM USED IN HEALTHCARE IS:

UNIT NUMBERING

WHICH IDENTIFICATION SYSTEM IS AT A DISADVANTAGE WHEN THERE ARE TWO PATIENTS WITH THE SAME NAME?

ALPHANUMERIC

THE MASTER PATIENT INDEX IS NECESSARY TO LOCATE HEALTH RECORDS WITHIN THE PAPER-BASED STORAGE SYSTEM FOR ALL THE TYPE OF FILING SYSTEMS EXCEPT:

ALPHABETIC

THE TERM USED TO DESCRIBE A COMBINATION OF PAPER-BASED AND ELECTRONIC HEALTH RECORDS IS:

HYBRID

WHICH OF THE FOLLOWING IS AN ADVANTAGE OF A CENTRALIZED UNIT FILING SYSTEM?

ONE LOCATION IN WHICH TO LOOK FOR RECORDS.

WHIC FILING SYSTEM IS CONSIDERED TO BE THE MOST EFFICIENT?

TERMINAL DIGIT

WHICH TYPE OF PAPER BASED STORAGE SYSTEM CONSERVES FLOOR SPACE BY ELIMINATING ALL BUT ONE OR TWO SIDES?

MOBILE FILING UNITS

WHAT FEATURE OF THE FILING FOLDER HELPS LOCATE MISFILES WITHIN THE PAPER BASED FILING SYSTEM

COLOR CODING

IN A PAER BASED SYSTEM, THE HIM DEPARTMENT ROUTINELY DELIVERS HEALTH RECORDS TO:

NURSING UNITS

WHICH OF THE FOLLOWING PAPER WEIGHTS WOULD BE THE MOST DURABLE FOR THE MEDICAL RECORD FOLDER?

TWENTY

WHAT MICROFILM FORMAT IS INSUFFICIENT WHEN PATIENTS HAVE MULTIPLE ADMISSIONS ON MICROFILMS?

ROLL

UNDER THE FALSE CLAIMS ACT, CLAIMS MAY BE BROUGHT UP TO HOW MANY YEARS?

GENERALLY 7, BUT COULD BE 10

RECORD RETENTION SHOULD BE BASED ON:

STATE REGULATIONS AND AHIMA REGULATIONS

WHICH OF THE FOLLOWING IS THE APPROPRIATE METHOD FOR DESTROYING MICROFILM?

SHREDDING

WHICH OF THE FOLLOWING IS THE APPROPRIATE METHOD FOR DESTROYING COMPUTERIZED DATA?

DEGAUSSING

THE TOOL USED TO TRACK PAPER BASED HEALTH RECORDS IS?

OUTGUIDE

WHAT SHOULD BE DONE WHEN THE HIM DEPARTMENT'S ERROR OR ACCURACY RATE IS DEEMED UNACCEPTABLE?

CORRECTIVE ACTION

THE FORMS DESIGN COMMITTEE:

PROVIDES OVERSIGHT FOR THE DEVELOPMENT, REVIEW, AND CONTROL OF FORMS AND COMPUTER SCREENS.

STATEMENTS THAT DEFINE THE PERFORMANCE EXPECTATIONS AND OR STRUCTURES OR PROCESSES THAT MUST BE IN PLACE ARE

STANDARDS

IN A PAPER BASED SYSTEM, INDIVIDUAL RECORDS ARE ORGANIZED IN A PRE-ESTABLISHED ORDER CALLED:

ASSEMBLY

REVIEWING A HEALTH RECORD FOR MISSING SIGNATURES AND MISSING MEDICAL REPORTS IS:

ANALYSIS

REVIEWING THE RECORD FOR DEFICIENCIES AFTER THE PATIENT IS DISCHARGED FROM THE HOSPITAL IS AN EXAMPLE OF WHAT?

RETROSPECTIVE REVIEW

INCOMPLETE RECORDS THAT ARE NOT COMPLETED BY THE PHYSICIAN WITHIN THE TIME FRAME SPECIFIED IN THE HEALTHCARE FACILITY'S POLICIES ARE CALLED:

DELINQUENT RECORDS

IN A PAPER BASED RECORD, ERROS SHOULD BE COMPLETELY OBLITERATED.

FALSE

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