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Terms in this set (457)
HIM has been recognized as an allied health profession since:
American College of Surgeons
The hospital standardization movement was inaugurated by the:
The traditional model of HIM practice was:
- Department based
- Information based
- electronic based
- analytically based
revenue cycle manager
What evolving role oversees the revenue cycle from documentation though billing?
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
What is the organization that accredits HIM education programs?
Health record reviewer
What evolving role assesses quality in health record banking?
Association of Record Librarians of North America
The HIM professional began in 1928 with the establishment of this organization.
American Health Information Management Association
With many name changes through out the years, this HIM professional organization went through its final name change in 1991.
foster professional development of its members
The primary focus of AHIMA is to:
House of delegates
Which of the following functions as the legislative body of AHIMA?
- House of Delegates
Which of the following promotes education and research?
- AHIMA Foundation
Communities of Practice
The virtual network used by AHIMA members is called:
__________ represent the basic facts about people, processes, measurements, conditions, and so forth.
____________ represents the meaning of data that has been collected.
personal health record
______________ is used to describe a health record that has been initiated and maintained by an individual. It is owned by the individual and comprised of data and information from healthcare providers and the individual.
National Committee on Vital and Health Statistics
In 2001, this organization issued a national report on how to build a national health information infrastructure.
patient care management
Which of the following is an example of a primary purpose of a medical record?
- policy making
- patient care management
communication between caregivers
examples of patient care delivery usage of the medical record include which of the following uses?
- developing of practice guidelines
- communication between caregivers
- reimbursement for patient care
- getting patients involved in their own care
Which of the following are considered as an institutional user of the health record?
- Third-party payer
patient care managers and support staff
Which if the following users would utilize aggregate data?
- patient care providers
- coding and billing staff
- law enforcement officers
- 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 must work for what type of organization?
Make decisions on healthcare reimbursement
How might CMS use the health record?
The purpose for which data are collected.
the process by which data are collected
The process and systems by which data are archived
the processes by which data are translated into information that can be used for designated application
______ means data are correct. Data should represent what was intended or defined by the original source of that data
______________ means that the data are easily obtainable.
_______________ means that all the required data elements are included in the health record. The record is complete.
____________ means that healthcare data should be up-to-date.
___________ refers to data being recorded at or near the time of the event or observation.
__________ means that the data and information documented in the health record are defined. Users of the data must understand what the data mean and represent.
____________ requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data.
___________ is the term used to describe expected data values. data values must also be defined.
_______________ means that the data in the health record are useful.
_________ can be defined as the right of individuals to control access to their personal information.
____________ refers to the expectation that the personal information share by an individual with a healthcare provider during the course of care will be used only for its intended purpose.
________________ is the protection of the privacy of the individuals and the confidentiality of health records. In other words, this term all only authorized users to access health records.
source oriented health record format
This type of paper record format organizes the information according to the patient care department that provided the care. For example: all lab tests are filed together, progress notes are filed together, and so forth.
problem-oriented health record format
This type of paper record format is a documentation approach in which the physician defines each clinical problem individually and all documentation related to that clinical problem is stored together. information about the issues are organized into 4 components: database, problem list, initial plans, and progress notes.
integrated health record format
This type of paper record format organizes all the paper forms in chronological order and mixes the forms created by different departments
Clinical Decision Support
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?
I just told my physician something embarrassing about myself. I told him because I expect him to use my information for my care only. This concept is called:
Someone suggested that we collect a patient's eye color. This was not implemented. What data quality characteristic would be the justification for not collecting this information?
It was suggested that we enter the patient's age manually in all of our information systems rather than having it entered once in one system and interfaced to the other systems. What data quality characteristic would be the justification for not doing this manual entry into each information system?
According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?
a characteristic of data whose values are defined at the appropriate level of detail.
a program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records
An individuals right to control access to their personal information
A characteristic of data that includes every required data element
A characteristic of data where the data are useful
administrative and clinical
what 2 types of data are stored in a health record?
This term refers to state or county regulations that healthcare facilities must meet to be permitted to provide care.
Det Norske Veritas Healthcare
Which of the following is an accrediting organization?
- State regulating agencies
- Det Norske Veritas healthcare
Undergo Medicare certification surveys
An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to:
- Meet licensure standards
- Undergo Medicare certification surveys
- Meet Medicare certificationstandards
national Committee for Quality Assurance
Which group focuses on accreditation of managed care?
- Accreditation Association for Ambulatory Healthcare
- National Committee for quality assurance
- Commission on Accreditation of rehabilitation facilities
- The joint Commission
Commission on Accreditation of rehabilitation facilities
Which group focuses on accreditation of rehabilitation programs and services?
The Joint Commission
Which one of this accreditation organizations provides standards for the widest variety of healthcare facilities?
- American Correctional Association
- The Joint Commission
- Accreditation Commission for Health Care
- American Osteopathic Association
Which of the following wouldn't be found in a medical history:
- chief complaint
- vital signs
- present illness
- review of systems
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The 2nd physician records impressions in what type of report?
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Written or spoken permission to proceed with care is classified as:
What type of report provides information on tissue removed during a procedure?
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of type of record?
Which of the following is NOT considered patient demographic information?
- Patient's DOB
- Name of next of kin
- type of admission
- admitting diagnosis
what is the name of the administrative document that provides information on the patient's desires for healthcare for use if they are incapacitated?
Outcomes and Assessment Information Set
What does OASIS stand for?
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?
Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record?
Hospital operative records
The ambulatory surgery record contains information most similar to:
- physician's office records
- emergency care records
- hospital operative records
- hospital OB records
care area assessment (CAA)
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?
End-stage renal disease
Interdisciplinary care plans are an important part of which type of health record?
Home health and hospice
Portions of a treatment record may be maintained in a patient's home in which two types of settings?
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?
long term care and correctional services
Paper records may require thinning in which 2 healthcare settings?
A growth and development record may be found in what type of record?
The document that indicates current and past medical conditions is called a________________.
Minimum Data Sets
In long-term care, the care plan is based on a format that's required by federal regulations. The RAI's are based on _____________________ for long-term care.
Resident assessment instrument
In long-term care, the care plan format is called the:
MDS, triggers, utilization guidelines, and care area assessments
What are the 4 things that make up the long term care's resident assessment instrument's framework?
These items are essential to home health reimbursement from Medicare. It is completed at the start or resumption of care, and again every 60 days, at change in condition, and upon patient transfer or discharge
Patient Assessment Instrument
This instrument is used in inpatient rehabilitation and is done shortly after admission and upon discharge of the patient.
intermixed in date sequence
In an integrated health record, documentation by health professionals is organized:
- in sections by type of professional
- in sections by problem number
- intermixed in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
In which electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?
A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:
In a problem-oriented record, problems are organized by:
Which of the following is designed to collect a minimum set of data about inpatients?
Uniform Hospital Discharge Data Set
What does UHDDS stand for?
Which of the following is used to collect data about ambulatory care patients?
Uniform Ambulatory Care Data Set
What does UACDS stand for?
Which of the following us used to gather data about Medicare beneficiaries receiving home care?
Collects data about hospital emergency encounters
What does the DEEDS data set do?
Data ELements for Emergency Department Systems
What does DEEDS stand for?
Which of the following is a set of performance measures used to compare the performance of managed healthcare plans?
healthcare effectiveness data and information set
What does HEDIS stand for?
Which of the following was developed by the Joint Commission?
Continuity of Care Record
What does CCR stand for?
Which of the following would be a core data set for a patient's clinical summary?
Continuity of Care Document
ASTM and HL7 combined their work to create this implementation guide for sharing CCR patient summary data using the CDA standards.
Abbreviated Injury Scale (AIS)
A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system
the process of extracting elements from a source document and entering them into an automated system
A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Final review during EHR implementation to ensure that all tests have been performed and issues resolved. Usually results in payment and contract for the system.
a report that provides a list of individuals that accessed the patient information during a given period
A number assigned to each case as it is entered ina cancer registry
A list of cases in a cancer registry in the order in which they were entered
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrollED IN THE TRADITIONAL FEE-FOR-SERVICE program
Accounts receivable (A/R)
Records of the payments owed to the organization by outside entities such as third party payers and patients
A voluntary process of institutional or organizational review in which a quasi -independent body created for this purpose periodically evaluates the quality of the entities work
Accreditation Association for Ambulatory Health Care
(AAAHC) A professional organization that offers accreditation programs for ambulatory and OP organizations.
Accreditation Commission for Health Care
(ACHC) A private nonprofit accreditation organization offering accreditation services for HOME HEALTH, HOSPICE, and alternate site healthcare such as infusion nursing, and home/durable medical equipment supplies.
Accredited Standards Committee X12N
A committee of the National Standards Institute that develops and maintains standards for the electronic exchange of business transactions.
Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness
Policies and procedures that address the management of computer resources
A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law
A term referring to HIPAAs attempt to streamline and standardize the healthcare industry's nonuniform and seemingly chaotic business practices, such as billing.
Admission Utilization review
A review of planned services (intensity of service) and/or a patient's condition (severity if illness) to determine whether care must be delivered in an acute care setting
Advance Beneficiary Notice of Noncoverage
(ABN) A statement signed by the patient when they are notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for service. wherein the patient indicates that they will be responsible for any charges
Affordable Care Act
Also known as Patient Protection and ___________. A federal statute that was signed into law in 2010. This act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama Administration.
Agency for healthcare Research and Quality
(AHRQ) The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services.
All patient DRGs
A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes
Ambulatory payment classification system
(APC) hospital outpatient prospective payment system (HOPPS); the classification is a resource-based reimbursement system; the payment unit is the ambulatory payment classification group
American Association of Health Plans
(AAHP) The trade organization for health maintenance organizations, preferred provider organizations, and other network-based health plans created by the merger of the Group Health Association of America and the American Managed Care and Review Association
American Association of Medical Colleges
(AAMC) The organization established in 1876 to standardize the curriculum for medical schools in the US and to promote the licensure of physicians
American Association of Medical Record Librarians
(AAMRL) The name adopted by ARLNA in 1944
American Medical Record Association
(AMRA) The name adopted by the AAMRL in 1970
American National Standards Institute
(ANSI) The organization that accredits all US standards development organizations to ensure that they are following due process in promulgating standards
American Recovery and Reinvestment Act of 2009
Previously known as the stimulus bill or HR1. The actions related to health information technology are spread throughout the law; however, the bulk of the items are in Title XIII-or HITECH Act.
American Society for Testing and Materials
(ASTM) A national organization whose purpose is to establish standards on materials, products, systems, and services
Software program that helps coders determine the appropriate ambulatory payment classification for an outpatient encounter
A request for reconsideration of a negative claim decision
In a state court system, that court that hears appeals of final judgements from state trial courts
a proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system
Association of Record Librarians of North America (ARLNA)
Organization that formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities.
Best of breed
A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class
Best of fit
A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor
An authorization for the release of confidential information from a certain point in time and any time thereafter
Blue cross and BLue Shield. Blue Shield, blue cross
The first prepaid healthcare plans in the US. The ______ traditionally covered hospital care and ____________ plans covered physician's services
A tool in the form of a graph that displays a five-number data summary
A formal organizational structure based on a rigid heirarchy of decision making and inflexible rules and procedures
According to the HIPAA Privacy Rule, an individual (or group) who is not a member of a covered entity's workforce but who helps the covered entity i the performance of various functions involving the use or disclosure of confidential patient information
the allocation of resources for long-term investments and projects
In law, a relationship between the defendant's conduct and the harm that was suffered
The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements
The process of performing an impact analysis and obtaining approval before modifications to the project scope are made
A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees, and their dependents
Civilian Health and Medical Program of the Uniformed services
What does CHAMPUS stand for?
Civilian Health and Medical Program-Veterans Affairs (CHAMPVA)
What does CHAMPVA stand for?
A system for grouping similar diseases and procedures and organizing related information for easy retrieval. A system for assigning numeric or alphabetic code numbers to represent specific diseases and/or procedures
Clinical data repository
A central database that focuses on clinical information
Clinical Data warehouse
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface
Clinical Decision Support System
A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions
Clinical Document Architechture
(CDA) HL7 electronic exchange model for clinical documents (such as summaries and progress notes)
Which of the following describes an SDO?
-Coordinates standards groups
- develops standards
- develops data sets
- develops best practices
Clinical data repository-CCR
Which one of the following should be used to communicate information from one provider to another for referral, transfer, or discharge of the patient?
Digital Imaging and Communication in Medicine- DICOM
This was adopted as the federal health information interoperability messaging standard for imaging.
This SDO develops messaging, data content, and document standards to support the exchange of clinical information
Institute of Electrical and Electronics Engineers- IEEE 1073
This is a standard for communication between bedside medical devices and patient care information systems.
HIT Policy Committee
One of the 2 official HHS advisory groups established as a result of ARRA responsible for making recommendations to the National Coordinator is:
Which standard assists in the sharing of information from one provider to another for patient care?
What organization coordinates the efforts of other Standards Development Organizations?
What type of standard establishes common definitions for medical terms?
American Medical Association (AMA)
Who updates the CPT?
annually, besides category 3 which is biannually
How often is the CPT updated?
Evaluation & Management, Anesthesia, Surgery, Radiology, Pathology/Laboratory, Medicine, Category II, and Category III
Name the 8 sections of CPT-4.
Category II Codes
These CPT codes are Supplemental tracking codes that can be used for performance measurement.
Category III Codes
These CPT codes were added to allow for temporary coding assignment for new technology and services that do not meet the rigorous requirements necessary to be added to the main section of CPT.
In the CPT book, this appendix describes each modifier
In the CPT book, this appendix is a summary of the additions, deletions, and revisions that have been implemented in the current edition.
In the CPT book, this appendix provides clinical examples of codes found in the E/M section of the book.
In the CPT book, this appendix is a list of CPT add-on codes. These add-on codes must be followed by a primary procedure code and would NEVER BE REPORTED ALONE.
Must never be reported alone
What is true about the add-on codes in the CPT Appendix D?
In the CPT book, this appendix is a summary of codes that are exempt from modifier 51.
In the CPT book, this appendix is a summary of codes that are exempt from modifier 63
In the CPT book, this appendix contains codes that include conscious/moderate sedation
In the CPT book, this appendix is an index of performance measures but was REMOVED from CPT.
In the CPT book, this appendix contains genetic testing code modifiers used for reporting with lab procedures related to genetic testing
In the CPT book, this appendix includes a listing of sensory, motor, and mixed nerves that are useful for nerve conduction surveys
In the CPT book, this appendix is a reference of the vascular families that includes first, second, and third-order vessels.
In the CPT book, this appendix lists procedures included in CPT that are not yet approved by the FDA
In the CPT book, this appendix displays a table of deleted CPT codes
In the CPT book, this appendix is a table of re-sequenced codes
Systematized Nomenclature of Medicine Clinical Terminology
What does SNOMED CT stand for?
This classification system's function is to provide a controlled vocabulary for coding the contents of the patient record and for facilitating the development of computer-based patient records
This classification system's function is to document nursing care and to facilitate the capture of nursing information on computer systems
This classification system's function is to provide a means to record information about patients treated for substance abuse and mental disorders
The total component of screens, navigation, and input mechanisms used to help the end user operate the encoding software
The amount of money that the patient is responsible for before the insurance kicks in is called the:
Hospitals cannot afford to provide care to uninsured patients
What is the main reason why the high percentage of uninsured is a concern?
Manage Medicare and Medicaid costs
Prospective payment systems were developed by CMS to:
The government agency that administers the Medicaid and Medicare program is called:
Catastrophic illnesses and injuries
What does major medical insurance cover?
Americans over the age of 65
What was the criteria for the ORIGINAL group of Medicare?
Medicare Part A provides:
Emergency Department, Ambulatory surgery center services, and outpatient services
Medicare Part B provides:
Individuals over age 65, disabled, and individuals with ESRD
Who is eligible for Medicare coverage?
Private fee-for-service plans
These types of plans allow beneficiaries to go to any doctor or hospital that accepts the terms of the plan's payment.
Title XIX of the Social Security Act Amendment of 1965 is also known as:
inpatient hospital services, prenatal care, and vaccines for children
In order to be eligible for federal matching funds, each state's Medicaid program must offer what 3 things?
State Children's Health Insurance Program
Which program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children?
Which of the following is NOT a place where PACE services can be provided?
- Day healthcare centers
Programs of All-Inclusive Care for the Elderly
This (PACE) provides an alternative to institutional care for individuals 55yrs. or older who require a level of care that is usually provided at a nursing home.
A healthcare program for active duty members of the military and other qualified family members which was originally called CHAMPUS.
A healthcare program for dependents and survivors of permanently and totally disabled veterans.
Indian Health Service- IHS
The agency responsible for providing healthcare services to American Indians and Alaska Natives is:
Insurance that covers healthcare costs and lost income associated with work-related injuries is called:
Federal Employees' Compensation Act (FECA)
Which agency/program provides federal employees injured in the performance of duty with workers' compensation benefits?
Independent Practice Association
This model of HMO is created when physicians join together in an organized group for the purposes of fulfilling a contract but retain individual practices
This model of HMO employs physicians and other healthcare professionals to provide healthcare services to members
In this HMO model, healthcare services are contracted with two or more multispecialty group practices instead of just one.
In this HMO contract, providers usually agree to devote a fixed percentage of their practice time to the HMO.
Premiums are paid directly to this type of HMO, and services are usually provided within corporate facilities.
This nonprofit organization contracts with physicians to manage their practices and owns clinical/business resources that are made available to participating physicians
Integrated provider organization
This organization manages and coordinates the delivery of healthcare services performed by a number of healthcare professionals and facilities and its physicians are salaried employees:
Physician- hospital organization
This arrangement makes it possible for the managed care market to view hospitals and physicians as a single entity for the purposes of contracting services:
Prospective (Prospective payment system)
The type of payment system where the amount of payment is determined before the service is deliver is called:
These payment arrangements are streamlined by the use of chargemasters:
The prospective payment system that was implemented in 1983 is referred to as:
Third party payers and/or patients issue payments to healthcare providers after healthcare services have been provided and payments are based on the specific services delivered refers to____________ reimbursement.
For many plans, the health plan and the patient share costs on a _____________ percent.
patient had 3 visits in the 60-day period
Which of the following patients qualify for LUPA?
- Patient had 10 visits in 60-day period
- Patient had 3 visits in the 60-day period
- Patient had 4 visits in the 60-day period
-Patient had 5 visits in the 60-day period
This POA indicator means that the diagnosis was present at the time of an inpatient admission
This POA indicator means that the diagnosis was NOT present at the time of an inpatient admission
This POA indicator means that the documentation is insufficient to determine whether the condition was present at the time of an inpatient admission
This POA indicator means that the provider is unable to determine whether the condition was present at the time of admission. = Clinically undetermined
Low-utilization payment adjustment
(LUPA) This is an alternative (reduced) payment made to home health agencies instead of the home health resource group reimbursement rate when a patient receives fewer than 4 home care visits during a 60-day episode
Ambulatory Payment Classification Groups (APCs)
The calculation of payment for services under the outpatient prospective payment system is based on the categorization of outpatient services in these groups according to the CPT/HCPCS codes, not the diagnosis codes.
Fee-for-service reimbursement methodology
prior to the implementation of the MS-DRG prospective payment system, Medicare Part A payments to hospitals were based on a:
The MS-DRG PPS rate is based on what type of diagnosis?
What type of hospitals are excluded from the Medicare acute PPS?
Major diagnostic categories
MS-DRGs are organized into:
Resource Based Relative Value Scale
What reimbursement system utilizes the Medicare fee schedule?
Balanced Budget Refinement Act of 1999 (BBA)
What legislation mandated the implementation of a skilled nursing facility PPS?
What tool is used to collect resident assessment data so that the SNF residents can be assigned to the appropriate resource utilization group?
What reimbursement system is associated with the Medicare outpatient PPS?
critical access hospitals
What organization is not reimbursed under the outpatient PPS?
Discounting of procedures
What concept is applied when multiple surgical procedures are furnished during the same operative session?
Per diem rate
The inpatient psychiatric facility's PPS reimbursement system is based on:
Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI)
What tool is used to calculate the Case Mix Group (CMG)?
The hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should they refer to?
The purpose of a physician query is to:
Medicare Administrative COntractors
______________ serve as the financial agent between providers and the federal government to locally administer Medicare Part A and Part B.
The _________ is submitted to Medicare carriers to process hospital outpatient claims.
Electronic Data Interchange
____________ is used to describe the electronic transfer of information such as a claims submission.
Outpatient Code Editor
The ________ applies a set of logical rules.
Fee schedules are updated by third-party payers ______________.(how often)
Provider accepts as payment in full whatever the payer reimburses
What does it mean to "accept assignment"?
This ____________ is developed by third-party payers and includes a list of healthcare services and procedures and their correlating charges.
Office of the Inspector General (OIG)
The essential elements of a Corporate Compliance Program are defined by ______________. ______________ also established compliance programs for the healthcare industry.
Unit numbering system
The system in which a health record number is assigned at the first encounter and then used for all subsequent encounters is the:
master patient index
The primary guide to locating a record in a numerical filing system is the:
All of them
What type of algorithm(s) may be used to identify duplicate medical records?
-All of the above
The health record number is usually assigned by:
- Patient registration
True/False:Both AHIMA and the Social Security Administration oppose to using the Social Security Number as the health record identifier.
Health information exchange
_______________ describes the electronic sharing of information among 2 or more entities.
Which identification system is at a disadvantage where there are 2 patients with the same name?
- Unit numbering
- Unit-serial numbering
straight numeric filing system
In this type of medical record filing system, the records are arranged consecutively in ascending numeric order.
terminal-digit filing system
In this type of medical record filing system, the last digit or group of last digits is the primary unit used for filing.
Ex: 44-37-98 is filed as File section 98, shelf number 37, and folder number 44.
middle-digit filing system
In this type of medical record filing system, the primary unit is the middle digit, or group of digits, and the secondary unit is the first unit to the left, followed by the last digits. Ex: 44-37-98 would be filed as file section 37, shelf number 44, and folder number 98.
What microfilm format is the least efficient when patients have multiple admissions on microfilm?
normally 7, but no more than 10 years
Under the False Claims Act, claims may be brought up to how many years?
State regulations AND AHIMA recommendations
Record retention should be based on ___________ regulations AND ______________ recommendations.
What is the most appropriate way for destroying microfilm?
what is the most appropriate way for destroying electronic data?
The tool used to track paper-based records is a(n):
_ Compliance documentation
re-audit the problem area
What should be done when the HIM department's error or accuracy rate is deemed unacceptable?
- A corrective action should be taken
- The problem should be treated as an isolated incident
- re-audit the problem area
Statements that define the performance expectations and/or structures or processes that must be in place are called:
Reviewing a health record for missing signatures and missing medical reports is called:
Electronic Document Management System
This system is used most often with the hybrid records, and encompasses a wide variety of technologies including turning scanned records int a digital format.
what term is used to describe the process of checking individual data elements, reports, or files against each other to resolve discreptancies?
patient registration system
The computer system that may serve as the MPI function is also the ____________ _______ system.
A chronological listing of data and called a(n):
Bob Smith is a 56 year old white male. This is an example of what type of data?
Benchmarking with other facilities
Which of the following is an example of how an internal user utilizes secondary data?
After the types of cases to be included in a registry have been determined, what is the next step in data acquisition?
What are the patient data such as name, age, address, and so forth called?
What type of registry maintains a database on patients injured by an external physical force?
It only contains Medicare patients
Why is the MEDPAR File limited in terms of being used for research purposes?
Health Care Quality Improvement Act of 1986
What act mandated the establishment of the National Practitioners Data Bank?
This type of data falls into groups or categories.
This type of variable data are those that fall into categories. They have only a limited number of values and cannot be staged as 2.5, 6.25, and so forth. AN example is the date, zip code, marital status, etc.
This type of variable data are measurements that can be subdivided into smaller values. An example is a person's weight, blood pressure, length of stay, and age.
Inpatient Service Day
A unit of measure that reflects the services received by one inpatient during a 24-hr period is called:
Hospital Ambulatory Care
Name the term: All hospital-directed preventative, therapeutic, and rehabilitative services provided by physicians and their surrogates to patients who are not hospital inpatients, but still patients of the hospital.
Name the term: A patient who receives ambulatory care services in a hospital-based clinic or dept.
Occasion of service
Name the term: A specified, identifiable service involved in the care of a patient that is not an encounter.
These types of charts are used to display data from one or more variables and may be dram vertically or horizontally, but do not touch.
This type of graph may be used to display time trends or patterns of quantitative data over time.
A ________ is used to display a frequency distributions. These are used to illustrate frequency distributions of continuous variables such as age, or LOS, and are touching.
A ____________ is an alternative to a histogram, and shows frequency distributions but in a line form rather than a bar form.
scatter charts, or scatter plots
____________________ charts are used when a person wants to determine if there is a relationship between two variables, such as charges and LOS.
This is a type of scatter chart with circular symbols used to compare three variables. The size of the symbol indicates the value of the third variable.
The ____________ is the simplest measure of spread. It is the difference between the smallest and largest values in a frequency distribution.
The _____________ of a frequency distribution is the average of the squared deviations from the mean.
The _______________are calculated by subtracting the mean of the frequency distribution from each value in the distribution. The difference of the 2 values is then squared. The squared values are then summed and divided by N-1.
Which of the following provide process measure metrics in a precise format?
- Structured indicator
- Outcome indicator
the focus of performance improvement should be on:
- Interpersonal skills
50% of our HIM staff have a nationally recognized credential. This is an example of what type of indicator:
Which tool is used to display performance data over time?
The type of variation that is caused by factors outside a system us called:
A _______________ chart looks like a bar chart, but the highest ranking item is listed first.
They have been made part of the decision.
Staff members adapt to change more readily when:
Evaluate whether or not a healthcare facility is meeting standards for accreditation
QIOs use peer review data analysis, and other tools to:
EMployees are participants in the performance improvement process
Shared leadership means:
commonly lead to patient injury
The NPSG scores organizations on areas that:
A group of processes that determine the appropriateness of medical services is:
Retrospective utilization review
A patient has been discharged prior to an administrative utilization review being conducted. What type pf review should be performed?
complete an incident occurrence report
A patient fell out of bed. What should be done?
A patient is dissatisfied with his or her care. Who should the patient contact at the hospital?
A woman dies in labor and delivery. The Joint Commission would call this type of outcome an:
What healthcare professional assists physicians in clinical assessments and patient education?
State licensure boards
Licensure tests to practice medicine are administered by:
Clinical laboratory science
Which of the following is considered to be an allied health career?
- Clinical laboratory science
- Medical student
The Adoption of Minimum Standards marked the beginning of what modern practice for healthcare organizations?
According to the AMA, which profession incorporates the healthcare-related professions that function to assist, and/or complement the work of physicians and other clinical specialists?
Healthcare Quality Improvement Act
What law created the Health Insurance Portability and Accountability Act?
National Institutes of Health
What government agency supports medical research?
Tax Equity and Fiscal Responsibility Act of 1982
A HIT student asked you why Medicare reimburses healthcare providers through prospective payment system. What is the legislation would you use as part of your explanation?
Diseases could be diagnosed earlier
A friend an I are debating cell-based technologies. Which of the following is a reason why I might argue for this technology?
- It uses magnetic and radio-frequency to record images of soft tissue
- Disease could be diagnosed earlier
- It studies the blood to diagnose conditions
- it looks at microorganisms
Federally mandated healthcare program for low-income people
How would you describe Medicaid?
Healthcare Quality Improvement Act of 1986
This legislation established the National Practitioner Data Bank
Omnibus Budget Reconciliation Act of 1990
This legislation required PROs to report actions taken against physicians to state medical boards and licensing agencies
Public Law 92-603 of 1972
This legislation required concurrent review of Medicare and Medicaid patients
Omnibus Budget Reconciliation Act of 1989
This legislation instituted and researched the Agency for Healthcare Policy
This legislation authorized grants for states to construct new hospitals
American Medical Association
What organization has the mission of promoting the science and art of medicine and to improve public health?
Commission of Certification of Health Information Technology
What organization's mission is to certify electronic health records?
Commission on Accreditation for health Informatics and Information Management of Education
A college wants to start a new HIT program. Who should the staff contact for program accreditation information?
Perform a root cause analysis
At our hospital, a patient died during child birth. As this is a sentinel event, what do we need to do?
American Hospital Association
I need to order the Coding Clinic for our coders. Who should I contact?
The Joint Commission
This organization developed the National Patient Safety Guidelines
American Nurses Association
Part of this organization's mission is to work for the improvement of health standards and the availability of healthcare services
American Medical Association
This organization shares information on health and medical practices
A not-for-profit hospital owned by a church
Give an example of a voluntary hospital
Board of directors
Who has the primary responsibility of guiding the direction of the hospital?
Clinical support services
The HIM Department is considered to be what type of department?
What service uses work and play to help the patient improve independent functioning?
Dr. Smith has been granted permission by Community hospital to perform cardiac catheterizations. This permission is called:
The right care is provided at the right time
Describe "quality of healthcare"
An integrated delivery system
I work for an organization that owns a hospital, a skilled nursing facility, and physician practices. I work for what type of an organization?
they help to improve the quality of patient care
What is the purpose of evidence-based guidelines?
At our facility, our staff on the nursing units are cross-trained to perform many tasks for a small group of patients. What is this concept called?
Quality has several components, including appropriateness, technical excellence, acceptability, and:
What type of program has been in place in hospitals for years and is required by the Medicare and Medicaid programs as well as accreditation standards?
Private medical practice
What type of care is it when the doctor owns their own office practice?
This type of treatment provides alternatives to inpatient care or serves as a transition from inpatient to outpatient care or discharge
skilled nursing facility
This type of treatment is healthcare that is rendered in a nonacute care facility to patients who require inpatient nursing and related services for more than 30 consecutive days
continuum of care
care provided by different caregivers at different levels of the healthcare system
The term that means the HIM professional applies rules consistently is:
This concept is the right of an individual to be left alone.
This term means to promote good
This term refers to "first do no harm"
This term applies to fairness is applying rules
The healthcare organization that created it
A medical record is owned by:
A subpoena requesting patient records must also be accompanied by __________________.
provide direct patient care and serve the patient's interests
The principal purpose of collecting and storing health information is to:
public or private
Law can be classified as:
define rights and duties among private parties
What is the purpose of private law?
Administrative law falls under the umbrella of:
A wrongful act that results in injury to another
AHIMA recommends that the operative index be retains for how many years?
the legal record
What record is disclosed upon request of subpoenaed records?
made for public health reporting purposes
An accounting of disclosures must include disclosures:
For as long as it is maintained
The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of their PHI:
When PHI is requested by the patient, how long does the facility have to provide it?
Accomplish the intended purpose
The term mimimum necessary means that healthcare providers and other covered entities must limit use, access, and disclosure to the minimum necessary to:
An incidental exposure
calling out patient names in a physician's office is considered as what type of disclosure?
treatment, payment or operations
What 3 things is a consent not usually required to be obtained for?
The use or disclosure of PHI for marketing does/does not require written authorization from the patient for face-to-face communications with the individual.
500 individuals addected
Per the HITECH breach notification requirements, what is the threshold for the immediate notification of each individual?
The maximum penalty per violation for HIPAA violations due to willful neglect with correction is:
Per the Fair and Accurate Credit Transactions Act (FACTA), which of the following is a red flag category?
- warnings from a customer reporting agency
- suspicious documents
- unusual activity relating to a covered account
- all of them
An information system
A ____________________ is a collection of related components that interact to perform a task in order to accomplish a goal, the integration of several elements in a business process to effect a specific outcome, and a process that refines raw facts into meaningful information.
a combination of hardware, software, and communications technology
What are the components of an information system?
Which of the following us an information system activity?
A physician ordering a lab test is an example of:
- business process
Planning, Analysis, Design, Implementation, Maintenance/Evaluation
What are the 5 phases in the system development life cycle?
operational support system
This type of information system facilitates the operational management of a healthcare organization. (OSS)
This is a computer-based information system that keeps track of an organization's business transactions through inputs and outputs. (TPS)
Management Information System
This is a computer-based system that provides information to a healthcare organization's managers for use in making decisions that affect a variety of day-to-day activities. (MIS)
Executive information system
This is an information system designed to combine financial and clinical information for use in the management of business affairs of a healthcare organization (EIS)
This is a type of information system that supports the work of professionals engaged in the development or evaluation of complex activities that require high-level knowledge u a well-defined and usually limited access
Decision support system
This is a computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in the decision-making tasks associated with non-routine and non-repetitive problems
End-user requirements are identified in the ____________ phase of the SDLC.
Testing the new IS system is part of the ________________ SDLC phase.
This is a type of network that works as a private internet.
World Wide Network
A system of internet servers that supports specifically formatted documents.
A type of network that allows the networks of separate organizations
A computer network that connects devices in a small geographical area
a COMPUTER NETWORK THAT CONNECTS DEVICES ACROSS A LARGE GEOGRAPHICAL AREA
A storage device for multiple databases that can be accessed via a single question-and-report- interface
Computers that are used to access shared resources in a network
A term used to describe a system of voice and data transmission
A type of database that stores data in predefined tables made up of rows and columns
A description of the structure of a specific database
Clinical Decision Support System
What type of clinical information system assists the physician in recording orders an in the decision-making process?
A system that allows physicians to treat patients at different sites.
Picture archival communication system
A system that allows reviewing digital images from a patient's MRI from different locations.
electronic document management system
A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks. The use of this system is also an intermediate step toward the EHR.
Human resource system
What system would be used to manage employee productivity, or department productivity?
The executive IS is designed to be used only by high level management
What is the difference between an Executive IS and a decision support system.
i will be conducting some analysis of data, but I only need a limited amount of data that are contained in the warehouse. What system should I utilize?
- data mining
- data mart
We receive a report each morning listing of the admissions from the day before. This is an example of what type of report?
To identify a new service for the hospital to implement
What is an example of when an executive support system should be used?
Decision support system
This system uses models and statistical analysis to help decision makers solve problems
This IS displays concise information and may be called a dashboard report
Chief information officer
What individual or group is responsible for developing the strategic vision for the organization's information?
Information resource management addresses information that is stored in what format?
Chief medical information system officer
Which role works with physicians to assist in the implementation of the ehr?
50% of patients treated at our facilities have Medicare as their primary payer. This is an example of what type of information?
- Patient Specific
- Expert knowledge
Electronic system design and development
What HIM role should be added to an information system?
Consumer health informatics
What HIM role is involved with the personal health record?
In what type of healthcare setting are the use of mobile devices critical to the efficient use of information systems?
The term ______________ refers to a set of components that work together to accomplish a goal.
laboratory information system
Which of the following is a source system:
- CLinical Decision support system
- Laboratory information system
- Results management system
drug knowledge database
The Dr. always orders the same 10 things when a new physician is admitted to the hospital in addition to some patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered within the clinical decision support system?
Point-of-care charting systems are primarily used by:
Electronic Data Management System (EDMS)
A transition technology that is used by many hospitals to increase access to health record content during the evolution to EHR is called:
Computerized provider order entry
The EHR component that is often the most challenging for which to gain adoption in a hospital is:
A system that is used by all intended users for at least basic functionality is considered as:
unintended consequences from using EHR technology are primarily due to issues with:
What is the biggest complaint physicians have with use of the EHR?
Personal Health Record
Exchange of a standard set of health information content between providers and with patients is facilitated by the use of a :
In what form of health information exchange are data centrally located but physically separated?
The function used to provide access controls, authentication, and audit logging in an HIE is called:
Clinical data warehouse
A database for analytical processing
A computer that has minimal processing capability of its own
Which of the following would reduce the risk that information is not accessible during a server crash:
- Storage Area Network
- Server Redundancy
- Disk Backup
A part of storage management that assures documentation is retained about changes is called:
What form of database does online analytical processing typically require?
______________ is the standard used for claims processing.
______________ is the standards used for data exchange
________________ is the standards used for clinical drug names.
_______________ are the standards used for clinical images.
NDC (National Drug Codes)
________________ are the vocabulary standards used for drug inventory.
This provides access to content of previous visit information in an EHR.
A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare organization is called:
This term is defined as ensuring timely and reliable access to and use of information.
Assigning passwords that limit access to computer stored information
Public Law 104-191
HIPAA is also known as what Public Law?
Which of the following provides the objective and scope for the HIPAA Security Rule as a whole?
- Administrative safeguards
- Documentation requirements
- general rules
- physical safeguards
A contingency plan
What type of plan ensures that procedures are in place to handle an emergency response in the event of an untoward event such as a power outage?
What type of control ensures that a user has only the information needed to perform their job function?
A visitor sign-in sheet is considered as what type of access control?
The process that encodes textual material, converting it to scrambled data that must be decoded is called:
Six years from date when last in effect
Covered entities must retain documentation of their security policies for at least:
Must be maintained in written format
Security policies must:
The staff workgroup that I am on has a multidisciplinary make-up. The purpose of the workgroup is ongoing. What is the best term that describes this type of workgroup?
The term that defines the right of a leader to make decisions is:
Reduces the delay in decision making
Which of the following occurs when a supervisor delegates authority?
- Decreases need for performance standards
- Reduces the delay in decision making
- Eliminates monitoring turnover
In which stage of performance management are performance evaluations conducted?
Strategic planning is concerned primarily with how the organization will respond in the foreseeable future to changes in its:
Together with inventory control and supplier relationships, what is the term that describes the element of supply management?
Working with the parties involved to find a mutually acceptable solution is the focus of:
prevent interaction between the two parties
The ultimate goal of constructive confrontation is to:
redundancies in a process
What could an analysis for a flowchart identify?
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