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An HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?

Scanning all documents at the time of patient discharge

In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation would a coder look for to substantiate the diagnosis of aspiration pneumonia?

Patient has history of inhaled food, liquid, or oil

Hospital A discharges 10,000 patients per year, Hospital B is located in the same town and discharges 5,000 patients per year. At Hospital B's medical staff committee meeting, a physician reports that he is concerned about the quality of care at Hospital B because the hospital has double the number of deaths per year than Hospital A. The HIM director is attending the meeting in a staff position. Which of the following action should the director take?

Suggest that the data be adjusted for possible differences in type and volume of patients treated.

Which of the following provide process measure metrics in a precise format?


Managing the adoption and implementation of new processes is called:

Change Management

How do health plans incentives providers to use EHRs?

Paying for performance programs

Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during performance improvement indicatives to facilitate___ among employees.


Change management is the process of planning for change. It concentrates on:

Addressing employee resistance to change in processes, procedures and policies

A report that lists the ICD-9-CM codes associated with each physician in a healthcare facility can be used to assess the quality of the physician's services before he or she is

Recommended for staff reappointment

The primary goal of the Hospital Standardization Program established in 1918 by the American College of Surgeons was to

Establish minimum quality standards for hospitals.

A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome is a:

Performance measure

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis exists for believing that the process, when executed will, will increase the probability of achieving a desired outcome

Process measure

The principle process by which organizations optimize the continuum of care for their patient is:

Case management

The National Patient Safety Goal (NPSG) have effectively mandated all healthcare organizations to examine care processes that have a potential for error that can cause injury to patients. Which of the following processes are included in the NPSG

Check patient medicines, prevent infection, and identify patients correctly

The interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines with an integrated environment are included in what area of performance measurement?


A performance measure that enables healthcare organization to monitor process to determine whether it is meeting process requirements is called


A Joint Commission-accredited organization must review its formulary annually to ensure a medication's continued

Efficacy and safety

Environmental assessments are performed as part of which of the following process?

Strategic planning

Through the establishment of the National Practitioner Data Bank, the federal government became involved in malpractice issues and what other type of issues?

Quality of care

All of the following are Joint Commission core measure criteria sets except: (a) Heart failure; (b) Acute myocardial infarction; (c) Pneumonia; (d) Diabetes mellitus

Diabetes mellitus

During training, the employee should be:

Evaluated to make sure work is error free

I reviewed the patient's record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This would be an example of:

Quantitative analysis

I reviewed the health record of Sally Williams and found the physician stated on her post-op note, "examined after surgery." This would be an example of

Qualitative analysis

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