Health Information Management Tech.
Terms in this set (208)
Which of the following carries out the operational tasks necessary to support the organization's mission and goals?
Our transcription is performed by a company outside of our organization. What is this called?
The services provided by HIM department is acute care hospitals usually include all the following except:
The patient registration department assists the HIM department in what way?
Assigning the health record number
Which of the following professional is not mentioned in this text as requiring licensing by all 50 states?
Health Information Management
Which of the following confers scholarships?
A member of the AHIMA Board of Directors is which of the following?
Patients in hospice care are expected to live a maximum of ______ days.
Which of the following elements is typically found in the paper health record?
Which of the following is a secondary purpose of the health record?
Support for research
What is the name given to the privileges assigned to physicians to provide clinical services in a hospital?
Which of the following is an example of information?
The number of patients discharged has increased 175% over the past year.
In which department or unit does the health record typically begin?
An RHIT is going back to earn her bachelor degree so that she can sit for the RHIA exam. What membership category is she qualified for?
Who is responsible for communicating information relevant to national issues and keeping members informed of regional affairs that affect HIM?
AHIMA component state associations
What committee oversees the development and approval of new forms for the health record?
Health information management committee
How many linear filing inches can a shelving unit hold based on the following data?
Shelving unit shelf width=36 in
Number of shelves per unit=9 shelves
Average record thickness=1/2 in
Which of the following is true about the AHIMA House of Delegates?
They meet virtually throughout the year
Long term care in mainly rehabilitative and supportive rather than curative.
What percentage of hospitals offers emergency services?
More than 90%
Sustained professional achievement is required by which of the following?
Which of the following should be taken into consideration when designing a health record form?
Including original and revised dates
Which organization's goal is centered on health information technology?
Who is responsible for final approval of the AHIMA Code of Ethics?
AHIMA House of Delegates
Two types of practitioners can hold the degree of Doctor of Medicine. They are:
Physician and Surgeon
Which of the following makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA?
Calculate the number of shelving units required for 35,000 linear filing inches of record if the shelving units has 7 shelves and is 36 inches wide.
Which of the following is a surgical specialty?
Dr.Smith wants to use a lot of free text in his EHR. What should be your response?
Dr.Smith, we recommend that you use little, if any, free text in the EHR.
How can the healthcare facility determine which physician has the best patient outcomes?
Which of the following filing method is considered the most efficient?
Terminal digit filing
The Social Security Act of 1935 has a healthcare component added by the Republican president, Franklin D. Roosevelt.
Which of the following classes of AHIMA membership requires that individuals have interest in HIM and will abide by the AHIMA code of ethics?
Critique this statement: Version control is not an issue in the EHR.
There are issues related to versions of documents, such as there must be a flag to indicate a previous version
AHIMA fellowship is conffered for:
Which one of the following are included in a list of institutional users of the health record?
Blue Cross and Blue Shield
Which of the following is true about the AHIMA certification program?
Candidates must pass an examination before obtaining any of the credentials.
The board of directors can also be called the board of trustees.
Which of the following statements describes alphabetical filing?
File the record alphabetically by the last name, following by the first name, and then the middle initial.
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record number of three records filed together within the filing system?
The release of information function requires the HIM professional to:
Disclose patient identifiable information to a third party
Why should the copy and paste function should not be used in the electronic health record?
The content may contain outdated inforamtion
Which of the following HIM tasks is eliminated by the electronic health record system?
Which of the following is a request from a clinical area to change out a health record?
Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public's health?
Surgeon General of the United States
What is the software that is used for voice recognition known as?
Natural Language Processing
Which of the following is a disadvantage of alphabetic filing?
Uneven expansion in file shelves or cabinets
Which step comes first in the accreditation process?
A health record with deficiencies that is not complete within the time-frame specified in the medical staff rules and regulations is called a(n) _________ record.
Who are the primary users of the health record?
Clinical professionals who provide direct patient care
The term used to describe controlling information is _______.
Which of the following best describes the most important function of the health record?
Storing patient care documentation
Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA?
Board of Directors
The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:
Which of the following lists of names is in correct order for alphabetical filing?
Smith, Carl J.
Smith, Mary A.
Smith, Paul M.
The difference in health insurance coverage between medical and psychiatric care is
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a ____________ review.
In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintained that identifier for all subsequent encounters?
Unit numbering system
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis?
This type of facility is more homelike and less institutional than in the past
Residential Care Facilities
The role of the AHIMA chief executive officer is to:
Manage the day-to-day operations
Which one of the following is in terminal digit order?
The average length of stay (LOS) for acute care hospitals is:
25 days or less
The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged what type of review?
Which of the following indexes is key to locating a health record?
Master Patient Index
Members of the AHIMA House of Delegates are:
Elected by members in component state organizations
With the implementation of the Affordable Care Act, U.S. states were given the opportunity to expand Medicaid, though not all have done so.
Cell-based technologies include
Stem cells for transplant
Where should new graduates begin their volunteer experience?
Which organization should be contacted regarding the certified healthcare documentation specialist exam?
Association for Healthcare Documentation Integrity
True or False? Auto-authentication is not in compliance with CMS Interpretive Guidelines for Hospitals
The data characteristics that refers to promptly entering up-to-date information into the patient's medical record is which of the following?
An example of a standard for forms development is to mandate that the title of the form appear on the rip center of the page
Which of the following represents the attending physician's assessment of the patient's current health status?
Patient history questionnaires are most often used in what setting?
The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module and released of information module with the electronic health record. This is an example of what data strategy method?
Which of the following is true of many electronic health records?
They are interoperable
The Uniform Hospital Discharge Data Set's core data elements are collected by
Acute care, short-term stay hospitals
When correcting erroneous information in a paper health record, which of the following is appropriate?
Add the reason for the change
CPT is a terminology and also a
True or False? Healthcare provider organizations normally do not have patients sign an acknowledgement addressing the fact that the healthcare provider organization is not responsible for the loss or damage of the patient's valuables
The ambulatory surgery record contains information most similar to which records?
Hospital operative records
AHIMA has created 8 principles to help organizations create ________________ within their organization?
True or False? The term ambulatory is the same as the term outpatient.
In what part of the health record would the social and personal history be found?
The ______________ established the Common Clinical Data Set
Create a clear and open documentation process for the information governance strategy and activities within an organization, instruments and clinical information systems
Which of the following is usually a component of acute care patient records?
Authorship validation is one part of _____________________________?
True or False? Analysis of patient registration information can promote population health management.
_____________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations?
Nursing terminologies are
Used to direct patient care given by nursing staff
Patient Account Information includes
Who drives which clinical terminology, classification, and code system in selected as the standard?
A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a health attack. The combined data is referred to as?
If you were coding a patient with the diagnosis of congestive heart failure, which classification would you use?
Which of the following procedure classifications include definitions?
Which of the following creates a visual process to understand the data being collected in two different systems and how it is linked to one another?
When defining the legal health record, what must the healthcare provider do?
Assess the legal environment
Which of the following represents documentation of the patient's current and past health status?
Which specialized type of progress note provided healthcare professionals impressions of patient problems with detailed treatment action steps?
Which of the following is the standard for healthcare equipment under HIPAA?
HCPCS Level II
What is a system of terms that follows pre-established naming conventions
A patient's birth data and gender documented in the health record are examples of a data?
Create a process for proper preservation of information based on requirements from regulations. accrediting organizations, and company policy
A healthcare organization must ensure that data is presented in a way that is appropriate for the purpose of the data
Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?
Commission on Accreditation of Rehabilitation Facilities
What is the general name for Medicare standards impacting healthcare organizations?
Conditions of Participation
The Healthcare Effectiveness Data and Information Set contains standard
When writing a query for clinical documentation questions, the requester should specifically state what diagnosis they are evaluating.
Which system would be used to classify a state of disability?
An example of clinical documentation improvement tool is computer-assisted coding (CAC)
Category II CPT is used for
True or False? An increase of healthcare-related identity theft has had no influence on a healthcare provider organization's decision not to collect Social Security Numbers from patients.
Interoperability is the capability of two or more systems and software applications to communicate electronically and exchange information
Data warehousing is the process of extracting information stored in structured data formats within a database.
A single or individual fact that represents a patient in healthcare is known as a/n
Which of the following contains the physician's findings based on an examination of the patient?
True or False? The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance.
True or False? An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance
The overall goal of documentation standards is to
Ensure what is documented in the health record is complete and accurately reflects the treatment
True or False? Nursing documentation should only be subjective
Which of the following is a clinical terminology?
One of the required descriptions for a SNOMED CT is
According to CMS, who is qualified to collect the OASIS data?
what is the function of a consultation report?
Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
Which of the following is an example of a long-term care setting?
Community mental health center
Safeguards established to support the data is available when and where is it needed under the data quality model is called which of the following?
True or False? CMS does not require healthcare providers to inform their patients about general patient rights afforded to them
A list of recommended data elements with uniform definitions is a
Which of the following is an example of an external user utilizing secondary data?
A notice of privacy practices should include a statement explaining that individuals may complain to the Secretary of the Department of Health and Human Services if they believe that their privacy rights have been violated.
Law that involves the government and its relationships with individuals or organizations
Process by which a lawsuit is initiated
Which of the following statements about the directory of patients maintained by a covered entity is true?
Individuals must be given an opportunity ti deny permission to place information about them in the directory
List of the operations and procedures performed in a facility, sequenced according to classification code numbers
Proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system
Registry that includes information from more than one facility in a geopolitical region
Spoken or written agreement; may be given by a patient to a healthcare provider to permit treatment
The main goal of Healthy People 2020 is to focus on promoting vaccine safety in public and private provider settings
Central collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery
What is the biggest threat to the security of healthcare data?
A level I trauma center provides care from initial evaluation through stabilization
Sworn testimony usually collected before a trial
A record is considered a primary data source when it
contains information about the patient that has been documented by the professionals who provided care to the pateint
Permission inferred when a patient voluntarily submits the healthcare treatment
A nurse cannot practice without
Critique this statement: Case definition for trauma registries is determined by individual facilities
This is a true statement
Mary's PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the physicians office's required action?
It must report the breach to HHR within 60 days after the end of the calendar year in which the breach occurred
Though the HIPAA Security Rule does not specify audit frequency, how often should an organization's security policies and procedures be reviewed
Once a year
Which of the following is required by HIPAA standards?
A written contingency plan
Law enacted by a legislative body
Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity
Can deny access to psychotherapy notes
Explain what the accession number 16-214 means
The year that the patient was entered in the registry is 2016 and this was the 214th patient entered in the registry during 2016
Written document directing an individual to furnish documents and other records to a court
Subpoena Duces Tecum
A risk analysis is useful to
Identify security threats
Which of the following is an organization's planned response to protect its information in the case of a natural disaster?
Business Continuity Plan
Information about the patient that is documented by the clinicians who provide services to the patient
Registry that includes only cases for a specific facility
An accession number is a number assigned to cases as it is entered in a cancer registry
Written permission to use or disclose patient-identifiable health information
Failure to meet the conditions specified under a legal agreement
breach of contract
The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of the
Healthcare Integrity and Protection Data Bank
Which of the following is a software program that tracks every access to data in the computer system?
What type of health records are subject to the HIPAA Privacy Rule
Health records in any format
In all cases, covered entity may deny an individual's request to restrict the use or disclosure of his or her PHI.
Which of the following situations is considered a breach of PHI
A patient's attorney is sent records not requested by the patient
Data extracted from individual patient records and combined to form information about groups of patients
Security controls built into a computer software program to protect information security and integrity are which of the following
Secondary data is generally used
by external users
individuals or party who is the object of a lawsuit
Who prohibits specific abbreviations from being used in the health record
In two computer systems the same data element is different. This is what type of issue?
What does the acronym PHI stand for?
Protected health information
Rules developed by administrative bodies empowered by law to regulate specific activities
Disclosure of pertinent facts or documents to the opposing parties in a legal case
Which of the following is an example of a physical safeguard that should be provided for in a data security program?
Locking computer rooms
The health cost and utilization project is a major initiative of which organization within the federal government?
The agency of Healthcare Research and Quality
Which of the following statements is true in responding to request from individuals who wish to access their PHI?
A cost-based fee may be charged for making a copy of the PHI
The HIPAA data integrity standard requires that organization do which of the following?
Keep documented logs of system access and access attempts
How many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHi is stored off-site?
What does the term access control mean?
Identifying which data employees should have a right to use
The Joint Commission sets the official record retention standards for hospital and other healthcare facilities
List of cases in a cancer registry arranged in the order in which the cases were entered
HIPAA administrative requirements include which of the following?
Designating a privacy officer
This type of control is designed to prevent damage cause by computer hackers
A valid Authorization requires which of the following?
AN expiration date or event
Rules and principles that define rights and duties among individuals or organizations
An audit identified that an employee accessed a patient whose last name is the same as the employee. This is known as a/an
List of patients by physician, usually arranged by physician code numbers
Information such as age and data of birth
Professional liability of healthcare providers in the delivery of care to patients
Identify the true statement about the health record
the health record is a primary data source
To identify cases to be entered into the trauma registry, where should someone look?
Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?
Notice of privacy practices
The services that a physician is allowed to perform in a healthcare facility is known as which of the following?
Amber files a medical malpractice lawsuit against Dr.Mason, who performed her surgery. She names no other defendant in the lawsuit. Dr. Mason files a complaint against Amber. By doing this, Dr. Mason has completed which legal action?
List of patients with severe injuries
PHR vendors that are nor part of a covered entity or business associate must report PHI breaches to
The Federal Trade Commision
Civil wrong doing
Secondary data source consists of
Individual who bring a lawsuit
AHIMA's record retention guidelines recommend that the master patient index be maintained for what length of time
The creation of hte National Practitioner Data Bank was mandated by teh
Health Care Quality Improvement Act
The physical health record is usually considered the property of which entity?
The organization or provider
Which of the following is a covered entity under the HIPAA Privacy Rule
Which of the following is one of the causes of action
Breach of Contract
AHIMA's record retention guidelines recommend that diagnostic images such as x-rays be maintained for what length of time?
at least 5 years