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Final Exam review

The primary function of the American Healthy Information Management Association is

To promote the accuracy, confidentiality, and accessibility of health record in every setting.

Which organization actively promotes education and research in health information management?

AHIMA Foundation

Which of the following accredits academic program in health information management?


Which of the following is true about AHIMA certification program?

Candidates must pass an examination before obtaining any of the credentials.

What is not a requirement for professional certification through the AHIMA?

Graduating from an accredited two year or four year educational program.

The primary goal of the Hospital Standardization Program was:

To raise the standards of surgical practice

Which class pf AHIMA membership requires that individuals hold AHIMA credentials?

Active membership

Which 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 new opportunity for HIM professionals that deals with data repositories and data warehouses is:

Data resources administrator

HIM has been recognized as an allied health profession since


What best describes the most important function of the health record?

storing patient care documentation

Who are the primary users of the health record?

The clinical professional who provides direct patient care

Healthcare information systems need to exchange information. This linkage between system is referred to as:


Which of the following represents an example of data granularity?

a numerical measurement carried out to the appropriate decimal place.

What are not flexible enough to meet all of the needs of every health record user.

Paper-based record systems

What best describes data accuracy?

Data are correct

The admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summer Mrs. Smith's birth date was recorded as July21, 1948. Which quality element is missing from Mrs. Smith's health record.

data aconsistency

I need an information system that will provide assist physicians in diagnosing and treating patients. They system I need is:

clinical decision support

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. which quality element is missing from the progress note?

data currency

Which of the following best describes data completeness:

data included all required elements

What is not usually a component of acute care patent records?

Problem list

The attending physician is responsible for which of the following types of acute care documentation?

discharge summary

The number of ligatures, sutures, packs, drains and sponges used in specimens removed would be found in the ____?

Operative report

What are the following is true of computer-based records?

can be accessed by multiple end users simultaneously

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 represents the attending physician's assessment of the patient's current health status?

Physical examination

In which setting may treatment records travel with the patient between treatment centers?

Correctional facility care

Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record?

Personal health record

Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?

Joint Commission on Accreditation of Healthcare Organizations

Which of the following organizations recently drafted functional standards for electronic health records?

Health Level Seven (HL7)

The _____data set is mandated for use in facilities that participate in the Madicare and Medicaid programs.


A corporation is evaluating several health plans for it's benefits package. the data set that provides comparison information about health plan performances is________?


using a hospital discharge database, a physician does a study of diabetes millitus comparing age of onset with response to a specific drug regimen. The physician has gathered ____from the database?


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

American Society for Testing and Measurement

Activities of daily living (ADL) are components of ________?


Messaging standards for electronic data interchanges in healthcare have been developed by


Once hospital discharge abstract systems were developed and their ability to provided comparative data to hospitals was established, it became necessary to develop ________?

data sets

OASIS data is used to assess the ___of home health services.


In healthcare, data sets serve two purposes. The first purpose is to identify data elements to be collected about each patient. The second is to ________?

provide uniform data definitions.

Data collected to evaluate facility performance in designated core measure areas in order to achieve accreditation is _______?


The first point of data collections and the area where the health record number is most commonly assigned in an acute care hospital is the _______?

patient registration department

The Joint Commission on requires that the medical record delinquency rate quarter average from the last four quarterly measurements is not greater than ______of the average monthly discharge rate.


The master patient index ________.

A list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility.

The annual volume statistics for New Town Hospital are noted below. How many shelving units will be required to store this years inpatient discharge records?
Average inpatient discharges = 12,000
Average impatient record thickness = 3/4 inch
Shelving units shelf width = 36 inches
Number of shelves per unit = 6

12,000 X .75 / 36 / 6 = round up

Reviewing the health record for missing signatures, missing medical reports and ensuring that all documents belong in the health record is an example of _______ review.


The release of information function requires the HIM professional to have knowledge of _______?

federal and state confidentiality

In which systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain tat identifier for all subsequent encounters?

Unit numbering system

What filing methods is considered the most efficient?

terminal digit filing

What indexes is considered to be the authoritative key to locating a health record?

master patient index

The Healthcare Cost and Utilization Project is a major initiative of which organization within the federal government?

The Agency for Healthcare Research and Quality

Critique this statement: The Medicare Provider Analysis and review File is made up of patient demographic data collected by acute care and skilled nursing facilities.

MEDPAR is actually made up of chains data which does include demographic data

Critique this statement: case definition for trauma registries is determined by individual facilities

This is a true statement

The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted int eh development of

The Healthcare Integrity and Protection Data Bank

Critique this statement: Interrater reliability depends on the consistency of data collection activities among abstractors

This is a true statement

A record is considered a primary data source when it _________?

contains information about the patient that has been documented by the professionals who provide care to the patient

The most prevalent trend in the collection of secondary databases is ________?

The increased use of automated data entry

Secondary data is derived from

the primary patient record, such a an index or a database

Which of the following databases was developed by the National Library of Medicine?

The Medical Literature, Analysis, and Retrieval System Online

The creation of the National Practitioner Data Bank was mandated by __________?

The Health Care Quality Improvement Act

An orderly arrangement of values that display data in rows and columns


One or more series of points connected by a line or lines to represent trends in time


A horizontal or vertical arrangement of rectangular shapes that represents data from one or more groups or categories

Bar Chart

An arrangement of pieces in a circular shape that represents the component parts of a single group or variable

Pie Chart

An arrangement of lines that represents one or more frequency distributions

Line graph

The IRB functions as a(n):

Ethics committee

What term is used for the number of calendar days of an impatient hospitalization from admission to discharge?

Length of stay

What term is used for the number of inpatient present at any one time in a healthcare facility.


What term is used for the number of inpatients present at the census-taking tie each day, plus any inpatients who were both admitted and discharged after the census-taking time the previous day?

Daily census

Given the numbers 47,20,11,33,30,30,35, and 50, what is the mean?


How do you determine the mean?

a true average

Given the numbers 47,20,11,33,30,30,35, and 50, what is the mode?


How do you determine the mode

"mo", "most": put all numbers in order and determine the most common number

Given the numbers 47,20,11,33,30,30,35, and 50, what is the median?


How do you determine the median?

The middle: Put all numbers in order and take the middle number. Unless there are an even number in the middle then average the two middle.

Given the numbers 1,5,10,25,26, and 66, what is the range?


How do you determine the range?

Take the lowest and subtract from the highest

What is the official count of inpatients taken at midnight called?

Daily inpatient census

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the daily inpatient census at midnight on May 2nd?


Community Hospital had a total of 3,000 inpatient service days for the month of September. What was the average daily census for the hospital during September?

100 patients

Mr. Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay for Mr. Jones?

10 days

Community Hospital discharged nine patients on April 1. The length of stay for each of the patients was as follows: for patients A, one day; for patient B, five days; for patient C, three days; for patient D, three day; for patient E, eight days; for patient F, eight days; for patient G, eight days; for patent H, nine days; patient I, nine days. What was the average length of stay for these nine patients?

6 days

Community Hospital discharged nine patients on April 1. The length of stay for each community patients was as follows: for patients A, one day; for patient B, five days; for patient C, three days; for patient D, three day; for patient E, eight days; for patient F, eight days; for patient G, eight days; for patent H, nine days; patient I, nine days. What was the median length of stay for these nine patients?

8 days

Community Hospital discharged nine days on April 1. The length of stay for each of the patients was as follows: for patients A, one day; for patient B, five days; for patient C, three days; for patient D, three day; for patient E, eight days; for patient F, eight days; for patient G, eight days; for patent H, nine days; patient I, nine days. What was the mode for the length of stay for these nine patients?

8 days

Community Hospital had 25 inpatient deaths, including newborns for the month of June.The hospital had a total number of 500 discharges for the same period, including deaths of adults, children and newborns. What was the hospital gross death rate for June?


Community Hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed five autopsies for the same period. What was the gross autopsy rate for the hospital for June?


What information is needed to calculate the net death rate for a period?

Total number of patients - deaths /total number of discharges (including adults and children & New born deaths) - deaths

The first professional association for health information managers was established in


The hospital standardization program was started by the American College of surgeons in


The formal approval process for academic programs in health information management is called


The formal process for conferring a health information management credential is called:


Which of the following are elected to their positions by AHIMA members?

AHIMA Board of Directors, members of the council on Certification and Members of the Commission on accreditation for health Information and Information Management Education

Which of the following functions as the legislative body AHIMA?

AHIMA House of Delegates

Which of the following make up a virtual network of AHIMA members?

AHIMA communities of Practice

Which of the following is an arm of AHIMA that promotes education and research in health information management?

AHIMA Foundation

Which of the following best describes the mission of the AHIMA?

Community of professionals providing support to members and strengthening the industry and profession

Which of the following is true about AHIMA?

Values of code of ethical health information management practice, values the public's right to private and high-quality health information and Celebrates and promotes diversity.

What is the potential impact of the copy/past functionality on the integrity of the data and information contained in a EHR?

Data integrity refers to the state of date being complete, accurate, consistent, and up to date. Use of copy/paste functionality has the potential to destroy data integrity if the data or information copied from a previous patient encounter into the current patient encour4nter is no longer accurate.

How might the hybrid record change health information management?

The HIM department needs to identify the location of all components of the health record. All of these components must be managed which would include security, disclosure, retention, and other data management functions.

How might a hospital overcome some of the issues created by the hybrid record?

There should be policies and procedures in place that address where the various components are stored as well as how to bring them together for patient care, release of information and other purposes.

What is the secondary purpose of the health record?

to generate a report to be used in performance improvement

What is an institutional user of the health record?

government policy maker

How do patient care managers and support staff use the data documented in the health record?

to evaluate the performance of individual patient care the services provided.

What is the definition that best describes the concept of confidentiality?

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

This statement does NOT pertain to paper-based health records:

they have a built-in access control mechanism.

What is the advantage offered by computer-based clinical decision support tools?

They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature. They review structured electronic data and alert practitioners to out-of range laboratory values or dangerous trends. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives.

The hospital where I work is transitioning to EHR. In the meantimie, we have part of the health record electronic and part still paper. This concept is known as

a hybrid record

Critique this statement: Data and information mean the same thing:

This is a false statement as data is raw facts and figures and information is data converted into a meaningful format

What does not pertain to electronic health records (EHR)?

EHRs are filed in paper folders

Support for research is an example of what sort of health record?

Support for research

Use of the health record by a clinician to facilitate quality patient care is considered

a primary purpose of the health record

use of the health record to monitor bio-terrorism activity is considered

a secondary purpose of the health record

How do accreditation organizations use the health record?

to examine results of experimental protocols

Attorneys for healthcare organizations use the health record

protect the legal interests of the facility and its health care providers.

Our record has all of the lab filed together, all of the progress notes filed together and o on. What format are we using?

Source oriented health record

Inaccurate data recorded in the health record could

compromise quality patient care, contribute to incorrect assumptions by policy makers, and invalidate research findings

The term to describe expected data values is

data precision

Protection of healthcare information from damage, loss and unauthorized alterations is also known as


Since we implemented a new technology, we have eliminated lost orders and problems with legibility. what technology are we using?

Computerized physician/provider order entry

The paper based health record format tat organizes all forms in chronological order is know as

the integrated health record

An individual's right to control access to his or her personal information is known as


When all required data elements are included in the health record, the quality characteristic for _______ is met

data comprehensiveness

Critique this statement: Patient care managers are individual users of heath records

This is a true statement

HEENT: Reveals the tympanic membranes, nares and pharynx to be clear. No obvious head trauma. Chest: Good bilateral chest sounds

physical examiniation

Microscopic: Sections are of squamous mucosa with no atypia

pathology report

Admit 3C. Diet: NPO Meds: Compazine 10mg IV Q 6PRN

Admission Order

Following induction of an adequate general anesthesia and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.

operation report

MD in an AM. Discharge instructions given to patient and he verbalized understanding. Discharged to home with family. Gait Steady.

nursing discharge note

CBC: WBC 12.OH, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93

laboratory report

c/o slight tingling in fingers, better when arm out of sling, fingers warm, color pink, wiggles fingers, will monitor

Nursing progress note

I authorize and direct William Smith, MD, my surgeon and/or associates of his choice to preform the following operation upon me.

operative consent

38 weeks gestation, Apgars 8/9, 6# 9.8oz, good cry, to room with mom

newborn record

Vital signs:
Time 0120 T 36, P 144, R 45
0430 T 37, P 132, R 36
0800 T 37, P 112, R 50

nursing flow record

Diagnoses: chronic atrial fibrillation, congestive heart failure, old myocardial infarction. She will be followed by me in the office.

discharge summary

Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block

ECG report

PA and Lateral Chest: the lungs are clear. the heart mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine

radiology report

I was asked to evaluate this Level I trauma patient with a n open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery

radiology report

Care plan, physical and psychosocial assessments, bereavement documentations

hospice care

patient's legal status, individualized treatment plan, documentation of seclusion or restraints, psychologist notes

behavioral health care

RAI and care plan, nutritional services and activities documentation

long term care

functional and disability diagnosis, evidence of patient/family participation in decisions, staff conference reports.

rehabilitative care

documentation of the patient's nutritional, anemia, vascular access, and transplant status; dialysis doses

end stage renal disease

documentation of all medications
including over the counter drugs
provided, dental examination,
medical and psychological evaluations

correctional facility care

patient problem list, patient history questionnaire, progress notes

ambulatory care

preoperative studies, operative report, anesthesia report, documentation of follow-up phone calls

ambulatory surgery

The following are functions of the health record:

planning and managing care, evaluating the adequacy and appropriateness of care, substantiating reimbursement claims and protecting the legal interests of both patient and healthcare providers

Which of the following clinical data elements is not usually documented in the acute care health record?

records of immunizations

Which of the following is not a function of the discharge summery?

providing information about the patient's insurance coverage

In what way can the patient 's consent to undergo treatment be expressed?

by his or her submission to treatment, by written agreement and by verbal agreement

What would not be considered clinical date?

name of insurance company

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