236 terms

HIM An Applied approach

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
What federal law resulted in the new privacy regulation for healthcare organizations?
The health Insurance Portability and Accountability Act
What includes names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed?
operative report
What is an example of an advance directive?
a living will
What materials is not documented in an emergency care record?
patient's complete medical history
What types of facility is not governed by Medicare long-term care documentation standards?
assisted living facilities
What specialized patient assessment tools must be used by Medicare-certified home care providers.
Outcomes and Assessments Information Set
What regulations are most commonly applied in end stage renal disease treatment?
Medicare Conditions for Coverage
what statements are not true of the process that should be followed in making corrections in paper-based health record entries?
The incorrect information should be obliterated
What types of healthcare facilities may seek accreditation from the Joint Commission?
Acute care hospitals, psychiatric hospitals, home care providers and ambulatory care organizations
The federal Conditions of Participation apply to which type of healthcare organization?
Any organization that treats medicare or Medicare patients.
what is not a traditional health record format?
process-oriented health record
Which health record format is most commonly used by healthcare settings as they transition into electronic records?
hybrid records
What is not an example of a data capture technology?
data dictionaries
The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is
What factors should be considered when designing a data retrieval system for an EHR?
presentation of data, quick-search capabilities, need to know and analytical capabilities
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?
Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) ___________ paper
Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words?
chief complaint
What creates a chronological report of the patient's condition and response to treatment during a hospital stay?
progress notes
What determines who can receive and transcribe verbal orders?
Medical staff bylaws
The name of the government agency that has led the development of basic data sets for health records and compute databases is the
National Committee on Vital and Health Statistics
The primary purpose of a minimum data set in healthcare is to
recommend common data elements to be collected in health records
The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the
Uniform Hospital Discharge Data Set
A National Health Information Network is:
A network of networks
The number that has been proposed for use as a unique patient identification number but is controversial becasue of confidentiality and privacy concerns is the
Social Security number
According to the UHDDS definition, ethnicity should be recorded on a patient record as ______
Hispanic, non-Hispanic, unknown
Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on _______
reason for encounter.
In long term care, the resident's care plan is based on data collected in the ________
MDS Version 2.0
Reimbursement for home health services in dependent of data collection from __________
A consumer interested in comparing the performance of health plans should review data from ____________
I need a standard that allows data to be transferee across the Internet. Which of the following is my choice?
Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for __________
core data elements
A statewide cancer surveillance system is an example of which of the NHII dimensions?
In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?
A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. the most important standards to implement in order to transmit images is ___________
A Core data developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is __________
Continuity of Care Record
Laboratory data is successfully transmitted back and forth from Community Hospital to three local physicians clinics. This successful transmission is dependent on which of the following standards?
As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for ________________
harmonizing of standards from multiple sources
Data that are collected on large populations of individuals and stored in databases are referred to as
aggregate data
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for _____________
performance improvement programs
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of ________
vocabulary standards
The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the _________
Health Insurance Portability and Accountability Act of 1996
Most healthcare informatics standards have been implemented by
A critical early step in designing an EHR is to develop a(n) _______ in which the characteristics for each data element are defined
data dictionary
Which of the following indexes and databases includes patient-identifiable information
Master patient/population index
Which of the following is an external user of data?
Public health department
Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?
What is the information identifying the patient (such as name, health record number, address, and telephone number) called?
Demographic data
Cancer registries receive approval as part of the facility cancer program from the _____ agency
American college of Surgeons
Which national database includes data on all discharge patients regardless of payer?
Healthcare Cost and Utilization Project
Two clerks are abstracting data for a registry. When their work is checked, discrepancies found. Which data quality component s lacking?
What does an audit trail check for?
Unauthorized access to a system
Which law requires the reporting of deaths and severe complications due to devices.
Safe Medical Devices Act of 1990
What is a database from the National Health Care Survey that uses the patient health record as a data source?
National Ambulatory Medical Care Survey
What captains a list maintained in diagnosis code number order of patients discharged from a facility during a particular time period?
Disease index
What contains a list maintained in procedure code number order of patients discharged from a facility during a particular time period?
Operation index
Which of the following is a collection of secondary data related to patients with a specific diagnosis, condition, or procedures?
Disease registry
Case findings is a method used to __________
Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry
In a cancer registry, the accession number _____
is the number assigned to each case as it is entered into a cancer registry
A population-based registry _______
Includes information from more than one facility in a particular geopolitical area, such as a state or region.
What makes up claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities?
The Medicare Provider Analysis and Review file is made up of __________.
Medicare claims from acute care hospitals and skilled nursing facilities.
Vital statistics include data on __________?
Births, deaths, fetal deaths, marriage, an divorces
What database must a healthcare facility query as part of the credentialing process when a physician initially applies for medical staff privileges?
What term would be applied to a comparison of the number of female patients to the number of male patients who were discharged form MS-DRG YYY?
Suppose that there are six males in a class of twenty students. What term could be used to describe the comparison?
What descriptive statistics s calculated by applying this equation (x/y)x10n?
Ratio, Proportion and Rate
In May, 270 women were admitted to the Obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculating the C-section rate?
Suppose that your want to display the number of deaths due to breast cancer for the years 1990 through 1999. What graphic technique would you choose?
Line Graph
Suppose that you want to display the average length of stay by gender and service for the month of August. What graphic technique would you choose?
Bar chart
If you are interested in displaying the parts of a whole in graphic form, what graphic technique would you use?
Pie chart
In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range?
I just realized that we may be misleading administration with the data we provided them. Which of the following might we have done?
Failed to adjust the baseline
I work for AHRQ and have to choose the next project for AHRQ. Which of the following would I choose?
A study to determine how the EHR improves patient safety and quality of care.
What is the mean for the following distribution: 10, 15, 20, 25, 25?
What rate describes the number of new cases of an illness for a specific time period?
Incidence rate
What term is used to describe the number of inpatients present at the census-taking time each day plus the number if inpatients who were both admitted and discharge after the census-taking time the previous day?
Daily inpatient census
Which unit of measure is used to indicate the services received by one impatient in a 24 hour period?
Inpatient service day
Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges
Gross hospital death rate
Suppose a patient who underwent orthopedic surgery acquired Klebsiella pneumonia while hospitalized. How could this illness be described?
as a postoperative infection,
as a hospital -acquired infection,
as a community acquired infection
What term is used to describe the number of calendar days that a patient is hospitalized?
Length of stay
What rage is used to indicate the percentage of the hospital's beds occupied by inpatients for a given time period
Total length of stay, and inpatient bed occupancy rate
Which rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths or the same period of time?
Gross autopsy rate
Suppose that five patients stayed int eh hospital for a total of 27 days. Which term would be used to describe the result of the calculation 27/5?
Average length of stay
The probability of death among diagnosed causes of a specific disease is termed?
case fatality rate
Which of the following data elements are considered protected under the HIPAA Privacy Rule?
Patient telephone number
Patient name
Medical record number
zip code