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A hospital has been the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal test result to the appropriate physician's pager number. What is the medical staff using?

clinical information system

A Chief Privacy Officer is evaluating software programs that will support the hospitals policy on security controls for computer terminals. One of the required items included in the RFP to vendors is ___ ___ __.

time out feature

Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(n) ___ ___.

interfaced system

The function of a(n) ____ ____ _____ is limited to data retrieval.

clinical data repository

A hospital, a 900 bed tertiary health care organization, is undergoing an information systems development. The system that would best meet its need is the ___ ___ ___ ___.

application service provider model

A 16 year old female delivers a stillborn infant at a hospital. The clinical documentation on the stillborn infant would be filed in the ____ record


When implementing the EHR, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?

access control

Of 750 records filed during the week, 75 were not located. What is the filing error rate?

10 percent

A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physicians, the coder is unable to find a code for the procedure. The coder should assign..

an unlisted procedure code located in the eye

A system of preferred terminology for naming disease processes is known as ____ ___.

medical nomenclature

True or False: Principal diagnosis is included in minimum data maintained in the MPI


You are reviewing all patients have a diagnosis of anterolateral myocardial infarction within the past 6 months. What would be the best source to identify necessary charts?

disease index

One of the major functions of the cancer registry is to ensure that the patients receive regular and continued observation and management. How long should patient follow up be continued?

for the life of the patient

DSM-IV-TR is used most frequently in what type of healthcare setting?

behavioral health centers

A coder notes that a patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are CHF and DM. The coder should query the physician about adding a diagnosis of ____.


The patient is diagnosed with CHF. A drug of choice is ____.


The ICD-10-CM utilizes a placeholder character, "__". This is used at a ____ character placeholder at certain 6 character codes to allow for future expansion.

x, 5th

The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct ___ ____ and _____ codes

E codes, ICD-9-CM

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The PE indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

acute pancreatitis

In general, all three key components for the E/M codes in the CPT should be met or exceeded when a ...

new patient is seen

Three key components for E/M codes

history, physical exam and medical decision making

Code first ____ ____.

underlying disease

What classification system was developed to standardize terminology and codes for use in clinical laboratories?



logical observation identifiers names and codes

What classification system is used to classify neoplasms according to site, morphology and behavior?



international classification of diseases for oncology

According to UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a ___ ___.

significant procedure

the "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the ____.


An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) ___ ___ ___.

logic based encoder

An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) ___ ___ ___.

logic based encoder

What classification system was designed with electronic systems in mind and is currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance and imaging?


The UMLS is a project sponsored by the ___ ___ ___.

national library of medicine


unified medical language system

A patient is admitted with SOB and hemoptysis, A Chest X ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospital stay a bronchoscopy with bx was done which revealed a sall cell carcinoma on the left upper lobe of the lung. A metastatic lesion was detected in the brain. The principal diagnosis is the....

small cell lung carcinoma

A patient was admitted to the ambulatory care unit of the hospital for a planned cholecystectomy for cholelithiasis. Before surgery, the patient developed tachycardia and the surgery was canceled. After a workup for tachycardia, the patient was discharged. The outpatient admission should be coded in the following sequence"

cholelithiasis, tachycardia, V code for canceled surgery

A 75 year old female was admitted for repair of a hiatal hernia that was performed on the day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur, which was surgically reduced. Further complications included severe angina for for which a cardiac catheterization and PTCA were performed. The principal procedure is..


Cod 402, Hypertensive Heart Disease, would appropriately be used in which of the following situations?

hypertensive cardiovascular disease with CHF

A patient is admitted to the hospital 6 weeks post MI with severe chest pains, what is the correct diagnosis?

acute MI

Tinnitus due to allergic reaction after administration of eardrops would be coded as a(n)..

adverse effect

acute transplant rejection usually occurs after a period of several ____.


A special immune globulin that can halt erythroblastosis


Receiving vaccination is an example of ____ _____.

artificial imunity

The first muscles affected by myasthenia gravis is the ____ muscles.


A diagnosis of AIDS is made when ____ cell count drops below ____ cells per microliter

T, 200


polymorphonuclear leukocyte

The leading cause of chronic illness in childhood is ____.


RA causes chronic inflammation of _____ ____.

connective tissue

people with rheumatoid arthritis have ____ ____ in their blood.

rheumatoid factor

destruction of RBC's


fever characterized by myocarditis and arthritis


type of transplant rejection that actually occurs during the surgical procedure


treatment that works to prevent infection or disease


blood vessel cancer that causes reddish-purple skin lesions

Kaposi's sarcoma

fusion or total loss of joint function


Common name for urticaria


type of immunity associated with circulating antibodies


another name for polymorphneuclear leukocytes


injection of an increasing amount of allergen over a long period of time


A fracture that has protruded through the skin is a/an ________.

open fracture

Joints that allow limited motion are referred to as ________.


An injury to ligaments inside the knee joint is referred to as a ________.

cruciate ligament tear

A rigid muscle contraction of the jaw muscles


a bone fracture appears to be mashed down, it is a/an _______

compression fracture

A traumatic injury to a joint with partial or complete tearing of ligaments is a ________.


Gout affects primarily ____.


condition caused by a metabolic error in the breakdown of certain protein foods is ________.



temporomandibular joint

Bone that is dense, smooth, and compact is referred to as ________.


The most common primary tumor of bone is _____.


An inflammation of the bone commonly cause by infection is ________.


A torn meniscus occurs in the ___.



herniated nucleus pulposus

A painful condition caused by the protrusion of the soft center of a disc in the spinal column is referred to as ________


a process that causes the characteristic hardness of bones


common incomplete fracture that occurs in children


cyst that usually forms on a tendon sheath near the wrist


overstretching injury of a muscle


partial separation of a joint



bone mass density

a thick fibrous connective tissue



rest, ice, compression, elevation

joints that have no movement


degenerative joint disease


joints that allow complete movement


impaired mineralization of the bone


measurement of bone thickness


joints that allow only limited movement


Spongy bone


deformity affecting the big toe

hallux valgus

The document in front of you includes a microscopic description of tissues excised during surgery. The type of document you are most likely to give this form is _____ _____.

pathology report

Patient data element that is collected in the MDS but not in the UHDDS is ____ ____.

cognitive patterns

In the number "10-001" listed in a tumor registry accession register, what does the prefix "10" represent?

the year the case was entered into the database

A risk manager needs to locate a full report of a patients fall from his bed, she would most likely find this information in the ____ ____.

incident report

For continuity of care, ambulatory care providers are more likely than providers of acute acre services to rely on the documentation found in the _____ ____.

problem list

Joint commission does not approve of auto authentication of entries in a health record because evidence cannot be proven that the----

physician reviewed and approved each report

You have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient form, the best place in the record to locate this information is the _____ _____.

prenatal record

An H&P is acceptable a week before admission as long as the doctor documents any ___ ____.

interval changes

You have been asked to identify every reportable case of cancer from a previous year. A key resource would be the facility's ____ ____.

disease index

Joint Commission requires the attending physician to countersign health record documentation that is entered by _____ or ____ _____.

interns, medical students

The minimum length of time for retaining original medical records is primarily governed by ___ ___.

state law

The use of personal signature stamps requires special measures to guard against delegated use. In a computerized patient record, similar measures might be utilized to govern the use of ____ ___.

electronic signatures

Discharge summary documentation must include...

significant findings during hospitalization

The performance of quality analysis is an important tool in ensuring data quality. These reviews evaluate...

the overall performance of documentation

Ultimate responsibility for the quality and completion of entries in patient health records belong to the ___ ___.

attending physician

The federally mandated resident assessment instrument used in LTC facilities consist of three basic components:

new care assessment, utilization guidelines, MDS

THe foundation for communicating all patient care goals in LTC settings is the _____ ___ __ ___.

interdisciplinary plan of care

In order to keep abreast changes in the workforce development of EHR specialists as outlined by ARRA and HITECH,you will need to regularly access this governmental agency


As part of Joint Commission, acute care hospitals are required to use these three elements before surgery.

identification of patient, confirm necessary documents are available, and mark the surgical site

Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis?


You have been asked to print a list of the medical record numbers of patients who had CABG's performed in the past year. Which secondary data source could be used quickly to gather this information?

operation index

Facilities that are scanning and imaging paper records as part of a computer based system must give careful consideration to ___ ___ ____.

bar code palcement

What is a form or view that is typically seen in the health record of LTC patient but is rarely seen in records of acute care patients?

pharmacy consultation

The health record states that the patient is a female, but the registration record has the patient listed as a male. Which of the following characteristics of data quality has been compromised in this case?

data accuracy

The first patient with cancer seen in your facility on January 1, 2012 was diagnosed with colon cancer with no known history or previous malignancies. The accesnsion number assigned to this patient is


Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data ____.


In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the ____ ____

federal register

In an acute care hospital, a complete H&P may not be dictated for a new admission when ...

a copy of a recent H&P in the attending physicians office is available

What resource would be most helpful in providing standard definitions for data commonly collected in acute care hospitals when completing a data dictionary?



uniform hospital discharge data set

Physicians can access patient information from another facility using ____.


When developing a data collection system, the most effective approach first considers....

the end users needs

A key data item you would find recorded on an ER record but not in an acute care record is the ...

time and means of arrival

A data item to include on a qualitative review checklist of infant and children inpatient health records that is not needed in adult records would be ..

growth and development record

In creating a new form or computer view, the designer should be most driven by...

end users needs

Under what circumstance can an original paper medical record be physically removed from the hospital?

acting in response to a subpoena duces tecum

Using the SOAP style, the patient states low back pain is as severe as it was on admission would be...


In 1987, OBRA helped shift the focus in LTC to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the ___.


You need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the facility's ___ ___.

data dictionary

A Medicare patient was admitted for disc surgery, but the progress notes indicate that due to heart irregularities, he may not be good surgical risk. You expect that a(n) ___ ____ will be added to his health record according to ____ regulations.

consultation report, COP

Physical assessment is an example of an ___ entry in the SOAP notes.


According to ___ and ____, H&P must be completed prior ____ after ___ or prior to ___.

JCAHO, COP, 24 hours, admission, surgery

Consistently entering data into the patients record at the time and location of service instead of waiting for retrospective analysis is called ___ __ ___ ____.

point of care documentation

An example of a primary data source for health care statistics is the ____ ___.

hospital census

During retrospective review of an inpatient's record, the clerk notes that on day 4 of hospitalization there was a missed dose of insulin. What type of review is the clerk performing?

qualitative review

In your facility, it has become critical that information regarding patients who are transferred to oncology unit to be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from the ____ ____.

R-ADT system

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing ____ ___ ___.

integrated progress notes

What service is least likely to be provided by a facility accredited by CARF?

palliative care

When partnering with other organizations, you value the importance of a development to support the exchange of health information across the continuum within a geographical community. You are promoting the organization to join a ____.


When comparing trauma care services to other hospital based ED's, to ensure that your facility is collecting the same data as other facilities, you review elements from what data set?


To obtain information about the qualifications of individuals in your facility who have been authorized to record verbal orders, you will consult the hospital's ___ ___ and ____

bylaws, rules, regulations

computers that share resources such as printers, or hard disk space across a network


the standard microcomputer interface, type of user interface that allows a user to interact with software using text, graphics, and visual images, such as icons.


GUI stands for

Graphical user interface

run in local network


can be run outside of a network



healthcare financing administration

formerly known as CMS


work to ensure health provisions for those receiving medicare, medicaid and childrens health car


works to standardize measures in health information management


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