• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

Card Range To Study



Play button


Play button




Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

109 Cards in this Set

  • Front
  • Back
The information system that assigns an ICD-10-CM code is called a(n):
Which is more likely to be round in a birth certificate system designed by a vendor than the state?
Which product would identify that Dr. Smith needs to sign a discharge summary?
chart deficiency
Which system would be used primarily by physicians, rather than HIM Department staff?
dictation system
A request for an accounting of disclosure has been received. I should access which of the following to fulfill this request?
disclosure management system
Letter notifying the individual that authorization was invalid would be part of _____.
information system
Tumor registry tracks _____.
follow up rates
This system could have voice recognition as a feature.
dictation system
I am entering the number of units of blood given to a patient during surgery, the presence or absence of a nosocomial infection and other information for the patient's chart. I must be using which system?
data quality indicator
I am entering the newborn's APGARs, the weight of the baby, request for social security number, name of parents, and other information. What system am I using?
birth certificate
The data element principal diagnosis is found in:
Based on the functionality of the systems, which of the following systems would you expect to become obsolete in the short term with the EHR?
chart locator
Where would you find a field entitled document type?
transcription system
As a general rule, which system would be utilized by departments other than HIM?
The _____ system's letters communicates with the _____.
release of information, requester
Encoders assign the code for both _____ and _____.
diagnosis, procedures
I need to enter Macon General Hospital as one of the requesters of health information. What would I use to enter the name of the facility, address and other information?
requester table
Release of information software can _____ and _____.
generate reports, track status of requests
Reports designed specifically for one time use is called what type of report?
ad hoc
You can check the social security death index with ______ software.
cancer registry
What Joint Commission mandate does the chart location system assist with compliance?
Patient follow-up is a key part of what HIM system?
cancer registry software
Management may use chart locator to generate _____.
productivity reports
True or false.

A registry tracks multiple diseases and conditions rather than specialize.

The dictation system has implications for _____ and _____.
physicians, HIM staff
The transcription system should collect the _____.
date of transcription
True or false.

The grouper should only be able to utilize the current Medicare grouper.

True or false. Data quality indicator systems collect voice from the dictation system to capture data.
This system is designed to manage all aspects of requests for PHI received and processed by the HIM department.
release of information
ROI system is used to _______ request into system, _____ requests, act as ______ and generate _____.
enter, track, historical database, reports.
This system tracks the disclosures made throughout the health care organization.
disclosure management
Covered entities must provide patient with _____ upon request.
accounting of disclosure
Disclosure management system tracks _______ as well as ______ and ________.
disclosures, requests for amendments to PHI, restrictions to disclosures
ROI can be used to check on status of _____ and _____.
requests, who was assigned request
The ROI is considered complete when record is
copied, printed
What are common ROI reports?
requests processed or not processed, turnaround time, revenue collected, productivity
If a supervisor receives a complaint from a requester regarding the inability to obtain copies of records, the first place to start would be
ROI system
ROI system is used in HIPAA compliance because it provides
accounting of disclosure
HIPAA requires accounting of disclosure information be available to patient for
3 years
These are an important part of the ROI system.
ROI tables can be used to _____ and _______ that may be released.
record charge information, identify all individual or groups of forms
Tables help
save time
ROI system uses _____ to _____.
customized letters, communicate with requester
This is used by coders to select the appropriate code for the diagnoses and procedures supported by medical record.
These types of coders require the user to type in the name or portion of the name of the diagnosis or procedure.
rules based
These types of coders generate a list of suggestions from which the coder selects.
rules based
This type of coder looks like a traditional index.
automated codebook
This assigns codes entered into the encoder into the appropriate MS-DRGs or other DRGs.
not ensured by the use of an encoder
coding quality, DRG assignment
The biggest advantage of the encoder/grouper is the use of
Assigned codes through the encoder must be validated through
medicare code editor, NCCI
Medicare editor, and NCCI edits look for _____, _____, _____, and _____ codes.
invalid, illogical, nonspecific
The encoder/grouper is usually linked to the hospital's _____ for _____.
financial system, billing purposes
system should I use to provide an accounting of disclosure
release of information
I have been hired to design and implement the HIM for a new hospital under construction. One of my tasks is to select systems that traditionally are used solely by the HIM department. Which system would I purchase?
chart deficiency system
a computerized system to help assign the proper code
The system used to notify requesters of invalid authorization
release of information
The software application that assigns MS DRG
All registries are designed to record data on patients who
meet criteria for inclusion
Registries generally require
demographic information, reporting, treatment, description of condition, long term patient tracking
This tracks information about the patient's cancer from time of diagnosis to the patient's death.
cancer registry
The cancer registry system can provide _____ reports and reports on ______.
management, content of registry
Life expectancy, follow up rate, patient abstracts, accounting of disclosures are common reports of _____.
cancer registry system
These types of reports are important part of registries.
ad hoc
This tracks patients with traumatic injuries from initial trauma treatment to death.
trauma registry
For trauma registries, the software package must meet or exceed reporting of
minimum data set
Data from trauma registry are reported to
The trauma registry system track care provided to patient ____, ___ and ______ hospital care.
before, during, after
Data abstracted by the trauma registry system can be abstracted and used to calculate
injury severity scores, revised trauma scores, and probability of survival
This scoring system is used for patients who have multiple trauma to indicate the severity of injury to anatomical locations.
injury severity
This scoring system considered to be a physiological scoring system that predicts the probability of death through blood pressure and respiratory rate.
revised trauma
This system is designed to track the paper medical record.
chart locator
The purpose of the chart locator is to provide the ability to _____ of ______ from _____.
change location, patient record, location to another
The chart locator system identifies
where the record is, when the record is due, when a record is overdue, who checked out the record
The entry of records into the system is frequently supported by
These speed the data entry process and improve the quality of the data entered thus improving efficiency and effectiveness of checking in and out records.
The term used to describe messages that let the user know there is a problem when abstracting a cancer patient into the cancer registry is called
Which type of registry tracks patients who have been injured?
Which system tracks the paper medical record?
chart locator
Barcodes are key to the efficiency of what type of system?
chart locator
Life expectancy is information that would come from the
cancer registry software
Birth certificate data are entered into state approved
birth certificate information system
Birth certificate information system reports births to the
state health agency
Birth certificate software may be developed by ____ or ____.
state, vendor
Birth certificate software collect data mandated by _____.
Some birth certificate software have incorporated the preparation of
fetal death reports
The state may use the birth certificate data to
feed other databases
_____ is critical to the chart deficiency system.
data quality
To improve data quality, _____ of the records should be conducted to ensure that records are still _____ and available to the _____.
routine audits, incomplete, physician
This is used to record and rectify deficiencies in the chart.
chart deficiency
This system identifies the incomplete records by physician so the physician can be notified for completion.
chart deficiency
Documentation omission is recorded and tracked in
chart deficiency system
Management staff use the chart deficiency system to _____ for _____.
age the deficiencies, Joint Commission tracking
can generate reports of suspended physicians, for delinquent records, to monitor the volume of deficiencies, by physician and service, and for auditing quality of data.
Chart deficiency system
Chart deficiency has
customizable letters
This system is used to type the various documents dictated by the physicians.
Transcription systems typically has ______ for each report type.
user defined templates
These allow transcriptionists to type an acronym and have the full phrase be automatically spelled out.
Expanders are otherwise known as _____.
Transcription system is used by management to
track productivity, incentive pay, monitor volume
This is an abstracting system that records information about the patient and the care provided to the patient.
data quality indicator
two critical aspects of the quality indicator systems.
abstracting, reporting
Information abstracted by the data quality indicator can be used to make changed in _____.
how care is provided
This is used by physicians to dictate various medical reports.
dictation system
Which system would tell a physician that she needs to sign an operation report?
chart deficiency
A physician speaks into a phone and gives a summary of the patient's care, which is later transcribed. What type of system is the physician using?
I am entering the number of units of blood that a patient received during the recent hospitalization. I must be using the _____.
quality indicator monitoring
I am entering the Apgar score. I must be using the _____.
birth certificate software
I type out the abbreviation EGD and the term for it is spelled ou. I am using _____.