Ch 7 - Computers In H I T

Front 1

The information system that assigns an ICD-10-CM code is called a(n):

Back 1

encoder

Front 2

Which is more likely to be round in a birth certificate system designed by a vendor than the state?

Back 2

productivity

Front 3

Which product would identify that Dr. Smith needs to sign a discharge summary?

Back 3

chart deficiency

Front 4

Which system would be used primarily by physicians, rather than HIM Department staff?

Back 4

dictation system

Front 5

A request for an accounting of disclosure has been received. I should access which of the following to fulfill this request?

Back 5

disclosure management system

Front 6

Letter notifying the individual that authorization was invalid would be part of _____.

Back 6

information system

Front 7

Tumor registry tracks _____.

Back 7

follow up rates

Front 8

This system could have voice recognition as a feature.

Back 8

dictation system

Front 9

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?

Back 9

data quality indicator

Front 10

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?

Back 10

birth certificate

Front 11

The data element principal diagnosis is found in:

Back 11

encoder/grouper

Front 12

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?

Back 12

chart locator

Front 13

Where would you find a field entitled document type?

Back 13

transcription system

Front 14

As a general rule, which system would be utilized by departments other than HIM?

Back 14

MPI

Front 15

The _____ system's letters communicates with the _____.

Back 15

release of information, requester

Front 16

Encoders assign the code for both _____ and _____.

Back 16

diagnosis, procedures

Front 17

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?

Back 17

requester table

Front 18

Release of information software can _____ and _____.

Back 18

generate reports, track status of requests

Front 19

Reports designed specifically for one time use is called what type of report?

Back 19

ad hoc

Front 20

You can check the social security death index with ______ software.

Back 20

cancer registry

Front 21

What Joint Commission mandate does the chart location system assist with compliance?

Back 21

accessibility

Front 22

Patient follow-up is a key part of what HIM system?

Back 22

cancer registry software

Front 23

Management may use chart locator to generate _____.

Back 23

productivity reports

Front 24

True or false.

A registry tracks multiple diseases and conditions rather than specialize.

Back 24

false

Front 25

The dictation system has implications for _____ and _____.

Back 25

physicians, HIM staff

Front 26

The transcription system should collect the _____.

Back 26

date of transcription

Front 27

True or false.

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

Back 27

false

Front 28

True or false. Data quality indicator systems collect voice from the dictation system to capture data.

Back 28

false

Front 29

This system is designed to manage all aspects of requests for PHI received and processed by the HIM department.

Back 29

release of information

Front 30

ROI system is used to _______ request into system, _____ requests, act as ______ and generate _____.

Back 30

enter, track, historical database, reports.

Front 31

This system tracks the disclosures made throughout the health care organization.

Back 31

disclosure management

Front 32

Covered entities must provide patient with _____ upon request.

Back 32

accounting of disclosure

Front 33

Disclosure management system tracks _______ as well as ______ and ________.

Back 33

disclosures, requests for amendments to PHI, restrictions to disclosures

Front 34

ROI can be used to check on status of _____ and _____.

Back 34

requests, who was assigned request

Front 35

The ROI is considered complete when record is

Back 35

copied, printed

Front 36

What are common ROI reports?

Back 36

requests processed or not processed, turnaround time, revenue collected, productivity

Front 37

If a supervisor receives a complaint from a requester regarding the inability to obtain copies of records, the first place to start would be

Back 37

ROI system

Front 38

ROI system is used in HIPAA compliance because it provides

Back 38

accounting of disclosure

Front 39

HIPAA requires accounting of disclosure information be available to patient for

Back 39

3 years

Front 40

These are an important part of the ROI system.

Back 40

tables

Front 41

ROI tables can be used to _____ and _______ that may be released.

Back 41

record charge information, identify all individual or groups of forms

Front 42

Tables help

Back 42

save time

Front 43

ROI system uses _____ to _____.

Back 43

customized letters, communicate with requester

Front 44

This is used by coders to select the appropriate code for the diagnoses and procedures supported by medical record.

Back 44

encoder

Front 45

These types of coders require the user to type in the name or portion of the name of the diagnosis or procedure.

Back 45

rules based

Front 46

These types of coders generate a list of suggestions from which the coder selects.

Back 46

rules based

Front 47

This type of coder looks like a traditional index.

Back 47

automated codebook

Front 48

This assigns codes entered into the encoder into the appropriate MS-DRGs or other DRGs.

Back 48

grouper

Front 49

not ensured by the use of an encoder

Back 49

coding quality, DRG assignment

Front 50

The biggest advantage of the encoder/grouper is the use of

Back 50

prompts

Front 51

Assigned codes through the encoder must be validated through

Back 51

medicare code editor, NCCI

Front 52

Medicare editor, and NCCI edits look for _____, _____, _____, and _____ codes.

Back 52

invalid, illogical, nonspecific

Front 53

The encoder/grouper is usually linked to the hospital's _____ for _____.

Back 53

financial system, billing purposes

Front 54

system should I use to provide an accounting of disclosure

Back 54

release of information

Front 55

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?

Back 55

chart deficiency system

Front 56

a computerized system to help assign the proper code

Back 56

encoder

Front 57

The system used to notify requesters of invalid authorization

Back 57

release of information

Front 58

The software application that assigns MS DRG

Back 58

grouper

Front 59

All registries are designed to record data on patients who

Back 59

meet criteria for inclusion

Front 60

Registries generally require

Back 60

demographic information, reporting, treatment, description of condition, long term patient tracking

Front 61

This tracks information about the patient's cancer from time of diagnosis to the patient's death.

Back 61

cancer registry

Front 62

The cancer registry system can provide _____ reports and reports on ______.

Back 62

management, content of registry

Front 63

Life expectancy, follow up rate, patient abstracts, accounting of disclosures are common reports of _____.

Back 63

cancer registry system

Front 64

These types of reports are important part of registries.

Back 64

ad hoc

Front 65

This tracks patients with traumatic injuries from initial trauma treatment to death.

Back 65

trauma registry

Front 66

For trauma registries, the software package must meet or exceed reporting of

Back 66

minimum data set

Front 67

Data from trauma registry are reported to

Back 67

state

Front 68

The trauma registry system track care provided to patient ____, ___ and ______ hospital care.

Back 68

before, during, after

Front 69

Data abstracted by the trauma registry system can be abstracted and used to calculate

Back 69

injury severity scores, revised trauma scores, and probability of survival

Front 70

This scoring system is used for patients who have multiple trauma to indicate the severity of injury to anatomical locations.

Back 70

injury severity

Front 71

This scoring system considered to be a physiological scoring system that predicts the probability of death through blood pressure and respiratory rate.

Back 71

revised trauma

Front 72

This system is designed to track the paper medical record.

Back 72

chart locator

Front 73

The purpose of the chart locator is to provide the ability to _____ of ______ from _____.

Back 73

change location, patient record, location to another

Front 74

The chart locator system identifies

Back 74

where the record is, when the record is due, when a record is overdue, who checked out the record

Front 75

The entry of records into the system is frequently supported by

Back 75

barcodes

Front 76

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.

Back 76

barcodes

Front 77

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

Back 77

alert

Front 78

Which type of registry tracks patients who have been injured?

Back 78

trauma

Front 79

Which system tracks the paper medical record?

Back 79

chart locator

Front 80

Barcodes are key to the efficiency of what type of system?

Back 80

chart locator

Front 81

Life expectancy is information that would come from the

Back 81

cancer registry software

Front 82

Birth certificate data are entered into state approved

Back 82

birth certificate information system

Front 83

Birth certificate information system reports births to the

Back 83

state health agency

Front 84

Birth certificate software may be developed by ____ or ____.

Back 84

state, vendor

Front 85

Birth certificate software collect data mandated by _____.

Back 85

NCHS

Front 86

Some birth certificate software have incorporated the preparation of

Back 86

fetal death reports

Front 87

The state may use the birth certificate data to

Back 87

feed other databases

Front 88

_____ is critical to the chart deficiency system.

Back 88

data quality

Front 89

To improve data quality, _____ of the records should be conducted to ensure that records are still _____ and available to the _____.

Back 89

routine audits, incomplete, physician

Front 90

This is used to record and rectify deficiencies in the chart.

Back 90

chart deficiency

Front 91

This system identifies the incomplete records by physician so the physician can be notified for completion.

Back 91

chart deficiency

Front 92

Documentation omission is recorded and tracked in

Back 92

chart deficiency system

Front 93

Management staff use the chart deficiency system to _____ for _____.

Back 93

age the deficiencies, Joint Commission tracking

Front 94

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.

Back 94

Chart deficiency system

Front 95

Chart deficiency has

Back 95

customizable letters

Front 96

This system is used to type the various documents dictated by the physicians.

Back 96

transcription

Front 97

Transcription systems typically has ______ for each report type.

Back 97

user defined templates

Front 98

These allow transcriptionists to type an acronym and have the full phrase be automatically spelled out.

Back 98

expanders

Front 99

Expanders are otherwise known as _____.

Back 99

macros

Front 100

Transcription system is used by management to

Back 100

track productivity, incentive pay, monitor volume

Front 101

This is an abstracting system that records information about the patient and the care provided to the patient.

Back 101

data quality indicator

Front 102

two critical aspects of the quality indicator systems.

Back 102

abstracting, reporting

Front 103

Information abstracted by the data quality indicator can be used to make changed in _____.

Back 103

how care is provided

Front 104

This is used by physicians to dictate various medical reports.

Back 104

dictation system

Front 105

Which system would tell a physician that she needs to sign an operation report?

Back 105

chart deficiency

Front 106

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?

Back 106

dictation

Front 107

I am entering the number of units of blood that a patient received during the recent hospitalization. I must be using the _____.

Back 107

quality indicator monitoring

Front 108

I am entering the Apgar score. I must be using the _____.

Back 108

birth certificate software

Front 109

I type out the abbreviation EGD and the term for it is spelled ou. I am using _____.

Back 109

expander