??? 100 Final Review Questions (I Found On Cram.com)

Front 1

What group is the primary accreditation organization for facilities that treat individuals who have functional disabilities ?

Back 1

Commission on Accreditation of Rehabilitation Facilities

Front 2

Which of the following is a disadvantage of alphabetic filing ?

Back 2

Uneven expansion of file shelves or cabinets

Front 3

Critique this statement, "the PHR and EHR are synonyms for each other".

Back 3

FALSE...the PHR is controlled by the patient, while the EHR is controlled by the care provider

Front 4

In which department or unit does the health record typically begin ?

Back 4

Patient registration

Front 5

Which of the following is not usually a component of acute care patient records ?

Back 5

Problem list

Front 6

When correcting erroneous information in a health record, which of the following is NOT appropriate ?

Back 6

Using a black pen to obliterate the entry

Front 7

A health record with deficiencies that is not completed within the time frame specified in the medical staff rules and regulations is called "what" ?

Back 7

Delinquent

Front 8

Who is responsible for final approval of the AHIMA code of ethics ?

Back 8

the AHIMA Home of Delegates

Front 9

Which of the following actively promotes education and research in health information management ?

Back 9

AHIMA

Front 10

Which organization developed the first hospital standardization program ?

Back 10

American College of Surgeons

Front 11

As many public and private standards groups promulgate health informatics standards, the office of the national coordinator of health information and technology has been given the responsibility for "what"?

Back 11

Building software systems to support EHR development

Front 12

What is the primary goal of integrated health delivery systems ?

Back 12

To insure that patients receive high quality cost effective care in the most appropriate setting.

Front 13

While the focus of inpatient data collection is on the principle diagnosis, the focus of outpatient data collection is "what" ?

Back 13

Reason for the encounter

Front 14

What was the main result of the publication of the Flexner Report ?

Back 14

Medical school standards were established

Front 15

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

Back 15

Personal Health Record (PHR)

Front 16

Members of the AHIMA House of Delegates are.....

Back 16

Elected to members in state component organizations

Front 17

Which of the following filing systems is considered the most efficient ?

Back 17

Terminal Digit

Front 18

Which of the following is an advantage of paper based records ?

Back 18

Standardized familiar format

Front 19

HIM has been recognized as an allied health profession since "when" ?

Back 19

1928

Front 20

The Joint Commission requires that the medical record delinquency rate quarter averaged from the last 4 quarterly measurements is not greater than _____ of the monthly discharge rate.

Back 20

50%

Front 21

I am arguing against the copy/paste function in the EHR...what would be my argument ?

Back 21

I am unable to identify the author

Front 22

Where was the first hospital organnized in the British Colonies of North America ?

Back 22

Philladelphia

Front 23

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

Back 23

The Joint Commission

Front 24

AHIMA strongly opposes using "this" as a patient identifier in an electronic record ?

Back 24

Social Security Number

Front 25

What federal legislation provides funding for the implementation of nationwide health information exchange ?

Back 25

American Recovery and Reinvestment Act of 2009

Front 26

Which of the following accredits accademic programs in health information management ?

Back 26

CAHIIM

Front 27

Which federal legislation enacted the Medicare and Medicaid programs ?

Back 27

Public Law 89 - 97 of 1965

Front 28

Which of the following is an example of data capture technology ?

Back 28

Document imaging

Front 29

A critical early step in designing an EHR is to develp a __________ in which the characteristics of each data element are defined.

Back 29

Data Dictionary

Front 30

What was the primary objective of the original social security act which became law in 1935 ?

Back 30

To provide retirement income for the elderly

Front 31

The individuals right to control access to his or her personal information is known as "what" ?

Back 31

Privacy

Front 32

Which of the following best describes "data accessibility" ?

Back 32

Data are easily attainable

Front 33

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is called a ____________ review ?

Back 33

Concurrent

Front 34

After patient leaves the hospital the review is called "what" ?

Back 34

Retrospective

Front 35

The _______ makes up a virtual network of AHIMA members who communicate via a web based program managed by AHIMA.

Back 35

Communities of Practice

Front 36

Which of the following best describes "data accuracy" ?

Back 36

Data are correct

Front 37

Which of the following best describes "data completeness" ?

Back 37

Data includes all required elements

Front 38

I have been asked to list institutional users of the health record. Which one of the following would I include on my list ?

Back 38

Blue Cross and Blue Shield

Front 39

Which type of patient record includes documentation of a family bereavement period ?

Back 39

Hospice record

Front 40

Which type of health record is designated to measure clinical outcomes, collect data at the point of care, and provide medical alerts ?

Back 40

Electronic record

Front 41

In long term care, the resident's care plan is based on data collected in ___________.

Back 41

MDS Version 2.0

Front 42

Reimbursement for home health services is dependent of data collected from ________.

Back 42

OASIS

Front 43

As many private and pubic standards groups promulgate health imformatics standards, the Office of the National Coordinator of Health Informatiion and Technology has been given responsibility for ___________.

Back 43

Harmonization of standards from multiple sources

Front 44

Which of the following is not ususally a part of a quantitative analysis review ?

Back 44

Checking that every word in the record is spelled correctly

Front 45

In health organizations, what is the database that is used to locate the medical record number usually called ?

Back 45

Master Patient Index

Front 46

What component of the budget would include money for the purchase of an EHR ?

Back 46

Capital Budget

Front 47

Which of the following task would the HIM department not perform in an electronic health record system ?

Back 47

Assembly

Front 48

Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers filed together within the filing system.

37-45-99
38-45-99
36-45-99

Back 48

Terminal Digit

Front 49

Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long roll ?

Back 49

Microfilm Roll

Front 50

Which of the following historical events had the most influence on the U.S. Government's role in financing healthcare delivery ?

Back 50

The Great Depression

Front 51

Which of the following is a secondary purpose of the health record ?

Back 51

Support for research

Front 52

The National Centers for Health Statistics is responsible for updating the diagnosis classifications of ICD-9-CM.
TRUE or FALSE

Back 52

TRUE

Front 53

Volume 3 of ICD-9-CM is part of the international version of ICD-9 and is used only in the United States.
TRUE or FALSE

Back 53

TRUE

Front 54

V-codes and E-codes are referred to as supplementary classifications in ICD-9.
TRUE or FALSE

Back 54

TRUE

Front 55

ICD-10 is used in the United States for morbidity reporting.
TRUE or FALSE

Back 55

TRUE

Front 56

An encoder is a tool that aids coders in assigning diagnostic and procedure codes.
TRUE or FALSE

Back 56

TRUE

Front 57

The 3rd volume of ICD-9-CM contains the tabular and alphabetic listsof diseases.
TRUE or FALSE

Back 57

FALSE

Front 58

The International Classification of Diseases for Oncology 3rd edition is a system used for classifying incidences of benign diseases.
TRUE or FALSE

Back 58

FALSE

Front 59

CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services.
TRUE or FALSE

Back 59

TRUE

Front 60

AHIMA has developed Standards of Ethical Coding.
TRUE or FALSE

Back 60

TRUE

Front 61

To avoid fraudulent behaviors, healthcare providers must develop compliance plans and establish internal controls.
TRUE or FALSE

Back 61

TRUE

Front 62

Providers should base their complinace programs on the compliance programs released by the AMA.
TRUE or FALSE

Back 62

FALSE

Front 63

Designation of a Chief Compliance Officer and a corporate compliance committee charged with the responsibility for operating and monitoring the compliance program and who reports directly to the CEO and the governing body is required for corporate compliance.
TRUE or FALSE

Back 63

TRUE

Front 64

Which of the following should be a violation of a corporate compliance plan ?

Back 64

Coders are given a bonus if the CMI exceeds a specified value.

Front 65

We have a hotline that employees can call to report compliance issues. This is mandated by the...

Back 65

Seven Elements of Corporate Compliance Plan

Front 66

I need to confirm the patient's principle diagnosis for the chart I am coding. How should I do this ?

Back 66

Review documents, such as the discharge summary

Front 67

The degree to which codes accurately reflect the patient's diagnosis and procedure is called "what" ?

Back 67

Validity

Front 68

Standardized vocabulary is needed to ......

Back 68

Facilitate the indexing, storage, and retrieval information in an EHR

Front 69

Which of the following would be an argument for the transition to ICE-10-CM/PCS ?

Back 69

More detail in the code

Front 70

Which of the following would be classified in ICD-9-CM with an "E-code" ?

Back 70

A fall from a curb

Front 71

I work at a substance abuse center. What system should I use to code diagnoses ?

Back 71

DSM-IV-TR

Front 72

WE ALSO NEED TO REMEMBER HOW TO FIND THE:
MEAN
MEDIAN
MODE
RANGE
PERCENTAGE

Back 72

MEAN: Add up all numbers given, and divide by the amount of numbers that were given...the "average"
MEDIAN: Place the numbers from lowest to highest and find the MIDDLE NUMBER, or average the two center numbers if a middle number is unavailable
MODE: Place the numbers from lowest to highest, then find the number(s) that occurs MOST OFTEN
RANGE: Place the numbers from lowest to highest, then subtract the lowest number from the highest number...this will give you your range.
PERCENTAGE: See the notes we took in class for this answer...it is the one where she multiplied by 100 then divided by "something"

Front 73

Which of the following is an example of an ancillary system ?

Back 73

Lab System

Front 74

Discrete data are generally entered into an EHR via....

Back 74

Templates

Front 75

The ability to electronically put tasks into a queue for someone to perform is called "what" ?

Back 75

Work Flow

Front 76

In a Regional Health Information Organization (RHIO), patients would most likely be identified using "what" ?

Back 76

Record Locator Service

Front 77

A special web page that offers secure access to data is called a(n).....

Back 77

Portal

Front 78

To run an analysis on a large set of data from many patients, the best tool is a(n).....

Back 78

Clinical Data Warehouse (CDW)

Front 79

An "interface" is....

Back 79

a program to exchange data

Front 80

Standards from "which organization" would be used for enabling exchange of clinical images ?

Back 80

DICOM

Front 81

Semantics refers to....

Back 81

meaning of a clinical concept

Front 82

Which of the following vocabularies is likely to be used to describe drus in a clinically relevant form ?

Back 82

RxNorm

Front 83

Which of the following is a core ethical obligation of HITs ?

Back 83

Protecting patient's privacy and confidential communications

Front 84

Which of the follwoing terms means "promoting good" ?

Back 84

Beneficence

Front 85

Which of the following terms means "treating others fairly"?

Back 85

Justice

Front 86

Which of the following ethical principles is being followed when an HIT professional ensures that patient information is ONLY released to those who have the leal right to access it ?

Back 86

Beneficence

Front 87

Which of the following priciples is being followed when an HIT professional applies rules fairly to all ?

Back 87

Justice

Front 88

Which of the following ethical principles is being followed when an HIT professional refuses to participate in a fraudulent act ?

Back 88

Nonmaleficence

Front 89

Which of the following activities is considered an unethical practice ?

Back 89

Backdating progress notes

Front 90

Privacy can be defined as ......

Back 90

The right of an individual to be left alone

Front 91

Confidentiality can be defined as .....

Back 91

The limitation of the use and disclosure of private information

Front 92

Which of the following represent(s) examples of the ethical obligations of HIT professionals ?

Back 92

Respecting and following the policies of their employers
Complying with all laws, regulations, and policies that govern the health information system
....and....
Refusing to participate in or conceal unethical practices

Front 93

The Health Insurance Portability and Accountablity Act (HIPAA).....

Back 93

provides a federal floor for healthcare privacy

Front 94

The content of the health record is defined by _______.

Back 94

State licensing rules and laws
Accrediting body standards
....and...
Medical staff bylaws

Front 95

What are the sources of law ?

Back 95

Statutes and constitutions
Judicial decisions
....and....
Administrative laws

Front 96

Which type of law defines the rights and duties among people and private businesses ?

Back 96

Private Law

Front 97

Law enacted by leislative body is a _________.

Back 97

Statute

Front 98

Which document directs an individual to bring originals or copies of records to court ?

Back 98

Subpoena duces tecum

Front 99

The physical health record is usually considered the property of ____________.

Back 99

The organization or provider that maintains and stores the record

Front 100

Under the HIPAA privacy rule, covered entities refers to
____________.

Back 100

Healthcare providers
Healthcare clearinghouses
....and...
Healthplans

Front 101

Under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________.

Back 101

30 days

Front 102

In which of the following instances can PHI (Personal Health Information) be used without patient authorization ?

Back 102

Release to an insurance company for payment
Release to another healthcare provider for treatment
.....and....
Release to public health authorities as required by law

Front 103

Which of the following provides a complete description to patients about how PHI (personal health information) is used in a healthcare facility ?

Back 103

Notice of Privacy Practices

Front 104

The form and content of the health record are determined by __________?

Back 104

Accreditation standards and public health reporting requirements

The needs of individual healthcare organizations

....and....

State and Federal laws and regulatory requirements

Front 105

When a healthcare provider purposely commits a wrongful act that results in injury to a patient, the provider can be held responsible for an intentional tort.
TRUE or FALSE

Back 105

TRUE

Front 106

The Joint Commission sets the official record retention standards for hospitals and other healthcare facilities.
TRUE or FALSE

Back 106

FALSE

the retention standards are set by the state

Front 107

Stricter state statutes related to the confidentiality of healthcare information takes precedence over the provisions of the HIPAA privacy rule.
TRUE or FALSE

Back 107

TRUE

Front 108

Which of the following spells out the powers of the three branches of the federal government?

Back 108

United States Constitution

Front 109

AHIMA's record retention guidelines recommended that the master patient index be maintained __________.

Back 109

Permanently

Front 110

Which of the following parties are considered covered entities under the HIPAA privacy rule ?

Back 110

Physicians
Hospitals
.....and....
Pharmacies