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281 Cards in this Set
- Front
- Back
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If a malignant lesion of 1.5 cm is excised with 0.5 cm margins, the total lesion size would be _____ |
2.5 cm |
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Terms listed in parenthesis after a main term in ICD-10 are called _____ |
Non-essential modifiers |
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The first character of an ICD-10-CM code is a _____ |
Letter |
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With the manifestation of chronic kidney disease, the underlying disease that can be assumed to have a cause-and-effect relationship (without being documented as related) is _____ |
Hypertension |
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In ICD-10-CM, which of the notes indicates "not coded here"? |
Excludes 1 |
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The definition of "principal diagnosis" according to UHDDS is: |
The condition established after study that is chiefly responsible for admission of the patient to the hospital |
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A surgical wound infection acquired in the hospital is an example of a/n _____ |
Nosocomial infection |
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Impairment that involves some difficulty speaking or understanding words is known as _____ |
Dysphasia |
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The abbreviation PIP stands for _____ |
Proximal interphalangeal (joint) |
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The suffix -megaly means enlargement. Which word means enlargement of the liver? |
Hepatomegaly |
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This uses ultra high frequency sound waves to produce the audible sound of blood flowing through an artery: |
Doppler ultrasonography |
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Which test could provide information to determine the extent of coronary artery narrowing? - Cardiac catheterization - Lipid profile - Electrocardiogram - Electrophysiologic study |
Cardiac catheterization |
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A severe systemic allergic reaction that can be life threatening: |
Anaphylaxis |
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Coughing up blood-tinged sputum is known as: |
Hemoptysis |
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Vomiting up blood is known as: |
Hematemesis |
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AKA or BKA are abbreviations for what type of surgery? |
Amputation |
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Telescoping of the intestine is known as: |
Intussusception |
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Which of the following tasks would the HIM department NOT perform in an electronic health record system? - Analysis - Document imaging - Assembly - Indexing |
Assembly |
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HIPAA requires that policies and procedures be maintained for a minimum of _____ |
Six years from date of creation or date when last in effect |
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Data security policies and procedures should be reviewed at least _____ |
Annually |
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For newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a _____ may be substituted for the discharge summary. |
Progress note |
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The Outcomes and Assessment Information Set (OASIS) includes a set of core data items collected on _____ |
Adult home health care patients |
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The stakeholders of the health information exchange includes _____ |
A wide variety of entities interested in patient information |
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Computer software programs that assist in the assignment of codes used with diagnostic and procedural classification are called ______ |
Encoders |
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Which of the following best describes data accuracy? - Data elements are correct - Data are easy to obtain - Data are reliable - Data include all required elements |
Data elements are correct |
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The data set collected to evaluate facility performance in designated core measures areas in order to achieve accreditation is: |
ORYX |
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Which of the following is an example of an advance directive? - A living will - An authorization to release information - A treatment consent - A patient's right acknowledgement |
A living will |
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The primary purpose of a minimum data set in healthcare is to: |
Recommend common data elements to be collected in health records |
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A laboratory employee forgot his user ID badge at home and uses another lab employee's badge to access the computer system. What controls should have been in place to minimize this security breach? |
Workforce security awareness training |
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According to an FBI study, most security breaches occur from _____ |
employees |
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Name one aspect of managed care that has had the greatest impact on healthcare organizations during the past twenty-five years. |
Cost control |
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Dr. Rogers is sitting in his home office and reviewing digital images from a patient's MRI. He must be using a(n) _____ |
Picture archival communication systems (PACS) |
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Within the context of data security, protecting data privacy basically means defending or safeguarding _____ |
Access to information |
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Consider the following: A 50-year-old female was admitted to the hospital for a below-the-knee amputation on the right leg. When the patient awoke from anesthesia, it was discovered that the operation was performed on the left leg. This occurrence would be subject to _____ under the Joint Commission's Sentinel Event Policy. |
Review |
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According to the Joint Commission standards, the operative report must contain all of the following except: - Specimens removed - Type of anesthesia - Name of the assistant - Findings |
Type of anesthesia |
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The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is _____ review. |
Retrospective |
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Where would you find the physician's instructions to other parties involved in patient care? |
Physician orders |
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Barb was discharged from the hospital today. Prior to leaving, the doctor told Barb to stop her antibiotics after three days. Which drug should Barb stop? - Tamiflu - Sporanox - Acyclovir - Azithromycin - Lamisil |
Azithromycin |
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A type of service provided by a physician when his or her advice is requested by another physician is known as a/n: |
Consultation |
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Which modifier is appended to a procedure code if a bilateral breast procedure is completed? |
Modifier -50 (all breast procedures are listed as unilateral procedures in the CPT code book) |
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In ICD-10-CM, how many codes are needed to correctly identify a pressure ulcer and the stage of that ulcer? |
One (1) |
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If a patient has three traumatic wounds repaired and they are all in the same anatomical grouping int eh parent code number and of the same repair type, how many CPT code numbers are assigned? |
One (1) |
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For coding purposes, the healing time for an acute myocardial infarction is defined in ICD-10-CM as: |
4 weeks |
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Which modifier is appended to E&M code numbers to indicate that the service provided is a significant, separately identifiable E&M service by the same physician on the same day of the performance of a procedure or other service? |
Modifier -25 |
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A graft transferred from one part of the patient's body to another part: |
Autograft |
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A tissue graft from a donor of the same species as the recipient but not genetically identical: |
Allograft |
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A tissue graft or organ transplant from a donor of a different species from the recipient: |
Xenograft |
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Intentional deception or misrepresentation that could result in some unauthorized benefit to himself or herself or some other person is the definition of: |
Fraud |
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This punctuation mark indicates to the coder that two codes are required to completely code the condition(s) and the one it encloses is listed second: |
Slanted brackets |
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Which type of E&M service consists of an annual physical exam, annual gynecological exam, employment physical, or well-baby visit? |
Preventive medicine |
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The removal of devitalized tissue by a physician using a scalpel, scissors, or other sharp instrument is the definition of: |
Surgical debridement |
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What is another term for Type I diabetes mellitus? |
Juvenile diabetes |
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Which of the following is not one of the principal components of communication? - Initiation - Feedback - Argument - Transmission |
Argument |
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Given the following standards, calculate the number of full time equivalents (FTEs): - One FTE = 40 hours/week - Work standard: 30 minutes per chart processing - Volume per day: 40 charts needing processing |
2.5 FTEs |
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A team composed primarily of rank-and-file employees may legally engage in |
Pursuit of work-simplification or methods improvements projects |
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The usual style of leadership among professional practitioners is: |
Laissez-faire |
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A health information manager choose off-site commercial storage for hard copy records and eliminates the space and staffing associated with in-house storage. This is an example of root decision making. |
True |
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The function of the manager which involves the design of a pattern of roles and relationships is: |
Organizing |
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The training method in which an employee is given job assignments in a variety of work assignments in a planned sequence: |
Job rotation appraoch |
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The budget category which cannot be cut or reduced is: |
Computer software licensing agreements |
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The 'ad hoc' committee is created for the express purpose of: |
Dealing with one issue and disbanding when that issue is resolved |
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In reviewing budget variances for the current budget year, a manager would give special attention to a line item that is over budget for the review period as well as overbudget for the year: |
True |
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In order to identify cause and effect relationships in a work flow, a manager would usually develop a: |
Ishikawa diagram |
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In order to identify trends in a work flow, a manager would usually develop a _____ |
Run Chart |
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It is essential for every health care organization to have work rules and personnel policies because: - These are required by various government agencies and other regulatory bodies - Without them, employees would be going their own way and doing as they wish - They are needed to guide employee behavior and provide the basis for consistent treatment of employees - Without their guidance, department managers will ignore many troublesome situations |
They are needed to guide employee behavior and provide the basis for consistent treatment of employees |
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According to straightforward interpretation of most organizations' codes of conduct, which of the following does not constitute an ethical violation: - Taking orders for one's home-based food container business at the office during the work day - Photocopying a recipe booklet on the office copier - Using one's own cell phone to place personal calls at one's work station during lunch hour - Selling one's children's fund-raising candy bars at work |
Using one's own cell phone to place personal calls at one's work station during lunch hour |
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Which of the following is an impersonal source of a manager's authority? - Functional authority - Official position - Law of the situation - Talent and traits of the manager |
Official position - This is another name for formal authority and is granted to one individual by the corporate executive and may have nothing to do with the skill of that individual |
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The following wording is associated with which type of plan: To process discharge summaries within eight hours of receipt of dictated report. |
Functional objective |
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In order to depict the chronological flow of work, a manager would usually develop a _____ |
Flow chart |
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A hospital's reimbursement for MS-DREG 283 in 2009 is found by _____ |
Multiplying the hospital's 2009 hospital base rate times the 2009 relative weight for MS-DRG |
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If the relative weight of MS-DRG 15 is 1.5000, it means that the average cost of patients in MS-DRG 15 is: |
1 1/2 that of the average Medicare patient |
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In Inpatient Rehab Facility PPS, once the Casemix Group (CMS) assignment is made, the payment rate is determined by: |
What tier any CCs are assigned to |
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DRGs 981-989 are assigned by the grouper when: |
The principal procedure is done for a diagnosis other than the principal diagnosis |
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A term used to describe an MS-DRG in which the cost is extremely high compared to the average costs for cases in the same MS-DRG. There is a provision for additional payment in these case. |
Outlier |
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Which of the following is NOT one of the three data elements generally needed to determine the Casemix Group in Inpatient Rehab Facility PPS? - Age - RIC - Comorbidity - FIM |
Comorbidity |
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A service that is an exception to the Hospital Outpatient Prospective Payment System. Certain expensive drugs, pharmaceuticals, and medical devices are paid separately rather than being included in the APC system. The term for these is: |
Pass-throughs |
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In the Inpatient Rehabilitation Facility, the scale used for assessing a patient's functional status on the Patient Assessment Instrument is the: |
FIM (functional independence measure) |
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When a patient is transferred from one IPPS acute facility to another acute care IPPS hospital facility, the transferring hospital gets reimbursed _____ |
A portion of the DRG payment based on how many days the patient was there |
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A patient was admitted for cholecystectomy and subsequently developed a postoperative wound dehiscence. According to the definition of terms associatead with the prospective payment system, the wound dehiscence would be considered a/n: |
Complication |
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In which of the following PPS systems is payment based on a per diem basis rather than one payment for the entire stay or treatment period? |
Skilled nursing facilities |
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The official DRG determination for reimbursement is made by the: |
fiscal intermediary |
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An obviously pregnant woman has applied for a job as a secretary with your company. Her qualifications are equivalent to a male applicant. What discrimination might you be accused of in hiring making a hiring decision? |
Sexual discrimination |
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The most common form of health care fraud and abuse is found in which of the following? |
Claims and billing practices |
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The agency of Health and Human Services that investigates and prosecutes fraud and abuse in the Medicare system is: |
Office of Inspector General |
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The most common form of health care fraud and abuse is found in _____ |
Claims and billing practices |
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Which institutional document details the data that will be retained, the retention period, and manner in which data will be stored? |
Record retention schedule |
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What is a financial settlement or arrangement that specifies rules of conduct to be followed to remedy any fraud and abuse plus any monitoring and reporting requirements? |
Corporate Integrity Agreement |
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Which of the following statements is true concerning the release of patient's information health information? - It requires an authorization by the patient - It permits removal of original records from the provider's control - It may be denied by the provider for any reason - It is enforceable past the expiration date |
It requires an authorization by the patient |
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What statement below is the most concerning the method of disclosure of patient information? - By mail with verification of receipt - By electronic transmission via encryption - By portable media such as CD, DVD, portable hard drive - By any method consistent with professional guidelines and institutional practices |
By any method consistent with professional guidelines and institutional practices |
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The process of providing work, engaging services or labor, and paying for the work performed is the definition of: |
Employment |
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Under the HIPAA Privacy Rule, if a covered entity refuses a patient's request to amend her health record, the patient has the right to: |
Add a statement of disagreement to her health record |
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A court command to appear and/or present documents and other things is the definition of: |
A subpoena |
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Implied consent may be used to treat a child in which one of the following instances? - Sutures are needed following a sporting event - The application of a band-aid by the school nurse for a scrape received on the playground - The surgical intervention for a ruptured spleen in the absence of available family members - The refusal of mother to allow a blood transfusion following an accident |
The surgical intervention for a ruptured spleen in the absence of available family members |
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Who owns the medical record? |
The owner of the medium where the information is stored |
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All of the following statements are true regarding the health record involved in litigation except: - Cannot be used as the basis of establishing physical disability - Serves as the backbone of every professional liability action - Used to establish cause of death - Supports an insanity defense |
Cannot be used as the basis of establishing physical disability |
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Which is true regarding a code of ethics? - Require a professional to place the profession's value above his own - Guides the professional to place her interests as subordinate to those of the client - Prohibits the professional from exercising her own morals or values in the conduct of her practice - Prevents malpractice suits from being brought |
Guides the professional to place her interests as subordinate to those of the client |
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Uses of a health record include all of the following except: - Supporting direct patient care - Credentialing of physicians - Establishing applicable standards of care - Providing proof of employment |
Providing proof of employment |
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What is an approved method to challenge the validity of a subpoena duces tecum called? |
Motion to quash |
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Usually involves a qui tam action: |
False Claims Act |
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When is the right to privacy limited? |
When the patient's right to privacy interferes in some way with the public good |
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When the HIM manager releases information, all of the statements below are true concerning the certification process except: - determines that all legal requirements are met for disclosure of the record - Verifies that the copy is an exact duplicate of the original - Includes a redisclosure statement especially for drug, alcohol, and HIV/AIDs cases - Signs the written certification letter - Keeps the copies of the medical information and sends the original records to the requestor |
Keeps the copies of the medical information and sends the original records to the requestor |
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The minimum necessary standard refers to the health care provider's effort to do what? |
Limit patient-specific health information released to only what is needed to accomplish the intended purpose |
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According to HIPAA, who has the right of access tot he patient's information? |
The patient |
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What were Good Samaritan laws enacted to do? |
Protect physicians and other rescuers who render appropriate emergency care |
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What is a Stark Violation? |
When a provider refers a patient to a facility in which he holds a financial interest |
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Which of the following is true about disclosure of health information regarding substance abuse? - It must be disclosed upon receipt of a discovery request - The disclosure may only be permitted with specific patient authorization - All requests should be refused for release under any circumstances - The information can only be obtained with a court order |
The disclosure may only be permitted with specific patient authorization |
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Which of the following are types of security issues that affect EHRs? - Politics - Personnel - Accreditation - Air quality requirements |
Personnel |
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When does health information become confidential? |
When it is made available by the patient to the health care provider |
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Which one of the following examples is NOT an example of an emancipated minor? - a 16-year-old who is married - a 17-year-old who entered the military - a 16-year-old with a 4-month-old child - a 17-year-old still living at home |
a 17-year-old still living at home |
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A security officer's responsibility are accomplished by which of the following? - Implementation of HIPAA security directives - Performi ng risk assessments - Improving IT security with vendors and consultants - All of the above |
- All of the above |
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What does E-SIGN refer to? |
Electronic Signatures in Global and National Commerce Act of 2001 |
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The legal definition of a health record relies on what criteria? |
A business record generated by the health care provider |
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Under the Americans with Disabilities Act, an employer is required to do which of the following? - Post potential solutions for offering reasonable accommodations - Provide the reasonable accommodation the disabled person prefers - Address questions of reasonable accommodations prior to considering a person for a position who may be disabled - None of the above |
None of the above |
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All of the following methods are used to destroy paper records except: - Magnetic degaussing - Burning - Shredding - Pulverizing |
Magnetic degaussing |
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When do kickback violations occur? |
When a provider receives compensation for patient referrals to a specific facility |
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When using email to transmit PHI, which of the following should the healthcare entity or provider NOT do? - Make his password available to other staff for more expeditious reporting of results to patients - Use encryption algorithms when sending emails to patients - Include a disclosure and redisclosure statement - Develop specific guidelines regarding the use of email that contains PHI |
Make his password available to other staff for more expeditious reporting of results to patients |
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Which statement below is a valid reason for restricting the patient's access to their health record? - The record would reveal information that might have a detrimental effect on the patient's mental health - The record would reveal information during litigation that would adversely impact that person's marriage - The release of the health information would reveal criminal behavior - The release of the health information might aid the patient's attorney in the decision to go forth with a civil lawsuit |
The record would reveal information that might have a detrimental effect on the patient's mental health |
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Which is true regarding statutes of limitations? - Are the same in all states - Require a plaintiff to bring suit within a specified period of time - Are intended to protect defendants from potential lawsuits - Is the same for persons of all ages |
Require a plaintiff to bring suit within a specified period of time |
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Which statement below is not among the guidelines that form the basis for the compliance program and financial settlement agreements? - Refusal to hire anyone who has a previous misdemeanor conviction - Use of consistent enforcement of standards, including disciplinary action - Establish compliance standards and procedures that all employees must follow - Assign specific individuals with overall responsibility to oversee compliance |
Refusal to hire anyone who has a previous misdemeanor conviction |
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How might the health information manager protect patient information from identity theft? |
Redaction of portions of credit card and social security numbers |
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In regards to the right of patients to correct information in their healthcare record, if a state law exists in addition to the federal HIPAA Privacy Rule, the healthcare provider must comply with which? |
Comply with both the federal and state laws |
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Under HIPAA, a patient has the right to which of the following? - Restrict all disclosures of information - Alter the original medical record - Receive copies of any record on request - Know how his information is being disclosed |
Know how his information is being disclosed |
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In a court of law, health records are considered to be _____ |
Hearsay evidence |
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All of the following are used to destroy electronic records except: - Pulverizing - Overwriting of data - Magnetic degaussing - Destruction of media |
Pulverizing |
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The health information manager must issue and post the health care provider's duties concerning PHI. This is called _____ |
Notice of Privacy Practice |
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With regard to minors, which is true regarding the statute of limitations? - Depends on whether the parents knew of the injury before the child reached the age of majority - Applies only if there is a permanent disability prior to the age of majority - Extended to the age of majority or beyond based on state statute - Prevents a child from suing for a birth injury since the parents must sue |
Extended to the age of majority or beyond based on state statute |
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Which is true when an employee has access to medical records? - The employee has a responsibility to allow the truth to be shared with the public - The released information should be limited to that which has been authorized by signed consent or demanded under subpoena - It's permissable to look into a celebrity's chart because they offer implied consent by virtue of their public status - The employer has implied that the employee should have control over release of medical information |
The released information should be limited to that which has been authorized by signed consent or demanded under subpoena |
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Which of the following is not contained in a valid subpoena? - Name of the parties to the suit - The release of information protected by statute - Docket number of the case - Specific documents to be produced |
The release of information protected by statute |
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What does ARRA provide? |
Reinforcement of patient's right to access own information |
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The billing fraud known as unbundling is defined as: |
Submission of separate bills for each component of a procedure that should have been billed together |
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In addition to a subpoena duces tecum, the HIM professional should also have which type of completed form to legally release medical information? |
Signed patient authorization that complies with all applicable confidentiality restrictions |
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What is the proper method of correcting an error in a paper medical record? |
Draw a single line through the error, write the word 'error', initials of the person making the entry, date and time |
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HIPAA addresses genetic testing in what manner? |
It prohibits insurance companies from considering genetic testing results as a pre-existing condition |
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What is true during the investigation of allegations of suspected fraud and abuse? - The health information manager must comply if presented with a search warrant - The health information manager is not obligated to notify provider's or organization's counsel since the warrant is issued by the court - The health information manager should answer all questions as best he can prior to the arrival of counsel - All of the above |
The health information manager must comply if presented with a search warrant |
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A chief compliance officer's duties might include which of the following? - Education and training - Complaints evaluation and resolution - Audits and monitoring of compliance - All of the above |
All of the above |
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All of the following below might be asked of the custodian of records when establishing trustworthiness except: - Have you made a full and complete search for the records in question? - Is the copy of the information presented today a true, complete copy of the patient's original record? - Are these records kept in the ordinary course of business? - Was the physician truthful when documenting his progress notes and dictation in the record? |
Was the physician truthful when documenting his progress notes and dictation in the record? |
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In the context of billing fraud, what is upcoding? |
Receiving a higher level of reimbursement than actually rendered |
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What purpose does the PEPP serve? |
Designed to reduce Medicare payment error rate |
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Personal and medical information that contains identifiers by which an individual can be recognized is the definition of: |
PHI - protected health information |
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How do HIPAA Security and Privacy Rules differ? |
Both protect information from different angles |
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What is a defining characteristic of an electronic health record? - Documentation created, authenticated, and retrieved by computers - Information that resides in a system specifically designed to provide accessibility to patient's medical chart - Is contained in a system that may also contain links to medical references and clinical decision support systems - All of the above |
All of the above |
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A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as: |
Longitudinal health record |
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The difference between EMAR and BC-MAR is: |
BC-MAR supports positive identification of patient and drug |
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Which of the following is not an element of the electronic signature form of authentication frequently used in an EHR - Date stamp - Encryption - Time stamp - User identification |
Encryption |
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An EHR is defined by the fact that there is collection of data from multiple sources, that provides decision support, and _____ - Is used at the point of care - Affords a paperless environment - Provides for continuity of care - Shares data with patients |
Is used at the point of care |
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Which of the following is metadata? - Paper copy of discharge summary - Print out of lab result - Audit trail - Screen shot of medication administration record |
Audit trail |
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Which of the following is NOT included in stage 1 of meaningful use criteria? - Electronic medication administration record - Computerized provider order entry - Clinical decision support - Provision of electronic copy of health information to patients |
Electronic medication administration record |
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Which of the following aids in an EHR help meet state law requirements to assume the accuracy of health records? - Authentication - Encryption - Reminders about proper documentation - Retrospective audits |
Reminders about proper documentation |
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What is a digitized signature? |
Image of a "wet" signature |
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The services provided by the HIM Department in an acute care hospital usually include all of the following except: - Medical transcription - Medical billing - Clinical coding - Release of information |
medical billing |
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The first point of data collection and the area where the health record number is most commonly assigned is the _____ department |
patient registration |
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As an HIM professional, you would be responsible for tracking compliance with: - Physical Plant Safety report - Allowable outstanding receivables - Averaged quarterly medical record delinquency rate - Medication errors |
Averaged quarterly medical delinquency rate |
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The master patient index: - Is the most important index maintained by HIM - Contains basic demographic info about the patient - Is commonly part of the admission, discharge, and transfer system - All of the above |
all of the above |
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Consider the following sequence of numbers: 56-44-98 37-45-99 38-45-99 What filing system is being used if the numbers represent health record numbers of three records filed together within the filing system? - Straight numerical - Terminal digit - Middle digit - Unit |
terminal digit |
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Reviewing the health record for missing signatures, medical reports, and ensuring all documents belong in the health record is an example of _____ Review - Quantitative - Qualitative - Concurrent - Retrospective |
Quantitative Review |
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The release of information (ROI) function requires the HIM professional to have knowledge of: - Clinical coding principles - Database development - Federal and state confidentiality laws - Human resource management |
Federal and state confidentiality laws |
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In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility? - Alphabetic filing system - Serial numbering system - Terminal digit filing system - Unit numbering system |
Terminal digit filing system |
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In which of the following systems does an individual receive a unique numerical identifier at the time of the first encounter with the facility and maintain that identifier for all subsequent encounters? - Alphabetic filing system - Serial numbering system - Unit numbering system - None of the above |
Unit numbering system |
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A record not completed within the time frame specified in the medical staff rules and regulations is called a: - Suspended record - Completed record - Delinquent record - Purged record |
Delinquent record |
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Which of the following should be taken into consideration when designing a health record form? - Assigning a unique identifying number to the form - Using a concise title that IDs the form's purpose - Including the original and revised dates for tracking purposes - All of the above |
All of the above |
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Which of the following statements describes alphabetical filing? - File by first name, middle initial, Last name - File by last name, first, then middle initial - File by last name, middle initial, first name - File the record by last name only |
File by last name, first, and middle initial |
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Which of the following filing methods is considered the most efficient? - Alphabetical filing - Alphanumeric filing - Straight number filing - Terminal digit filing |
Terminal digit filing |
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Which of the following indexes is considered to be the authoritative key to locating a health record? - Disease index - Master Patient index - Operation index - Physician index |
Master patient index |
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What committee oversees the development for an approval of new forms for the health record? - Quality review committee - Medical staff committee - Executive committee - Forms committee |
Forms committee |
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What is the singular form of 'data' |
datum |
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Data represent _____ while information represents _____ |
facts; meaning |
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The organization responsible for administering the Medicare Program |
Centers for Medicare and Medicaid Services |
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The area of healthcare dealing with the health populations in geographic areas such as counties and states is known as: |
public health |
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Vital statistics include data on _____ |
births, deaths, fetal deaths, marriages, divorces |
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A record is considered a primary data source when it _____ |
contains information about the patient that has been documented by the professionals who provided care to the patient |
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A clinical trial consists of _____ study phases |
4 |
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A list of rules and procedures to be followed during a clinical trial is known as a/n _____ |
protocol |
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Which of the following indexes and databases includes patient-identifiable information? - Master patient / population index - UMLS - MEDLINE - Clinical trials database |
master patient / population index |
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Case finding 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 |
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The name of the government agency that has led the development of basic data sets for health records and computer databases |
National Committee on Vital and Health Statistics |
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Minimum data set healthcare are developed to _____ |
recommend common data elements to be collected in health records |
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Data that are collected from individual records and then combined are referred to as _____ |
aggregate data |
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The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the _____ |
Uniform Hospital Discharge Data Set |
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Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for _____ |
performance improvement programs |
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True/False: The continuity of care record contains only current clinical information |
False - It contains both future and past clinical information |
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Standardizing medical terminology to avoid differences in naming various medical conditions and procedures is one purpose of: |
vocabulary standards |
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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 (HIPPA) |
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A key technology tool for enabling data is _____ |
content standard |
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Most healthcare informatics standards have been implemented by _____ |
census |
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A critical early step in designing an EHR is to develop a _____ in which the characteristics of each data element are defined |
data dictionary |
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According to the UHDDS definition, ethnicity should be recorded on a patient record as: - race of mother - race of father - Hispanic, non-Hispanic, unknown - free text descriptor as reported by patient |
Hispanic, non-Hispanic, unknown |
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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? - DEEDS - UACDS - MDS Version 3.0 - OASIS |
DEEDS |
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While the focus of inpatient data collection is the principal diagnosis, the focus of outpatient data collection is _____ |
reason for encounter |
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In long term care, the resident's care plan is based on data collected in the _____ |
MDS Version 3.0 |
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Reimbursement for home health services is dependent on data collected from _____ |
OASIS |
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A consumer interested in comparing the performance of health plans should review data from _____ |
HEDIS |
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HEDIS is designed to collect ______ |
Administrative, claims, and health record review data |
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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 |
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A statewide cancer surveillance system is an example of which of the NHII dimensions? |
community |
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Providers and health plans need to share information. What standard must they use? |
X12N |
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Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: - data sets - data elements - electronic data interchange - bills of mortality |
data sets |
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In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: - provide uniform data definitions - guide efforts toward computerization - determine statistical formulas - provide a research database |
provide uniform data definitions |
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A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is _____ - UHDDS - UACDS - MDS - ORYX |
UHDDS |
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Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and UACDS? - They define minimum data elements to be collected - They provide a complete and exhaustive list of data elements that must be collected - They provide a framework for data collection to which an individual facility can add data items - The federal government recommends, but does not mandate, implementation of most of the data sets |
They provide a complete and exhaustive list of data elements that must be collected |
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The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems except _____ - alphabetical - middle digit - terminal digit - straight numerical |
alphabetical |
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In which of the following systems are all encounters or patient visits filed or linked together? - serial numbering system - unit numbering system - straight numerical filing system - middle-digit filing system |
unit numbering system |
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Which of the following is a disadvantage of alphabetical filing? - easy to train new personnel to file - uneven expansion of file shelves or cabinets - ease of creation - relies on an index or authority key |
uneven expansion of file shelves or cabinets |
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Which of the following is a request from a clinical area to check out a health record? - outguide folder - requisition - MPI |
requisition |
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In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? - account level - MS-DRG level - MDC level - MS-DRG triples, pairs, and singles |
MS-DRG triples, pairs, and singles |
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Which of the following tools is usually used to track health records that have been removed from their permanent storage locations? - deficiency slips - master patient indexes - outguides - requisition slips |
outguides |
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What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage? - media control - integrity - mitigation - audit controls |
integrity |
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Incorporating a workflow function in an electronic information system would help support ____ - tasks that need to be performed in a specific sequence - moving patients from point to point - registration of patients - making computer output available on a laser disk |
tasks that need to be performed in a specific sequence |
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An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: - granularity - consistency - comprehensiveness - relevancy |
granularity |
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The data set designed to organize data for public release about the outcomes of care is _____ -UHDDS - DEEDS - MDS - HEDIS |
HEDIS |
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Which of the following allows a user to insert, update, delete, and query data from a database? - C++ - C - Java - SQL |
SQL |
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Which of the following indexes and databases includes patient-identifiable information? - MEDLINE - clinical trials database - master patient/population index - UMLS |
master patient/population index |
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The physician is able to look up the patient's health information from another physician practice and a hospital across town. He must be using a _____ |
health information exchange |
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T/F: Health information exchanges are designed to specifically to benefit only healthcare providers |
False |
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T/F: Health information exchanges must be operated by governmental entities |
False |
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T/F: Clinical information systems collect and store information related to patient care |
True |
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T/F: The results of an H1N1 blood test can be looked up on an emergency medical system |
False |
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T/F: A clinical decision support system will identify a medication contraindication |
True |
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T/F: Document imaging is the same as the EHR |
False |
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T/F: Telematics is an example of a clinical information system |
True |
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T/F: Embedded guidelines are recommendations for patient care |
True |
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What is the difference between the executive information system and decision support system? |
The executive information system is designed to be used by high-level management |
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Uses models and statistical analysis to help decision makers solve problems |
decision support system |
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Displays concise information and may be called a dashboard report |
executive information system |
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Tracks productivity and turnover |
human resource management system |
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Is updated periodically and used for strategic decision support |
data warehouse |
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Creates reports needed to manage the day-to-day activities of the organization |
management information system |
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Which role works with physicians to assist in the implementation of the EHR? |
Chief medical information system officer |
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Fifty percent of patients treated at our facilities have Medicare as their primary payer. This is an example of what type of information? |
aggregate |
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What HIM role determines what functions should be added to an information system? |
electronic system design and development |
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What HIM role is involved with the personal health record? |
consumer health informatics |
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T/F: Ambulatory information systems are the same as inpatient information systems |
False - they have many functions in common, but they each have unique functions as well |
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In what type of setting(s) are mile devices critical to the efficient use of information systems? |
home health |
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A formal agreement between separately owned and controlled facilities to officially coordinate and share certain activities is most appropriately referred to as _____ |
an affiliation |
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A group of registered nurses open an independent health clinic in a local shopping mall. This clinic offers walk-in, non-emergency care. The clinic staff refers complicated cases to the local hospital. The opening of this clinic in the same geographic area as the hospital is an example of _____ |
bureaucratic imperialism |
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The authority associated with self employees is termed _____ |
functional authority |
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A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a problem-oriented health progress note would this be written? - objective - assessment - plan |
subjective |
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A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note should this be written? - subjective - objective - assessment - plan |
assessment |
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What is the difference between data and information? - data represent basic facts, whereas information represents meaning - data are expressed in numbers, whereas information is expressed in words - information must be kept confidential, whereas data are meant to be shared - information is about people, whereas data are about things |
data represent basic facts, whereas information represents meaning |
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Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called _____ standards - vocabulary - structure of content - transaction - security |
structure and content |
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Which of the following is used to plot the points for two variables that may be related to each other in some way? - force-field analysis - pareto-chart - root cause analysis - scatter diagram |
scatter diagram |
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Which of the following elements is not a component of most patient records? - patient identification - clinical history - invoice for services - test results |
invoice for services |
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Which of the following is not a characteristic of high-quality healthcare data? - data relevancy - data currency - data consistency - data acountability |
data accountability |
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Which of the following represents an example of data granularity? - a progress note recorded at or near the time of the observation - an acceptable range of values defined for a clinical characteristic - a numerical measurement carried out to the appropriate decimal place - a health record that includes all of the required components |
A numerical measurement carried out to the appropriate decimal place |
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Which of the following is a primary purpose of the health record? - document patient care delivery - regulation of healthcare facilities - aid in education and nurses and physicians - assist in process redesign |
document patient care delivery |
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Which of the following best describes data comprehensiveness? - data are correct - data are very easy to obtain - data include all required elements - data are reliable |
data include all required elements |
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Which of the following best describes data accessibility? - data are correct - data are easy to obtain - data include all required elements - data are reliable |
data are easy to obtain |
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The attending physician is responsible for which types of acute-care documentation? - consultation discharge - discharge summary - laboratory report - pathology report |
discharge summary |
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A nurse is responsible for which of the following types of acute-care documentation? - operative report - medication report - radiology report - therapy assessment |
medication report |
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Which of the following is an example of clinical data? - admitting diagnosis - date and time of admission - insurance information - health record number |
admitting diagnosis |
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Which of the following is not documented in an emergency care record? - patient's instructions at discharge - time and means of the patient's arrival - patient's complete medical history - emergency care administered before arrival at the facility |
patient's complete medical history |
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In a problem-oriented health record, problems are organized ______ - in alphabetical order - in numeric order - in alphabetical order by body system - by date of onset |
in numeric order |
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Which of the following best describes an integrated health record format? - each section of the record is maintained by the patient care department that provided the care - integrated health records are intended to be used in ambulatory settings - documentation is integrated and arranged in alphabetical order by documentation type - documentation from various sources are integrated and arranged in strict chronological order |
documentation from various sources are integrated and arranged in strict chronological order |
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A secondary purpose of the health record is to provide support for which of the following? - provider reimbursement - patient self-management activities - research - patient care delivery |
research |
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In designing an electronic health record, one of the best resources to use i helping to define the content of the record as well as to standardize data definitions are standards promulgated by the: - Centers for Medicare and Medicaid Services - American Society for Testing and Measurement - Joint Commission - National Center for Health Statistics |
American Society for Testing and Measurement |
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Messaging standards for electronic data interchange in healthcare have been developed by: - HL7 - HEDIS - The Joint Commission - CMS |
HL7 |
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Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking? - completeness - validity - reliability - timeliness |
reliability |
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Which of the following terms refers to incidence of death? - classification - morbidity - mortality - vital statistics |
mortality |
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Review of disease indexes, pathology reports, and radiation therapy reports are parts of which function in the cancer registry? - case definition - case finding - follow-up - reporting |
case finding |
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Cancer registries receive approval as part of the facility cancer program from which of the following agencies? - American Cancer Society - National Cancer Registrar's Association - National Cancer Institute - American College of Surgeons |
American College of Surgeons |
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Which of the following is a database from the National Health Care Survey that uses the patient health record as a data source? - National Health Provider Inventory - National Ambulatory Medical Care Survey - National Employer Health Insurance Survey - National Infectious Disease Inventory |
National Ambulatory Medical Care Survey |
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Which of the following indices contains a list maintained in diagnosis code number order for patients who are discharged from a facility during a particular time period? - physician - master patient - disease - operation |
disease |
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Which one of the following indices contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period? - physician - master patient - disease - operation |
operation |
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Case finding is a method use to: - Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry - define which cases are to be included in a registry - identify trends and changes in the incidence of disease - identify facility-based trends |
identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry |
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In a cancer registry, the accession number: - identifies all the cases of cancer treated in a given year - is the number assigned to each case as it is entered in a cancer registry - identifies pathologic diagnosis of an individual cancer - is the number assigned for the diagnosis of a cancer patient that is entered into the cancer registry treatments and at different stages of cancer |
is the number assigned to each case as it is entered into a cancer registry |
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The most prevalent trend in the collection of secondary databases is: - increased use of encryption technology - increased use of encoders - increased use of automated data entry - widespread implementation of electronic medical records |
increased use of automated data entry |
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In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range? - 5 to 20 - 15 - 7.5 - 20-5 |
15 |
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What is the mean for the following frequency distribution: 10, 15, 20, 25, 25? - 47.5 - 20 - 19 - 95 |
19 |
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Suppose that five patients stayed in the hospital for a total of 27 days. Which term would be used to describe the result of the calculation 27 divided by 5? - average length of stay - total length of stay - patient length of stay - average patient |
average length of stay |
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Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the mode? - 30 - 32 - 32.5 - 35 |
30 |
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Mr. Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay for Mr. Jones? - 5 days - 10 days - 11 days - 15 days |
11 days |
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Community Hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed five autopsies for the same period. What is the gross autopsy rate for the hospital for June? - 0.02% - 5% - 20% - 200% |
20% |
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If you want to display the parts of a whole in graphic form, what graphic technique would you use? - table - histogram - line graph - pie chart |
pie chart |
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Which rate describes the probability of risk of illness in a population over a period of time? - mortality - incidence - morbidity - prevalence |
incidence |
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Which term is used to describe the number of inpatients present at the census-taking time each day plus the number of inpatients who were both admitted and discharged after the census-taking time the previous day? - inpatient bed occupancy rate - bed count - average daily census - daily inpatient census |
daily inpatient census |
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Which unit of measure is used to indicated the services received by one inpatient in a 24-hour period? - inpatient service day - volume of services - average occupancy services - length of stay |
inpatient service day |
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Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges - net hospital death rate - fetal/newborn/maternal death rate - gross hospital death rate - adjusted hospital death rate |
gross hospital death rate |
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Which autopsy rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths for the same period of time? - net - gross - hospital - average |
gross |
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What term is used for the number of inpatients present at any one time in a healthcare facility? - average daily census - census - inpatient service day - length of stay |
census |
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What is the official count of inpatients taken at midnight called? - average daily census - census - daily inpatient census - inpatient service days |
daily inpatient census |
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Which of the following use data from the MDS for long-term care? - Centers for Medicare and Medicaid Services - Home health hospice agencies - Home health agencies - Rehabilitation facilities |
Centers for Medicare and Medicaid Services |
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Which of the following is an internal user of data? - public health department - state data bank - hospital administrator - quality improvement organization |
hospital administrator |
