Chapter 2: Functions, Careers, and Credentials of the HI Professional

What is the role of a case manager?

A case manager determines the utilization of healthcare services.

Quantitative analysis

A process that ensures all documents are present in the individual health record

What is the purpose of the PPE?

Allows the student to apply theory in real life situations in the healthcare field Gives the student the opportunity to develop competency in medical coding Is part of an educational program leading the student to earn an AHIMA credential

What is the name of the current professional organization for HIM professionals?

American Health Information Management Association

Which law passed in 2009 provided financial incentives in the installation of electronic health records?

American Recovery and Reinvestment Act

What is the key element needed to ensure each patient is in a database only one time?

An accurate and complete master patient index

What was the name of the first professional organization for HIM?

Association of Record Librarians of North America

Who are the professionals that collect, maintain, and report cancer statistics?

Cancer registrars

The health record is used to

Communicate patient care between healthcare providers

Prior to the electronic health record, how was abstracting completed?

Data from paper records was abstracted and the abstracts were sent to a processing company.

Which of the following are components of the UHDDS?

Discharge date Attending physician

What is the process and policies that govern the digital collection, maintenance, and archiving of data?

E-Health management

What are the advantages of electronic records?

Enhance communication with the ability to easily exchange information between healthcare providers Improve quality of care by allowing greater support functions for clinical decision making

What is the role of the revenue cycle manager?

Ensure efficient and effective processes from the time a patient is registered until the bill is paid in full Ensure accurate coding accuracy to reflect higher reimbursements from insurance companies Audit documentation procedures

Compliance officer positions are often held by

HIM professionals. administrators.

When assigning diagnostic codes, medical coders use which classification system?

ICD

Why is information security important?

Increase in threats by computer hackers and viruses Increase in federal regulations by HITECH and HIPAA

What is the process of ensuring administrative, technical, and physical safeguards?

Information security

Which of the following is true of HITECH?

It provides financial incentives to healthcare providers investing in EHRs

What does the health record provide for third-party payers?

Justification for reimbursement

Which of the following is a responsibility of administration?

Managing the health record process

What federal legislation instituted the use of recovery audit contractors?

Medicare Modernization Act of 2003

What is the responsibility of a compliance officer?

Monitoring the activities that may be susceptible to fraud, misuse, abuse or overutilization

Who is responsible for giving the orders for care and treatment of the patient?

Physician

Which HIM professional compiles requests for a copy of a health record?

ROI coordinator

What do medical records document?

Reason for patient visit Past medical history Reason for medical procedure

In the electronic filing process,

Records are imaged and viewed on the computer screen.

Delinquent records

Records that are incomplete after a specified time frame

Which of the following are examples of ambulatory healthcare settings?

Rehabilitation centers and reference laboratories Physician's office and clinics Urgent care centers

The RAC coordinator performs which of the following tasks?

Requests copies of health records and compares medical coding to documentation Determines overpayments made by Medicare

What are the traditional functions of HIM professionals using the paper record?

Retrieve records for readmissions Compile statistical reports Code diagnoses and procedures

Medical staff bylaws

Set policies to ensure medical staff members act within set rules and regulations

What are nontraditional PPE settings?

Software companies Insurance companies Consulting firms

Which of the following is the difference between the role of the privacy officer and the ROI coordinator?

The ROI coordinator compiles and sends requested health information and the privacy officer investigates potential breaches in confidentiality.

Authentication

The process in which a person identifies oneself as the person who entered data into a health record

Which of the following is true about release of information for electronic records?

The release of information coordinator prints the images directly from his or her computer to the printer or send the documents electronically.

What was the purpose in forming the HIM professional association?

To elevate the status of individuals who processed medical records To meet as a group to network and discuss current issues To set standards for the education or knowledge set held by clerks

What is the role of AHIMA?

To provide guidance, resources, and expertise to health information professionals

What are the necessary skills for a revenue cycle manager?

Understanding of Medicare and other government plans Knowledge of insurance carrier requirements A strong accounting background

HIM professionals are responsible for which of the following functions during record processing?

Verifying all records show authentication Quantitative analysis Notifying healthcare professionals of missing information in the health record

The traditional work of HIM professionals from the 1920s through the early 2000s was

a manual paper process.

What are the levels of education for AHIMA credentials?

a master's degree. an associate degree. a baccalaureate degree.

With the advent of the electronic health record, every person who ______, _______, or _________ information in a record can be traced.

accesses edits enters

The privacy officer

adheres to the confidentiality and privacy laws. is a higher level position. monitors the facility's release of information practices

Care coordinators

are the primary point of contact for clinicians. are responsible for coordinating all services. are typically nurses or social workers.

Allied health professionals

carry out physician orders. receive specified training.

The data abstracted from each cancer patient's health record includes

diagnostic findings and therapies used to treat the cancer. patient's medical, surgical, family, and social histories. demographic data.

During the electronic filing process,

document scanning equipment is used health records are backed up in electronic format

The Office of National Coordinator for Health IT (ONC) defines the benefits of electronic health record as

enhancing the collecting of clinical data in a digital format to improve communication and exchange among healthcare providers.

EHRs are designed to do all of the following EXCEPT

focus on episodes of care within a single specialty or single health system.

A key difference between ICD procedure codes and CPT codes is that ICD codes are used in ______ settings and CPT codes are used in _______ settings.

inpatient; outpatient

A health record is also known as a

medical record.

Management personnel are responsible for

overall planning of the health record process. organizing and leading the health record process.

The health record is owned by

the facility where the treatment was rendered.

The privacy and security regulations for the health record in the ambulatory setting are

the same as those for the inpatient setting.

EMRs do not meet Meaningful Use certification requirements because

they are not designed to be part of a larger system. they provide limited data analytics. they focus on episodes within a single specialty or single health system.