Chapter Three:Professional Review Guide(quiz one), RHIA EXAM

Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure. ●-22, Increased Procedural Services ●-54, Surgical Care Only ●-32, Mandated Service ●-55, Postoperative Management Only

-55, Postoperative Management Only Modifiers are appended to the code to provide more information or alert the payer that a payment change is required. Modifier -55 is used to identify that the physician provided only postoperative care services for a particular procedure

Patient has HIV with disseminated candidiasis. What is the correct code assignment? *042 Human Immunodeficiency virus (HIV) disease *112.0 Candidiasis of mouth *112.5 Candidiasis, disseminated *112.89 Candidiasis, of other specified sites, other ●042, 112.0 ●112.5, 042 ●042, 112.5 ●042, 112.89, 112.5

042, 112.5 Patients who are admitted for admitted for an HIV-related illness should be assigned a minimum of two codes in the following order: code 042 to identify the HIV disease and additional codes to identify the related diagnosis

The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is a. 12-0000/01. b. 12-0001/00. c. 12-0000/00. d. 12-0001/01.

12-0001/00

Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every a. 90 days. b. 60 days. c. month. d. week.

60 days

The pathologist performed a gross and microscopic examination of a kidney biopsy. What is the correct CPT code assignment? *88300 Level 1, Surgical pathology, gross examination only *88305 Level 4, Surgical pathology, gross and microscopic examination *88307 Level 5, Surgical pathology, gross and microscopic examination ●88400, 88305 ●88305 ●88307 ●88300, 88307

88305 Codes 88302-88309 are assigned based on the specific specimen examined. The type of specimen included in each code is listed alphabetically under the code. A kidney biopsy specimen examination, both gross and microscopic, is coded to 88305

According to the following table, the most serious record delinquency problem occurred in which of the following months? Record Delinquency for Second Quarter April May June Percentage incomplete records 70% 88% 79% Percentage delinquent records 51% 43% 61% Percentage delinquent due to missing H&P 3% 1.4% 0.5% a. May b. June c. April d. cannot determine from these data

April

Staff disagreements within the health record should be: ●Avoided ●Detailed and thorough ●Included in incident reports ●Documented according to state regulations

Avoided Documention of staff disagreements in the health records heightens the risk of liability for both the healthcare organizaiton and those involved in the disagreement. Individuals documenting in the health record should avoid recording disagreements in the patient record so as not to raise red flags that will result in the record becoming the centerpiece of litigation

What type of data display tool is used to display discrete categories? ●Bar graph ●Histogram ●Pie chart ●Line chart

Bar graph Discrete data are whole numbers that may or may not be related, so a bar graph is the best data graph is the best data display tool to use.

Which of the following would likely be recorded on an information system issues log? ●Alan is present every day there is a system test ●Betty reported receiving 25 erroneous e-mail messages ●Dr. Brown effectively uses e-prescribing ●John requested a supply of tamper-proof paper for his office

Betty reported receiving 25 erroneous e-mail messages Because of the number of tasks and their complexity and dependencies in EHR implementation, it is important to have an issues management program. An issues management program serves to receive and document issues and track them to their resolution

In this EHR implementation strategy virtually every nursing unit, department, clinic, or other organizational unit goes live at the same time with a given component of the EHR. ●Phased roll-out ●Big bang roll-out ●Pilot ●Straight turnover

Big bang roll-out The implementation of all aspects of the EHR component (or entire EHR in an ambulatory setting) in all organizational units virtually simultaneously

Which of the following processes is an ancillary function of the health record ●Medical error prevention ●Data and information storage ●Patient assessment and care planning ●Biomedical research

Biomedical research Biomedical research is considered an ancillary function of the health record

The individual most likely to lead strategic planning for a healthcare organization's information is the: ●CEO ●HIM director ●CIO ●Medical director

CIO The CIO is responsible for helping to lead the strategic IS planning process, managing the major functional units within the IS department, and overseeing the management of information resources throughout the enterprise

Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and: ●AMA ●OIG ●CMS ●WHO

CMS Changes and updates to ICD-9-CM Coordination and Maintenance Committee, co-chaired by representatives from the NCHS and the Centers for Medicare and Medicaid Services (CMS). The NCHS is responsible for Volumes 1 and 2 (Diagnoses), and the CMS is responsible for Volume 3 (Procedures)

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets a. CMS standards. b. HL-7 standards. c. NHIN standards. d. Joint Commission standards.

CMS standards.

In this function of the utilization management program, an evaluation occurs at preset intervals to ensure that the patient requires continued care. ●Admission review ●Concurrent review ●Discharge planning ●Pre-admission review

Concurrent review Continued-stay or concurrent review ensures that the patient is remaining in the facility because of medical necessity and is being treated appropriately. The review ensures that the patient is evaluated at present intervals to determine the appropriateness of care rendered and that beds are utilized efficiently. The specific interval is commonly ties to the diagnosis and procedure

Which of the following is the definition of revenue cycle management? ●The regularly repeating set of events that produce revenue or income ●The method by which patients are grouped together based on a set of characteristics ●The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization ●Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

Coordination of all administrative clinical functions that contribute to the capture, management, and collection of patient service revenue Revenue cycle management is the supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set? a. ORYX b. MDS c. UHDDS d. DEEDS

DEEDS

Most facilities begin counting days in accounts receivable at which of the following lines? ●Date the patient registers ●Date the patient is discharged ●Date the bill drops ●Date the bill is received by the payer

Date the bill drops Once the claim is submitted to the third-party payer for reimbursement, the accounts receivable clock begins to tick

According to the OIG, insufficient or missing documentation and which one of the following are responsible for 70 percent of bad claims submitted to Medicare? ●Local coverage decisions ●Unbundling of procedures ●Failure to document medical necessity ●Overcoding

Failure to document medical necessity Failure to document medical necessity appropriately is one of the two area in which the OIG says is responsible for 70 percent of bad claims. The other area is insufficient or missing documentation

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the a. MDS. b. Uniform Clinical Data Set. c. UHDDS. d. Uniform Ambulatory Core Data.

MDS

Which of the following is an example of analog data? ●CT scan ●Photographic, chest x-ray film ●MRI exam ●EKG tracing

Photographic, chest x-ray film Photographic, chest x-ray film are all diagnostic image data that are based on analog, photographic films

Which of the following are used to report information about mortality and morbidity at local, state, and national levels? ●Rates, populations, and ratios ●Ratios, proportion, and continuous variables ●Proportions, populations, and continuous variables ●Proportion, ratios, and rates

Proportions, ratios, and rates Many healthcare statistics are reported in the form of a ratio, proportion, or rate. These measures are used to report morbidity (illness), mortality (death), and fatality (birthrate ) at the local, state, and national levels

Who is responsible for ensuring the quality of health record documentation? ●Board of directors ●Administrator ●Provider ●Health information management professional

Provider The provider is responsible for ensuring the quality of the documentation of the healthcare record

In which type of reimbursement methodology, do healthcare insurance companies reimburse providers after the costs have been incurred? ●Retrospective payment ●Block grant ●Prospective payment ●Global payment

Retrospective payment Retrospective payment is a type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered

Exceptions to the Federal Anti-Kickback statute that allow legitimate business arrangements and are not subject to prosecution are: ●Qui tam practices ●Safe practices ●Safe harbors ●Exclusions

Safe Harbors Safe harbors are activities that are not subject to prosecution and protect the orgnization from civil penalties under the Federal Anti-Kickback statue. The OIG has created a number of regulatory safe harbors covering such arrangements

Which of the following is a continuous quality improvement (CQI) tool frequently used to display data? ●Scatter diagram ●Brainstorming ●Nominal group technique ●Multivoting

Scatter diagram A scatter diagram is data analysis tool used to plot points of two variables suspected of being related to each other in some way

The Donabedian Quality Assessment Model includes which three measures? ●Plan, do, act ●Structure, process, outcome ●Indication, process, evaluation ●Scope, response, action

Structure, process, outcome Avidas Donabedian's QA model has been used and accepted for many years. The model's approach to the assessment of healthcare is based on the following three measures: Structure measures examine the organization's capability to provide services. Process measures look at how care or services is provided to patients. The activities or protocols of care have some impact on the patient's outcome. Outcome measures assess the end results of the care or services provided

A quality improvement team is focusing on the unacceptable number of unsigned doctors' orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be a. devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient's care. b. developing an open-record review process. c. holding a printed order sheet on the medical care unit at least 24 hours postdischarge to give the physician time to sign. d. performing a retrospective review where all orders can be flagged at one time.

developing an open-record review process.

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain a. discharge order. b. stop orders. c. telephone orders. d. standing orders.

discharge order.

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the a. risk manager. b. health information manager. c. clinical data specialist. d. information security manager.

health information manager.

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data a. completeness. b. legibility. c. accessibility. d. reliability.

reliability

Accreditation by Joint Commission is a voluntary activity for a facility and it is a. required for reimbursement of certain patient groups. b. conducted in each facility annually. c. required for state licensure in all states. d. considered unnecessary by most health care facilities.

required for reimbursement of certain patient groups.

According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited? a. 4 mg Lasix b. 40 mg Lasix c. 0.4 mg Lasix d. .4 mg Lasix

.4 mg lasix

Which of the following is an example of demographic data? ●125 Oak Street, Smallville, KS ●Temperature:100 degrees F ●Mother died of heart disease ●History of appendectomy at age 4

125 Oak Street, Smallville, KS Demographic data includes basic factual details about the individual patient

A 27-year-old female has a vaginal delivery with single live born female. Episiotomy and repair. What diagnosis and procedure codes would be assigned for this patient? *650 Normal delivery *664.41 Unspecified perineal laceration, delivered, with or without mention of antepartum condition *665.40 High-vaginal laceration, unspecified as to episode of care or not applicable *V27.0 Single liveborn *73.6 Episotomy (with subsequent repair) *75.69 Repair of other current obsteric laceration ●664.41, V27.0, 73.6, 75.69 ●650, V27.0, 73.6, 75.69 ●650, V27.0, 73.6 ●665.40, 73.6

650, V27.0, 73.6 This is an example of a normal delivery, full-term, single, healthy liveborn infant with an episiotomy. No other procedures or manipulation needed to aid in delivery

Identifying user information needs is part of the _____ phase of the systems development life cycle. ●Analysis ●Design ●Implementation ●Evaluation

Analysis During the analysis phase, the need for a new information system is explored further, problems with the existing system are solidified, and user needs are identified

For Medicare patients, how often must the home health agency's assessment and care plan be updated? ●Every 60 days ●As often as the severity of the patient's condition requires ●At least every 60 days or as often as the severity of the patient's condition requires ●Every 30 days

At least every 60 days or as often as the severity of the patient's condition requires Home health agencies are expected to conduct an assessment that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires

The surgery department is evaluating its postoperative infection rate of 6 percent. The chief of surgery asks the quality improvement coordinator to find the post-operation infection rates of 10 similar hospitals in the same geographic region to see how the rates compare. This process is called: ●Universal precautions ●Internal comparisons ●Benchmarking ●Critical pathway analysis

Benchmarking Benchmarking is the systematic comparison of the products, service, and outcomes of an organization with those of a similar organization. Benchmarking also can be made using regional and national standards of some combination

The term "hard coding" refers to: ●CPT codes that are coded by the coders ●CPT codes that appear in the hospital's charge master ●ICD-9-CM codes that are coded by the coder's ●ICD-9-CM codes that appear in the hospital's charge master

CPT codes that appear in the hospital's charge master Hard coding is a term used in regard to the Charge master CPT codes that are automatically entered

What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user? ●Clinical data repository ●Data exchange standard ●Central processor ●Digital system

Clinical data repository A clinical repository is a centralized database that captures, sorts, and processes patient data and then sends it back to the user

Under what access security mechanism would an individual be allowed access to ePHI if they have proper log-in and password, belong to a specific group, and their workstation is located in a specific place within the facility? ●Role-based ●User-based ●Context-based ●Job-based

Context-based Context-based access is the most stringent type of access control. It takes into account the person attempting to access the data, the type of data being accessed, and the context of the transaction in which the access attempt is made

Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? ●Deemed status ●Judicial decision ●Subpoena ●Credentialing

Credentialing Credentialing is the process that requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility

What is the other term used to denote contingency planning which is a requirement of HIPAA? ●Data backup ●Data recovery ●Disaster recovery planning ●Emergency mode of operation

Disaster recovery planning Contingency or disaster recovery planning (DRP) is an important component of protecting ePHI. Healthcare providers need plans in the event of a power failure, disaster, or other emergency that limits or eliminates access to facilities and ePHI

What is the most important factor in determining the best storage method for health record? ●Ensuring that the records are readily accessible and secure ●Ensuring that the records are factual and informational ●Ensuring that the records are both electronic and paper based ●Ensuring that the records are personal and private

Ensuring that the records are readily accessible and secure The most important factor in determining data storage and retrieval is ensuring that the records are readily accessible and secure

What architectural model of health information exchange allows participants to access data in point-to-point exchange? ●Consolidated ●Federated - consistent database ●Federated - inconsistent databases ●Switch

Federated - inconsistent database The federated - inconsistent databases - model for HIE includes multiple enterprises agreeing to connect and share specific information in a point-to-point manner

Which health record format is arranged in chronological order with documentation from various sources intermingled? ●Electronic ●Source-oriented ●Problem-oriented ●Integrated

Integrated The integrated health record format is arranged in chronological order with documentation from various sources intermingled

Which microfilming system is best when you plan to file the film using terminal-digit unit record system? ●Jackets ●Roll ●Cartridge ●Rotary

Jackets The microfilm jacket has the advantage of serving as an individual folder for storing the records of one patient. Additional filed images can be added to the jacket or changed. The jackets are usually 4x6 inches and have a strip at the top on which to record the patient's name and number

Which type of architecture has one powerful central computer that performs all processing and storage functions while sending and receiving date to/from various terminals and printer? ●Client/server ●Mainframe ●Super computer ●Web-based

Mainframe Mainframe computers use a single large computer with many terminals directly connected to it and sharing the resources of the single computer

This type of performance measure indicates the result of the performance or nonperformance of a function or process. ●Outcome measure ●Data measure ●Process measure ●System measure

Outcome measure An outcome measure may be the effect of care, treatment, or services on a customer

The Universal Protocol requires a "time-out" prior to the start of any surgical invasive procedure to conduct a verification of: ●Patient and procedure ●Patient, procedure, and site ●Surgeon and site ●Surgeon, patient, and site

Patient, procedure, and site Universal protocol incorporates the principles of eliminating wrong-site, wrong-procedure, and wrong-person surgery. The steps involved in this protocol include preoperative verification process, marking the operative site, and a "time-out" before starting any procedure

The Joint Commission has published a list of abbreviations classed as "Do Not Use" for the purpose of: ●Assisting coders to read physician handwriting ●Preventing potential medication errors due to misinterpretation ●Making terminology consistent in preparation for electronic records ●Identifying physicians who are dispensing large quantities of drugs

Preventing potential medication errors due to misinterpretation Healthcare organizations need to be very clear about which abbreviations are not acceptable to use when writing or communicating medication orders. The organization's policy should also define whether or when the diagnosis, condition, or indication for use is included on a medication order

A health information exchange organization that has no access to personal health information is an example of this kind of architectural model: ●Consolidated ●Federated - consistent database ●Federated - inconsistent databases ●Switch

Switch Switch is a service that enables the exchange of information across multiple independent enterprises that have unilateral independent exchange data in which there is no access to personal health information

The foundations of care giving, which include buildings, equipment, professional staff, and appropriate policies are included in what area of performance measurement? ●Outcomes ●Processes ●Systems ●Benchmarks

Systems Healthcare performance improvement philosophies most often focus on measuring performance in systems, processes, and outcomes. The foundations of caregiving, buildings, equipment, professional staff, and policies are all examples of systems

Which part of the problem-oriented medical record is used by many facilities who have not adopted the whole problem-oriented format? ●The problem list as an index ●The initial plan ●The SOAP form of progress notes ●The database

The SOAP form of progress notes The Subjective, Objective, Assessment, Plan (SOAP) notes are part of the problem-oriented medical records (POMR) approach most commonly used by physicians and other healthcare professional. SOAP notes are intended to improve the continuity of client services by enhancing communication among healthcare professionals

The practice of quality is most focused on: ●Top management ●Successful product lines ●The customer ●Frontline workers

The customer The popularity of these quality improvement approaches has demonstrated the growing importance of customer satisfaction

Which of the following is an acceptable means of authenticating a paper record entry? ●The physician's assistant signs for the physician ●The HIM clerk stamps entries with the physician's signature stamp ●The charge nurse signs the physician's name ●The physician personally signs the entry

The physician personally signs the entry A physician signing an entry on a paper record is an acceptable mean of authenticating a paper record

What does an audit trail check for? ●Unauthorized access to a system ●Loss of data ●Presence of a virus ●Successful completion of a backup

Unauthorized access to a system An audit trail is a chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? a. Uniform Hospital Discharge Data Set b. Conditions of Participation c. Minimum Data Set d. Federal Register

Uniform Hospital Discharge Data Set

For inpatients, the first data item collected of a clinical nature is usually a. review of systems. b. admitting diagnosis. c. expected payer. d. principal diagnosis.

admitting diagnosis.

Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis? a. plan b. subjective c. assessment d. objective

assessment

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record? a. delegated use of computer key by radiology secretary b. a unique identification code entered by the person making the report c. identifiable initials of a nurse writing a nursing note d. written signature of the provider of care

delegated use of computer key by radiology secretary

Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? LaTour and Eichenwald-Maki, p 331 a. procedure index b. pediatric census sheet c. patient register d. disease index

disease index

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's a. number control index. b. physicians' index. c. disease index. d. patient index.

disease index

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that a. evidence cannot be provided that the physician actually reviewed and approved each report. b. electronic signatures are not acceptable in every state. c. it is too easy to delegate use of computer passwords. d. tampering too often occurs with this method of authentication.

evidence cannot be provided that the physician actually reviewed and approved each report

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the a. hospital bylaws. b. Joint Commission accreditation manual. c. CARF manual. d. Federal Register.

federal register

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show a. missing operative reports. b. absence of SOAP format in progress notes. c. missing discharge summaries. d. missing signatures on progress notes.

missing operative reports

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates a. compliance with Joint Commission standards. b. compliance with Medicare regulations. c. noncompliance with Joint Commission standards. d. compliance with Joint Commission standards for nonsurgical patients.

noncompliance with Joint Commission standards

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the a. labor and delivery record. b. postpartum record. c. prenatal record. d. discharge summary.

prenatal record

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the a. discharge summary. b. transfer record. c. interdisciplinary patient care plan. d. problem list.

problem list

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? a. progress notes b. initial plan c. problem list d. database

problem list

In preparing your facility for initial accreditation by the Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended change is to a. have the committee report to the Executive Committee. b. have a physician perform all the reviews. c. have more frequent committee meetings. d. provide for record reviews to be performed by an interdisciplinary team of care providers.

provide for record review . . .

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? a. qualitative review b. legal review c. quantitative review d. utilization review

qualitative review

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of a. legal analysis. b. qualitative review. c. quantitative review. d. peer review.

qualitative review.

Which of the following is a component of the Resident Assessment instrument? ●The resident's health record ●A standard Minimum Data Set (MDS) ●Preadmission Screening Assessment ●Annual Resident Review

A standard Minimum Data Set (MDS) The content of the Resident Assessment Instruments (RAIs) is ultimately determined by each state and may differ from state to state. The RAI consists of a standard Minimum Data Set, Resident Assessment Protocol, and utilization guidelines

Topology refers to a(n): ●Arrangement of a network ●Beginning of a network ●End point of a network ●Network connection

Arrangement of a network There are two types of topology: physical and logical. A physical topology is the way in which network devices are connected. Networks are generally arranged in one of three topologies: bus topology, star topology, and ring topology. Logical topology describes how data are transmitted through the physical devices

A healthcare organization remains committed to purchasing a vendor's product, which the organization finds solid in its financial and administrative application but weaker in clinical applications. What is the term for this strategy? ●Bridge ●Best-of -fit ●Best-of-breed ●Legacy

Best-of-fit The opposite of best-of-fit. In this situation, virtually (though not absolutely) all applications are provided by a single vendor. This frequently makes it easier to add new applications from that vendor, but potentially even more difficult to add products from other vendors. Many organizations find their best-of-fit financial/administrative and operational system vendor is not as strong in EHR as they would desire. Alternatively, best-of-breed organizations find it difficult and costly to sustain this approach

To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? ●Brain injury ●Chronic myelogenous leukemia ●Acute myocardial infarction ●Cancer

Brain injury To meet the CMS's definition of an IRF, facilities must have an inpatient population in which at least 75 percent of the patients require intensive rehabilitation services and one of the 13 conditions: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur, brain injury, neurologicl disorders, burns, active polyarticular, rheumatoid arthritis, systemic vasculiticles, severe or advanced osteo-arthristis, or knee replacement

In this type of network, all computers on the network receive the same message at the same time, but only one computer at a time can transfer information, and if one segment of the network goes down, the entire network is affected. ●Star topology ●Ring topology ●Bus topology ●Logical topology

Bus topology Bus topology is the simplest network topology, connecting one device to another along a "backbone"

Which of the following is a method of grouping patients according to a predefined set of characteristics? ●Case-mix analysis ●Case management ●Clinical practice guidelines ●Core measures

Case-mix analysis Case-mix analysis is a method of grouping patients according to a predefined set of characteristics

What term is used to refer to an organized collection of data that have been stored electronically to facilitate easy access? ●Digital formatting ●Database ●Telemedicine ●Data capture

Database A database is a term used to refer to an organized collection of data that have been stored electronically to facilitate easy access

What form of logical topology is most widely used for local area networks? ●Bus ●Ethernet ●Gateway ●POTS

Ethernet An Ethernet is a family of frame-based computer networking technologies that currently are the most widely use topologies for LANs

Which of the following controls external access to a network? ●Access controls ●Alarms ●Encryption ●Firewall

Firewall Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders. However, they also can be used to protect entities within a single network, for example, to block laboratory technicians from getting into payroll record. Without firewalls, IT departments would have to deploy multiple-enterprise security programs that would soon become difficult to manage and maintain

Topography codes in ICD-O-3 use the same categories as which other classificaion? ●ICD-10 ●ICD-9-CM ●ICD-10-PCS ●SNOMED

ICD-10 The International Classification of Diseases for Oncology (ICD-O-3) is currently in its third revision. This classification is used for coding diagnosis of neoplasms in tumor and cancer registries and in pathology laboratories. The topography code describes the site of origin of the neoplasm and uses the same three- and four- character categories as in the neoplasm section of Chapter 2 of ICD-10

In large research institutions, informed consent forms are generally monitored by the: ●Chief of staff ●CIO ●Institutional Review Board (IRB) ●Health information management professional

Institutional Review Board (IRB) The purpose and responsibilities of the IRB are to protect the rights and welfare of human subjects as they engage in research activities. The IRB must abide by the regulations as listed in 45 CFR 46.111 and 21 CFR 56.111. The IRB must first determine if research is being conducted and then determine if human subjects are being protected

Which one of the following set represents criteria for medical necessity and utilization review? ●Intensity of Service, Severity of Illness, and Discharge Screens ●Uniform Hospital Admission and Discharge Data Set ●Kaiser and Scripps Guidelines ●Federal Register Index and Ratings

Intensity of Service, Severity of Illness, and Discharge Screens Medical necessity and utilization are reviewed using objective, clinical criteria from multiple sets of criteria including but not limited to Intensity of Service, Severity of Illness, and Discharge Screens (ISD), Appropriateness Evaluation Protocol (AEP), and Millman Care Guidelines

You want to graph the number of deaths due to prostate cancer from 2000 through 2009. Which graphic tool would you use? ●Frequency polygon ●Histogram ●Line graph ●Pie chart

Line graph A line graph is used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the number of prostate cancer deaths

This type of data display tool is used to show the relationship of each part to the whole. ●Bar graphs ●Histogram ●Pie charts ●Line graphs

Pie charts A pie chart is an easily understood chart in which the sizes of the slices of the pie show the proportional contribution of each part. Pie charts can be used to show the component parts of a single group or variable and are intended for interval or ratio data

The minimum length of time for retaining original medical records is primarily governed by a. medical staff. b. state law. c. Joint Commission. d. readmission rates.

state law

Which of the following would be an indicator of process problems in a health information department? ●5% decline in the number of patients who indicate satisfaction with hospital care ●10% increase in the average length of stay ●15% reduction in bed turnover rate ●18% error rate on abstracting data

18% error rate on abstracting data Performance measurement is the process of comparing the outcomes of an organization, work unit, or employee to pre-established performance standards. The results of performance measurement are usually expressed as percentages, rates, ratios, averages, or quantitative assessment. It is used assess quality and productivity in clinical and administrative services

Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. ●32405, Biopsy, lung or mediastinum, percutaneous needle ●37609, Ligation or biopsy, temporal artery ●20206, Biopsy, muscle, percutaneous needle ●31629, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance when performed; with transbronchial needle aspiration biopsy(s), trachea, mainstem and/or lobar bronchus

37609, Ligation or biopsy, temporal artery Begin with main term biopsy, artery, temporal

What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? __________________________________________________ *58555 Hysteroscopy, diagnostic (separate procedure) *58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) *58740 Lysis of adhesions (salpingolysis, ovariolysis) ●58555, 58559 ●58559 ●58559, 58740 ●58555, 58559, 58740

58559 Main term: Hysteroscopy; lysis; adhesions

Community Memorial Hospital discharge nine patients on April 1st. The length of stay for each patient is shown in the following table. What is the mode length of stay for this group of patients? Patient / Number of Days A - 1 B - 5 C - 3 D - 3 E - 8 F - 8 G - 8 H - 9 I - 9 ●5 days ●6 days ●8 days ●9 days

8 days The mode is the simplest measure of central tendency. It is used to indicate the most frequent observation in a frequency distribution. In this data set there are three occurrences of the value 8, and only two or less occurrences of any other values, so, 8 is the mode

Which of the following represents one of the biggest challenges in EHR development and implementation? ●Images of handwritten and printed documents ●Data exchange standards ●A workable capture process ●A clinical data repository

A workable data capture process A workable data capture process has proved to be one of the biggest challenges in EHR system development and implementation

You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use? ●Bar graph ●Histogram ●Line graph ●Pie chart

Bar graph Bar charts are used to display data from one or more variables. The bars may be drawn vertically or horizontally. Bar charts are used for nominal or ordinal variables. In this case, you would be displaying the average length of stay by service and then within each service have a bar for each gender

What is the average of the sum of the relative weights of all patients treated during a specified time period? ●Case-mix index ●Outlier pool ●Share ●Mean qualifier

Case-mix index Case-mix index is the sum of the relative weights of all patients treated during a specified time period

Passwords provide: ●Access control ●Data Authentication ●Entity authentication ●Firewall control

Data authentication Data authentication and entity authentication are under access control

This type of data is numerical values that represent whole numbers. ●Nominal data ●Ordinal data ●Discrete data ●Continuous data

Discrete data Examples of discrete data that must be represented by whole numbers include the number of children in a family or the number of unbillable patient accounts

Medicare's payment system for home health services consolidates all types of services, such as speech, physical, occupational therapy, into a single lump-sum payment. What type of healthcare payment method does this lump-sum payment represent? ●Global payment ●Capitated rate ●Customary, prevailing, and reasonable ●Resource-based relative value scale

Global payment In the global payment method, the third-party payer makes one combined payment to cover the services of multiple providers who are treating a single episode of care. This payment method consolidates payments from the healthcare payer

Ultimate responsibility for the quality of care in an acute care organization falls to the: ●Safety Committee ●Governing body ●Centers for Medicare and Medicaid Services ●Quality Improvement Steering Committee

Governing body The governing body is ultimately responsible for the quality of care provided in any organization. Today, governing bodies are more involved in QI efforts than ever before. Board members are seeking training, asking questions, and insisting on seeing data confirming that care is improving within their organization. When a board expresses interest and concern about the quality of care being provided, it sets the bar for medical staff, administrative, and staff involvement

A patient's name is typically stored in a database as three data elements-last name, first name, and middle name- and not as a single data element. Which dimension of data quality is being applied when this occurs? ●Accuracy ●Granularity ●Precision ●Currency

Granularity Data granularity is sometimes referred to as data "atomicity," which means that the individual data elements cannot be further subdivided; they are "atomic"

This type of data display tool is used to illustrate frequency distributions of continuous variables, such as age or length of stay (LOS). ●Bar graph ●Histogram ●Pie chart ●Scatter diagram

Histogram A histogram is used to display a frequency distribution. It is different from a bar graph in that a bar graph is used to display data that fall into groups or categories (nominal or ordinal data) when the categories are non-continuous or discrete

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the a. Hospital Bylaws, Rules, and Regulations. b. Policy and Procedure Manual. c. Federal Register. d. Consolidated Manual for Hospitals.

Hospital Bylaws, Rules, and Regulations.

The Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) expanded CMS quality initiative to which two settings? ●Skilled nursing facilities and ambulatory surgical centers ●Hospital outpatient departments and ambulatory surgical centers ●Hospital outpatient department and physician group practices ●Skilled nursing facilities and physician group practices

Hospital outpatient departments and ambulatory surgical centers The Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) expanded CMS quality initiatives to the hospital outpatient and ambulatory surgical center areas

A health record that includes all health-related information generated for an individual during his or her lifetime is called: ●Latitudinal health record ●Electronic health record ●Personal health record ●Longitudinal health record

Longitudinal health record The longitudinal health record is a health record that may include all health-related information generated for an individual during his or her lifetime

The federlly mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the a. MDS. b. OASIS. c. UHDDS. d. DEEDS.

MDS

Which of the following is a genetic term for a healthcare reimbursement system that manages cost, quality, and access to services? ●Quality improvement ●Subacute care ●Managed Care ●Patient-focused care

Managed care Managed care is a genetic term for a healthcare reimbursement system that manages cost, quality, and access to services. Most managed care plans do not provide healthcare directly. Instead, they enter into contracts with the physicians, hospitals, and other healthcare providers who provide medical services to enrollees in the plans.

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for LaTour and Eichenwald-Maki, p 530 a. including the surgeon in the preanesthesia assessment. b. marking the surgical site. c. including the primary caregiver in surgery consults. d. apprising the patient of all complications that might occur.

Marking the surgical site

Which one of the following healthcare information systems is most likely to utilize barcoding technology for patient safety purposes? ●Telemedicine ●Medication administration ●Computerized provider order entry (CPOE) ●Picture archiving and communication systems (PACS)

Medication administration The bar code symbol was standardized for the healthcare industry, making it easier to adopt bar-coding technology and to realize its potential. Since then, bar-coding applications have been adopted for labels, patient wristbands, specimen containers, business/employee/patient records, library reference materials, medication packages, dietary items, paper documents, and more

The technology that considers syntax, semantics, and context to accurately process and extract speech data is: ●Boolean word search ●Speech recognition technology ●Continuous speech input ●Natural language processing

Natural language processing Natural language processing technology considers sentence structure (syntax), meaning (semantics), and context to accurately process and extract free-text data, including speech data for application purposes. When one talks at natural speed without pausing between words, the natural voice bytes are, indeed, processed by this technology

Among the following, who on the IT department staff would likely have as part his/her position description "design, test, and evaluate LAN, internet and intranet"? ●Database administrator ●Network administrator ●Telecommunications specialist ●Systems analyst

Network administrators Network administrators are involved in installing, configuring, managing, monitoring, and maintaining network applications. They are responsible for supporting the network infrastructure and controlling user access

Still referring to the information in the table in question 88 and the delinquent record rate shown in the answer for question 89, would the facility be out of compliance with Joint Commission standards? a. Yes b. No

No

What part of the Medicare program was created under the Medicare Modernization Act of 2003 (MMA)? ●Part A ●Part B ●Part C ●Part D

Part D Medicare drug benefit was created by the Medicare Modernization Act (MMA) and implemented on January 1, 2006. The program offers outpatient drug coverage provided by private prescriptions drug plans and Medicare Advantage

Which of the following is an example of a 1:1 relationship? ●Patients to hospital admissions ●Patients to consulting physicians ●Patients to clinics ●Patients to hospital bed

Patients to hospital bed A one-to-one relationship exists when an instance of to entity (a row or record) is associated with one instance of another entity, and vice versa. There is only one bed per patient and one patient per bed. One-to-one relationships are rare models because they often indicate a separate entity is unnecessary

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome. ●Outcome measure ●Data measure ●Process measure ●System measure

Process measure Performance measurement gives healthcare providers an indication of an organization's performance in relation to a specified process or outcome. A process measure has a scientific basis for it

An audit trail is a good tool for which one of the following? ●Holding an individual patient accountable for actions ●Reconstructing electronic events ●Defending the corporation against an IRS audit ●Stopping attacks from the intranet to the internet

Reconstructing electronic events An audit trail is a record that shows who accessed a computer system, when it was accessed, and what operations were performed. These can be categorized as follows: individual accountability, reconstructing electronic events, problem monitoring, and intrusion detection

Which of the following are considered dimensions of data quality? ●Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency ●Relevancy, granularity, timeliness, currency, atomic, precision, and consistency ●Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency ●Relevancy, granularity, equality, currency, precision, accuracy, and consistency

Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency Common characteristics of data quality are relevancy, granularity, timeliness, currency, accuracy, precision, and consistency

Two clerks are abstracting data for a a registry. When their work is checked, discrepancies between similar data abstracted by the two clerks. Which data quality component is lacking? ●Completeness ●Validity ●Reliability ●Timeliness

Reliability Reliability is a measure of consistency of data items based on their reproducibility and an estimation of their error of measurement

A coding supervisor checks coding quality each month by having two or more coders code the same set of records and then comparing the results. This process addresses the data quality element of: ●Validity ●Granularity ●Timeliness ●Reliability

Reliability The quality of coded clinical data depends on a number of factors, including reliability. Reliability is the extent to which the data can be reproduced by subsequent measurements or tests (for example, coded clinical data are considered reliable when multiple coders assign the same codes to a record)

Formatting and/or structuring of captured information that includes the process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record defines: ●Patient health records ●Information capture ●Report generation ●Generating images through x-rays and scans

Report generation Report generation consists of the formatting and/or structuring of captured information. It is the process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record

A process of prescreening vendors before detailed vendor proposals are requested is called: ●Proposal framing ●Outsourcing analysis ●Systematic design ●Request for information

Request for information A request for information (RFI) is generally sent to a fairly extensive list of vendors that are know to offer products or systems that meet the organization's needs. The RFI is used to obtain general product information and to prescreen vendors

Who owns the health records of patients treated in a healthcare facility? ●The patient ●The physician ●The facility ●The patient's family

The facility Health records and other documentation related to patient care are the hospital or healthcare provider that created them

These codes are used to assign a diagnosis to a patient who is seeking health services but is not necessarily sick, ●E Codes ●V Codes ●M Codes ●C Codes

V Codes V codes are diagnosis codes and indicate a reason for a healthcare encounter

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin and used for administration of drugs during resuscitation." a. operative record b. nursing progress notes c. physician progress notes d. physical examination

operative record

Which of the following services is LEAST likely to be provided by a facility accredited by CARF? a. vocational evaluation b. brain injury management c. palliative care d. chronic pain management

palliative care

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? a. medical consultation b. physical exam c. pharmacy consultation d. emergency record

pharmacy consultation

Rates for population-based statistics are reported per 1,000, 10,000, or 100,000 individuals. Rate for healthcare facility statistics are reported per _____ cases. ●100 ●1,000 ●10,000 ●100,000

100 Reporting statistics for a healthcare facility is similar to reporting statistics for a community. Rates for healthcare are reported as per 100 cases or percent; a community rate is reported as per 1,000, 10,000, or 100,000 people

Patient - Length of Stay 1 - 1 2 - 3 3 - 5 4 - 3 5 - 2 6 - 29 7 - 3 8 - 4 9 - 2 10 - 1 ●29 ●1 ●5 ●28 The following table shows the LOS for a sample of 11 discharged patients. Using the data listed, calculate the range.

28 The range is the simplest measure of spread. It is the difference between the smallest and largest values in a frequency distribution: Range = Xmax - Xmin For this scenario, the range is 1 to 29 (29-1) or 28

Community Memorial Hospital discharged nine patients of April 1st. The length of stay for each patient is shown in the following table. The average length of stay for these nine patients was: Patient - Number of Days *A - 1 *B - 5 *C - 3 *D - 3 *E - 8 *F - 8 *G - 8 *H - 9 *I - 9 ●5 days ●6 days ●8 days ●9 days

6 days The average length of stay (ALOS) is calculated from the total LOS. The total LOS is divided by the number of patient discharged is the ALOS. Using the data provided, the ALOS for the 9 patients discharged on April 1st is 6 days. (54/9)

Patient was admitted for cellulitis of the palm of the hand following a non-venomous insect bite 3 days prior to the encounter. How would this encounter be coded? *008.43 Campylobacter *682.1 Other cellulitis and abscess, neck *682.4 Other cellulitis and abscess, hand except fingers and numb *914.5 Superficial injury of hand(s), except finger(s) alone, insect bite, nonvenomous, infected *E9064 Other injury caused by animals, bite of nonvenomous arthropod *86.3 Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue _________________________________________________ ●914.5, E906.4, 86.3 ●682.2, 914.5 ●008.43 ●682.4, 914.5, E906.4

682.4, 914.5, E906.4 The cellulitis is of the palm and should be coded first as the reason for the encounter. Additional codes are also used to represent the insect bite

A patient that has been diagnosed with hypertension visits her physician on a monthly basis. The nurse conducted the blood pressure check under the physician's supervision. Code the office visit. ●99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician ●99201, Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components: problem focused history and examination, straightforward medical decision ●99203, Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components: detailed history and examination, low complexity medical decision ●99212, Office or other outpatient visits for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: problem focused history and examination, straightforward medical decision

99211, Office or other outpatient visits of the evaluation and management of an established patient that may not require the presence of a physician For established patients, the requirements differ depending on the level of service. Code 99211 does not require a history, examination, medical decision making or presence of a physician

For healthcare organizations, this modern process began with the adoption of the Minimum Standards: ●Accreditation ●Licensing ●Reform ●Educational

Accreditation Adoption of the Minimum Standards was the basis of the Hospital Standardization Program and marked the beginning of the modern accreditation process for healthcare organizations. Basically, accreditation standards are developed to reflect reasonable standards

In its payment notice (remittance advice), the healthcare plan lists that the payment for an individual laboratory test is $39. The bill that the pathologist's office submitted for the laboratory test was $45. What does the amount of $39 represent? ●Cost ●Allowable fee ●Premium ●Capitated rate

Allowable fee In a fee-for-service environment, third party payers establish a fee schedule. A fee schedule is a predetermined list of fees that the third-party payer allows for payment for all healthcare services. The allowable fee represents the average or maximum amount the third-party payer will reimburse providers for the service

Which of the following sites is considered a facility in the RBRVS payment system? ●Physician office ●Dialysis center ●Independent laboratory ●Ambulance

Ambulance Physician offices, clinics, dialysis centers, independent laboratories, non-skilled nursing facilities, and patients' homes are all considered non-facilities in the RBRVs

In data quality management the purpose for which data are collected is: ●Warehousing ●Collection ●Application ●Analysis

Application Data quality management functions involve continuous improvement for data quality throughout an organization. This includes the application process which is the purpose for which data are collected.

University Medical Center contracts with the XYZ Corporation for a clinical information system. The hospital pays a fixed monthly fee. XYZ owns the hardware and hosts the application software using the Internet. The Medical Center accesses the system through onsite workstations. In this situation, XYZ Corporation is a(n): ●Application service provider ●Neural network ●Health information system database ●Clinician portal

Application service provider Application service providers (ASPs) are service firms that deliver, manage, and remotely host ("remote hosting" being a common term associated with (ASPs) standardized (prepackaged) applications software through centralized servers via a network, not exclusively, but more commonly, the Internet

Which of the following is an effective method of evaluating responses to a request for proposal (RFP) ●Testing the new system ●Negotiating contracts with all vendors and assessing the best price ●Attending user group meetings ●Visiting sites that use the systems of product competitors

Attending user group meetings Formal and informal mechanisms should be used to evaluate each vendor and its products. For example, the project may hold vendor presentations, check references, attend user group meetings, and make site visits to other facilities that use the product. The purpose of these activities is to gather as much relevant information as possible to make an informed decision

Which of the following is a mechanism that records and examines activity in information systems? ●eSignature laws ●Audit controls ●Minimum necessary rules ●Access controls

Audit controls Audit controls are the mechanisms that record and examine activity in information systems. HIPAA does not specify what forms of audit controls must be used, how or how often they must be examined, or how long they must be retained

A CT scan is an example of _____ data. ●Audio ●Bit-mapped ●Free-text ●Structured

Bit-mapped Diagnostic image data, such as a digital chest x-ray or a computed tomography (CT) scan stored in a diagnostic image management system, represent a different type of data called bit-mapped data. The format of bit-mapped data also is unstructured. Saving each bit of the original image creates the image file

The preadmission Screening Assessment and Annual Resident Review (PASARR) is a requirement that provides a mechanism for screening mental illness and mental retardation (MI/MR) and is mandated by: ●The federal government ●State government ●Local government ●Both the federal and state government

Both the federal and state government The PASARR for MI/MR is required under the Omnibus Budget Reconciliation Act of 1987. It is completed preadmission and annually

A medical staff committee wants to compare long-term survival rates for breast cancer by comparing outcomes for the mastectomy versus lumpectomy approaches. The best source of this information is the: ●Disease Index ●Operative Index ●Cancer registry ●Master patient index

Cancer registry A cancer registry collects demographic information (such as name, health record number, address), type and site of cancer, diagnostic methodologies, treatment methodologies, stage at the time of diagnosis and periodically collect follow-up on the patient's survival status

In data quality management, the process by which data elements are accumulated is: ●Warehousing ●Collection ●Application ●Analysis

Collection The second process of data quality management is collection, which is the process by which data elements are gathered.

Which of the following is the goal of quantitative analysis performed by HIM professional? ●Ensuring the record is legible ●Identifying deficiencies early so they can be completed ●Verifying that health professionals are providing appropriate care ●Checking to ensure bills are correct

Identifying deficiencies early so they can be completed Quantitative analysis is a review of the health record for identifying deficiencies for completeness and accuracy. It is generally conducted retrospectively, that is, after the patient discharge from the facility or at the conclusion of treatment

A protocol to pass data from the R-ADT system of one vendor to the laboratory information system of another vendor is called: ●OLAP ●Integration ●TCP/IP ●Interface

Interface Interface is the hardware, software, data definitions, and standard messaging protocols required for data to be exchanged among separate computer systems. In this case, the interface allows the information to pass from the R-ADT system to the laboratory vendor system

Of the following, what is the most likely to happen to the health records of a physician's patient when a physician leaves an office practice? ●It will be sent to the state department of health ●It will be sent to outside storage ●It will be destroyed ●It will be retained by the practice

It will be retained by the practice In physician practices, patients are informed of their option to transfer their records to another provider. The majority of complete contracts specify that the provider group owns health records

What is the term used for the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business, or payment purpose? ●Minimum data record ●Legal health record ●Mixed-media health record ●Electronic health record

Legal health record The legal health record is the record of care in any health-related setting, used by healthcare professionals while providing patient-care or for administrative, business, or payment purposes

An encoder takes a coder through a series of questions and choices is called a(n): ●Automated codebook ●Automated code assignment ●Logic-based encoder ●Decision support database

Logic-based encoder A logic-based encoder prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition and any possible complications or comorbidities

The ability to interconnect networks of clinicians, make information portable, and move consumers from one healthcare provider to another are the primary objectives of: ●National Health Information Network ●National Committee on Vital and Health Statistics ●Health Level Seven ●EHR Collaborative

National Health Information Network The National Health Information Network's primary objectives are to interconnect networks of clinicians, make information portable, and move consumers from one healthcare provider to another

This type of data is also called ranked data and expresses the comparative evaluation of various characteristics or entities, and relative assignment of each, to a class according to a set of criteria. ●Nominal data ●Ordinal data ●Discrete data ●Continuous data

Ordinal data Most survey data use a Lickert scale to quantify or rank statements. This is an example of the ordinal data

The combination of certain items (such as anesthesia, supplies, and drug(s) for the purpose of reimbursement is called: ●Packaging ●Discounting ●Rate setting ●Case mix

Packaging Packaging means that payment for that service into payment for other services and, therefore is no separate PAC payment. Packaged services might include minor ancillary services, inexpensive drugs, medical supplies, and implantable devices.

In figuring a drug dosage, it is acceptable to round up to the nearest gram if the drug is to be closed in milligrams. Which dimension of data quality is being applied in this situation? ●Accuracy ●Granularity ●Precision ●Currency

Precision Precision often relates to numerical data. It denotes how close to an actual size, weight, or other standard a particular measurement is

A person who states, "Our main job is to prevent injury and property loss," is primarily concerned with: ●Credentialing ●Utilization management ●Risk management ●Severity indexing

Risk management Risk management is a program designed to reduce or prevent injuries and accident and to minimize or prevent financial loss to the organization

The process of overseeing the medical, legal, and administrative operations within a healthcare organization is performed in this quality management function. ●Infection control ●Clinical quality management ●Utilization management ●Risk management

Risk management Risk management is a program designed to reduce or prevent injuries and accidents and to minimize or prevent financial loss to the organization

An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system? ●Role-based ●User-based ●Context-based ●Situation-based

Role-based Role-based access control (RBAC) is a control system in which access decisions are based on the roles of individual users as part of an organization

The role of the chief information officer (CIO) focuses on: ●Programing applications ●Supporting network infrastructure ●Installing and maintaining network applications ●Strategic information systems planning

Strategic information systems planning The CIO is responsible for helping to lead the strategic IS planning process, managing the major functional units within the IS department, and overseeing the management of information resources throughout the enterprise

What does syntax refer to? ●Common meaning of terms in a message ●Context of words in narrative form ●Structure of data elements in a message ●Text processing

Structure of data elements in a message Message format standards ensure that the structure and format of data are the same, as they are being transmitted from one system to another. This data structure and format is called syntax. Each proprietary system has its own syntax. For systems to exchange data or "talk" to one another, the syntax must be made the same

For an EHR to provide robust clinical decision support, what critical element must be present? ●Structured data ●Internet connection ●Physician portal ●Standard vocabulary

Structured data If an EHR is to provide clinical decision support it requires two things: structured data and clinical data repository

The data elements in a patient's automated laboratory result are examples of: ●Unstructured data ●Free-text data ●Financial data ●Structured data

Structured data The data elements in a patient's automated laboratory order, result, or demographic or financial information system are coded and alphanumeric. Their fields are predefined and limited. In other words, the type of data is discrete, and the format of these data is structured

What is your zip code? Sex (circle one): Male Female What is your age? 00-17_____ 18-35_____ 36-45_____ 46-60_____ For the following excerpt from a patient satisfaction survey, determine if, in the development of this survey, the designer is adhering to good survey design principles. ●All survey design principles were applied in the development of this survey ●The survey design principle of consistent format was applied in the development of this survey ●The survey design principle of mutually exclusive categories was applied in the development of this survey ●The survey design principles were not applied in the development of this survey

The survey design principles were not applied in the development of this survey Surveys should be written at the reading level of the respondents, consistent formats should be used, all possible responses should be mutually exclusive, and terminology that the respondents understand should be incorporated. This survey used inconsistent formatting and did not have mutually exclusive responses in the age question

The health plan reimburses Dr. Tan $15 per patient per month. In Janurary, Dr. Tan saw 300 patients so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan? ●Traditional retrospective ●Capitated rate ●Relative value ●Discounted fee schedule

Capitated rate Capitated rate is a method of payment for health services in which the third-party payer reimburses providers a fixed, per capita amount for a period. Per capita mean per head or per person. A common phrase in capitated contracts is per member per month (PMPM). The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs

This document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in an LTCH. ●Face sheet ●Care plan ●Diagnosis plan ●Flow sheet

Care plan Care plans are required documentation in an LTCH. Some LTCHs may use critical paths (or clinical pathways) for specific patients

All records for a specific patient, both inpatient and outpatient, are filed together One benefit of the unit filing system that all records for a specific patient, both inpatient and outpatient, are filed together

Electronic data interchange Electronic data interchange (EDI) allows the transfer (incoming and outgoing) of information directly from one computer to another by using flexible, standard formats. The billing function was one of the first to utilize this technology in healthcare

A computer software program that supports a coder in assigning correct codes is called a(n): ●Encoder ●Grouper ●Automated coder ●Decision support system

Encoder An encoder is used to increase the accuracy and efficiency of the coding process. Although encoders can cite official coding guidelines and provide code optimization guidance, they require user interaction. Encoders promote accuracy as well as consistency in the coding of a diagnoses and procedures

The national association that promotes quality care by certifying qualified professionals is know as the: ●National Committee on Quality Assurance ●National Association of Healthcare Quality ●Institute for Clinical Systems Improvement ●Healthcare Facilities Accreditation Program

National Association of Healthcare Quality The National Association of Healthcare Quality (NAHQ) promotes continuous QI efforts in healthcare organizations by certifying qualified professionals. This organization offers QI professional's educational opportunities regardless of the healthcare setting they work in

A system of names or terms used for a particular discipline created to facilitate communication by eliminating ambiguity is called: ●Data dictionary ●Clinical classification ●Nomenclature ●Clinical vocabulary

Nomenclature A nomenclature is a system of names or terms used for a particular discipline created to facilitate communication by eliminating ambiguity. The terms classification and nomenclature are often used interchangeably, but they are different. A classification system categories and aggregates, while a nomenclature supports detailed descriptions

This type of data is also called categorical data and includes values assigned to name-specific categories. ●Nominal data ●Ordinal data ●Discrete data ●Continuous data

Nominal data Gender can be subdivided into two groups, male or female, or groups 1 or 2. This is an example of nominal or categorical data

Which RFP component would fit the following description? Describe the EHR product's data architecture, analytical processes supported, necessary interfaces, reliability and security features, system capacity, expansion capabilities, response time, downtime, and other issues associated with system maintenance. ●Functional specifications ●Operational requirements ●Organizational profile ●Vender information

Operational requirements The operational requirements elicit information on the EHR product's data architecture, analytical processes supported, necessary interfaces, reliability and security features, system capacity, expansion capabilities, response time, downtime, and other issues associated with system maintenance

The incidence of postoperative wound infections occurring in ORIF procedures in which antibiotics were and were not utilized is an example of this type of performance measure? ●Outcome measure ●Data measure ●Process measure ●System measure

Outcome measure Performance measurement in healthcare provides an indication of an organization's performance in relation to a specified process or outcome. An outcome measure may be the effect of care, treatment, or services on a customer

This EHR turnover strategy continues with its paper processing until the EHR works as planned. ●Parallel processing ●Phased roll-out ●Pilot ●Straight turnover

Parallel processing Parallel processing is a turnover strategy where the organization in manual form as electronic form. The intent is to validate the electronic processing against the manual processing

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is a.)Pathology b.) operative report c.)discharge summary d.) recovery room record

Pathology report

The clinical statement: "microscopic sections of the gallbladder reveal a surface lined by tall columnar cells of uniform size and shape" would be documented on which health record form? ●Operative report ●Pathology report ●Discharge summary ●Nursing note

Pathology report A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also contain information about the size, shape, and appearance of a specimen as it looks to the naked eye. This information is known as the gross description.

The MPI includes which of the following information? ●Patient's date of birth, height, and gender ●Patient's health record number, blood pressure reading, and age ●Patient's gender, height, and weight ●Patient's date of birth, gender, and health record number

Patient's date of birth, gender, and health record number The MPI includes data elements necessary to identify a patient. These elements include date of birth, complete address, phone numbers, health record number, billing or account number, name of attending physician, dates of admission and discharge, disposition, marital status, gender, race, and patient's emergency contact

Establishing security, confidentiality, retention, integrity and access standards are examples of which HIM function? ●Policy development ●Data modeling ●Strategic planning ●Classification and coding

Policy development A policy is a critical tool to ensure consistent quality performance. It is a statement about what an organization or department does. One function of the HIM professional would have to develop policies related to security, confidentiality, retention, integrity, and access standards

The interrelated activities in healthcare organizations that promote effective and safe patient outcomes across services and disciplines within an integrated environment are included in what area of performance measurement? ●Outcomes ●Processes ●Systems ●Benchmarks

Processes Healthcare performance improvement philosophies most often focus on measuring performance in systems, processes, and outcomes. The interrelated activities in healthcare organizations that promote effective and safe patient outcomes are examples of processes

An important characteristic of web-services architecture is: ●Freely available software from the web ●Programs that act as a web browser ●Use of the Internet for transmission of information ●Wide area network design

Programs that act as a web browser Web-based, or web service architectures (WSA), uses the technology concepts of the Internet and World Wide Web for local area (intranets) or wide area (extranet) network design

The following performance standard, "File 50 to 60 records per hour" is an example of a: ●Quality standard ●Quantity standard ●Joint Commission standard ●Compliance standard

Quantity standard Quantity standards (also called productivity standards) and quality standards (also known as service standards) are generally used by managers to monitor individual employee performance and the performance of a functional unit or the department as a whole. To properly communicate performance standards, managers need to make the distinction between quantitative and qualitative standards and identify examples of each for this HIS functions

What process helps to ensure the quality and completeness of health record content in both paper-based and computer-based environments? ●Standardization of data-capture tools ●Data exchange standards ●Standardization of abbreviations ●Authentication of health record entries

Standardization of data-capture tools Standardization of date-capture tools helps ensure the quality and completeness of health record content in both paper-based and computer-based environments

The inpatient data set incorporated into federal law and required for Medicare reporting is the: ●Ambulatory Care Data Set ●Uniform Hospital Discharge Data set ●Minimum Data Set for Long-term Care ●Health Plan Employer Data and Information Set

Uniform Hospital Discharge Data Set Medicare requires that all inpatient hospitals collect a minimum set of patient-specific data elements, which are in databases formulated from hospital discharge abstract systems. The patient-specific data elements are referred to as the Uniform Hospital Discharge Data Set

Copies of personal health records (PHRs) are considered part of the legal health record when: ●Consulted by the provider to gain information on a consumer's health history ●Used by the organization to provide treatment ●Used by the provider to obtain information on a consumer's prescription history ●Used by the organization to determine a consumer's DNR status

Used by the organization to provide treatment Only when copies of the PHR are used for treatment can they be considered part of the facilities' legal health record

A key element in the structure of a decision support system that assists in presenting the results to the user is called the: ●Brain of the DSS ●User interface ●Report wizards ●Quick response

User interface The user interface element provides a friendly and interactive environment for user interaction with system. The user interface presents questions, checks responses for legal answers and supplies user's responses to the inference engine

A key element in effective systems implementation is: ●Contract negotiation ●User training ●System evaluation ●RFP analysis

User training During the implementation phase of the SDLC, a comprehensive plan for implementing the new system is developed. This plan would include all plans for training managers, technical staff, and other end-users

Data mining is a process that involves which of the following? ●Using reports to measure outcomes ●Using sophisticated computer technology to sort through an organization's data to identify unusual patterns ●Producing summary reports for management to run the daily activities of the organization ●Producing detailed reports to track productivity

Using sophisticated computer technology to sort through an organization's data to identify unusual patterns Data mining is the process of probing and extracting business data and information from a data warehouse and then quantifying and filtering the data for analysis purposes

A group of processes used to measure how efficiently healthcare organizations use their resources is performed in what quality management function? ●Infection control ●Clinical quality assessment ●Utilization management ●Risk management

Utilization management A utilization management program helps ensure that patients receive appropriate care in an efficient and cost-effective manner

What process is being carried out when a hospital reviews the quantity and type of resources being used in the provision of chemotherapy treatments? ●FOCUS-PDCA review ●Accreditation Review ●Medication reconciliation ●Utilization management review

Utilization management review Utilization management is defined as the evaluation of the medical necessity, appropriateness of the use of healthcare services, procedures, and facilities. In this situation, the organization is reviewing the appropriateness of resources related to chemotherapy treatments

Data edits included in software to detect errors are used to check the____ of the data. ●Validity ●Reliability ●Timeliness ●Compatibility

Validity Validity refers to the accuracy of the data. (The extent to which data corresponds to the actual state of affairs or that an instrument measures what it supports to measures)

A group of devices that connect to a local area network via radio waves is what type of network? ●Local area network ●Wide area network ●Wireless local area network ●Virtual private network

Wireless local area network A wireless local area network (WLAN) is a group of wireless devices that connect to a LAN via radio waves

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be a. recorded by persons authorized by hospital regulations and procedures. b. co-signed by the attending physician within 4 hours of giving the order. c. accepted by charge nurses only. d. written within 24 hours of the patient's admission.

recorded by persons authorized by hospital regulations and procedures.

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with a. recovery audit contractors. b. QIO physicians. c. MEDPAR representatives. d. the OIG.

recovery audit contractors.

If an HIM department receives gifts from vendors in exchange for purchasing a specific encoder software, this is: ●Abuse ●Negligence ●Malpractice ●A Kickback

A kickback The Federal Anti-Kickback Statute establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce business for which payment may be made under any federal healthcare program. This includes transfer or anything of value, in cash or in kind, whether made directly or indirectly

Which of the following statements is true about APCs? ●APs are based solely on the patient's principal diagnosis ●ICD-9-CM procedure codes are used to group patients ●Severity of illness is taken into consideration when grouping APCs ●APCs are based on the CPT or HCPCS code(s) reported

APCs are based on the CPT or HCPCS code(s) reported Ambulatory payment classification (APCs) are based on the CPT or HCPCS code(s) reported in billing

What organization was established in 1847 to represent the interests of physicians across the United States? ●American Association of Medical Colleges ●American College of Surgeons ●Committee on Medical Education ●American Medical Association

American Medical Association The American Medical Association (AMA) was established in 1847, to represent the interests of physicians across the United States. However, members who had strong ties to the medical schools and the status quo dominated the AMA. Its ability to lead a reform of the profession was limited until its ties with the medical schools in 187. At that time, the association encouraged the creation of independent state licensing boards

In data quality management, _____ is the process of translating data into information utilized for an application. ●Analysis ●Warehousing ●Collection ●Application

Analysis Data quality management functions involve continuous improvement for data quality throughout an organization and include four key processes for data. These processes are application, collection, warehousing, and analysis. Analysis is the process of translating data into information

The primary responsibility of a coder is to: ●Ensure timely processing of coded data ●Ensure quality of coded data ●Avoid claims rejections by third-party payers ●Ensure maximum reimbursement for the facility

Ensure quality of coded data The coding professional's first responsibility is to ensure the accuracy of coded data. To this end, AHIMA has established a code of professional ethics by which coders must abide

Which of the following best describes the intent of strategic information systems planning ●Provide the potential for growth and expansion ●Ensure that all IS technology initiatives are integrated and aligned with the organization's overall strategy ●Assess community/market needs and resources ●Ensure ongoing accreditation

Ensure that all IS technology initiatives are integrated and aligned with the organization's overall strategy Strategic IS planning is the process of identifying and prioritizing IS needs based on the healthcare organization's mission and strategic goals

What is the data model that is most widely used to illustrate a relational database structure? ●Unified medical language ML ●Entity-relationship diagram ●Object model ●Relational model

Entity-relationship diagram The entity-relationship diagram (ERD) was developed to depict relational database structures. It can be used to depict conceptual-level models for any type of database but would only be used to model a relational database at the logical level

When an Entity Relationship Diagram (ERD) is implemented as a relational database, an attribute will become a(n): ●Table ●Field ●Object ●Query

Field Attributes are the characteristics or data elements to be collected about each entity. They can be depicted in an ERD as oval shapes coming off an entity. Attributes become the fields or column headings within the data tables of a relational database

What type of data is exemplified by the insured party's member identification number? ●Demographic data ●Clinical data ●Certification data ●Financial data

Financial data Financial data includes details about the patient's occupation, empoyer, and insurance coverage and are collected at the time of treatment

Which of the following is a kind of technology that focuses on data security? ●Clinical decision support ●Bit-mapped data ●Firewalls ●Smart cards

Firewalls Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders

The process of normalization in a data warehouse works to eliminate: ●Access ●Redundancy ●Transactions ●Queries

Redundancy In a transactional system, the database has been constructed according to well-established principles of relational database design, in particular, normalization. Normalization seeks to eliminate redundancy in data storage

An HIM director wants to conduct research to learn about the physician's view of the department's image. What type of scale should she use to collect data? ●Meta-analytical scale ●Semantic differential scale ●Two-point scale ●Purposive Scale

Semantic differential scale Researchers, marketers, and others use a semantic differential scale to ascertain a group's perspective image of a product, healthcare organization, or program

The federal physician self-referral statute is also known as the: ●Sherman Anti-Trust Act ●Deficit Reduction Act ●False Claim Act ●Stark Law

Stark Law The Stark Law or Federal Physician Self-Referral Statute prohibits physicians ordering services for Medicare patients from entities with which the physician or an immediate family member has a financial relationship

Performance measures can be described best as: ●Methods for data analysis ●Safety practices ●Statements of expectation ●Universal protocols

Statements of expectation Individuals involved in QI processes in healthcare organizations must determine who the customers are, what they want, and what must be done to meet their expectations. Expectations must translate into performance requirements so that healthcare professionals can evaluate whether customers' needs are being met. This leads to developing statements of expectation or performance measures

When an ERD is implemented as a relational database, an entity will become a(n): ●Query ●Form ●Object ●Table

Table An entity becomes a table in your relational database because it is the person, place, or thing about which you are collecting the data in your database, You would need to be able to query data on each entity from the database

Which numerical filling system results in an even distribution of records and ensures activity throughout the filing area? ●Serial-unit filing system ●Serial filing system ●Unit filing system ●Terminal-digit filing system

Terminal-digit filing system A terminal-digit filing system is a health record identification and filing system in which the last digit or group of digit (terminal digits) in the health record numbers determines file placement

The statement "All patients admitted with a diagnosis falling into IC-9-CM code numbers 800 through 959" represents a possible case definition for that type of registry? ●Birth defect registry ●Cancer registry ●Diabetes registry ●Trauma registry

Trauma registry Disease registries are collections of secondary data related to patients with a specific diagnosis, condition, or procedure. Registries are different from indexes in that they contain more extensive data. Index reports can usually be produced using data from the facility's existing databases. Registries often require more extensive data from the patient record. Each registry must define the cases that are to be included in it. This process is called case definition. In a trauma registry, for example, the case definition might be all patients admitted with a diagnosis falling into ICD-9-CM code numbers, the trauma diagnosis codes

A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers' compensation insurance. The workers' compensation insurance paid the fees of the neurosurgeon. Which entity is the "third party"? ●Patient ●Neurosurgeon ●Basic Manufacturing Company ●Workers' compensation insurance

Workers' compensation insurance Workers' compensation is a payer that pays for healthcare services due to work-related incidents

In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? ●X12N ●LOINC ●IEE 1073 ●DICOM

X12N X12N refers to standards adopted for electronic data interchange. In order for transmission for healthcare data between a provider and payer, both parties must adhere to these standards.

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement? a. Yes, within 24 hours postsurgery b. Yes, prior to surgery c. No, as long as it is done ASAP d. Yes, within 8 hours postsurgery

Yes, prior to surgery

As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use a. follow-up files. b. accession register. c. patient index. d. patient abstracts.

accession register.

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave a. documented in both the progress notes and the discharge summary. b. reported to the Executive Committee. c. reported as a potentially compensable event. d. documented in an incident report and filed in the patient's health record.

documented in both the progress notes and the discharge summary.

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of a. voice recognition systems. b. expert systems. c. fingerprint signatures. d. electronic signatures

electronic signatures

As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the a. MDS. b. glossary of health care terms. c. facility's data dictionary. d. UHDDS.

facility's data dictionary.

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the a. subjective review of systems. b. family history as related by the patient. c. chief complaint. d. general appearance as assessed by the physician.

general appearance as assessed by the physician.

A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be a. condition on discharge. b. time and means of arrival. c. chief complaint. d. growth and development record.

growth and development record.

An example of a primary data source for health care statistics is the a. hospital census. b. MPI. c. accession register. d. disease index.

hospital census.

The authors of all entries in a health care record should be a. identified by biometrics. b. approved by the HIM Director. c. identified by a PIN. d. clearly identified.

identified by biometrics

The foundation for communicating all patient care goals in long-term care settings is the a. medical history. b. interdisciplinary plan of care. c. legal assessment. d. Uniform Hospital Discharge Data Set.

interdisciplinary plan of care

You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be a. medical staff rules and regulations. b. Joint Commission accreditation manual. c. quality management plan. d. medical staff bylaws.

medical staff rules and regulations

In creating a new form or computer view, the designer should be most driven by a. medical staff bylaws. b. needs of the users. c. QIO standards. d. flow of data on the page or screen.

needs of the users

The best example of point-of-care service and documentation is a. using occurrence screens to identify adverse events. b. doctors using voice recognition systems to dictate radiology reports. c. using an automated tracking system to locate a record. d. nurses using bedside terminals to record vital signs.

nurses using bedside terminals to record vital signs

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? a. physician index b. master patient index c. disease index d. operation index

operation index

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following. a. patient moving about very cautiously, appears to be in pain b. adjust pain medication; begin physical therapy tomorrow c. sciatica unimproved with hot pack therapy d. patient states low back pain is as severe as it was on admission

patient states low back pain is as severe as it was on admission

An example of objective entry in the health record supplied by a health care practitioner is the a. physical assessment. b. chief complaint. c. past medical history. d. review of systems.

physical assessment.

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document a. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant. b. a chronological description of patient's present condition from time of onset to present. c. past and current activities, such as smoking and drinking habits. d. objective symptoms observed by the physician.

subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

When developing a data collection system, the most effective approach first considers a. applicable accreditation standards. b. hardware requirements. c. the end user's needs. d. facility preference.

the end user's needs

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman a. that you apologize for not noticing the H&P she provided. b. the H&P copy is acceptable as long as she documents any interval changes. c. a new H&P is required for every inpatient admission. d. Joint Commission standards do not allow copies of any kind in the original record.

the h&p is acceptable as long as she doc any interval change

The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate a. adverse effects and contraindications of drugs utilized during hospitalization. b. potentially compensable events. c. quality of care through the use of preestablished criteria. d. the overall quality of documentation.

the overall quality of documentation.

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding a. whether the severity of illness and/or intensity of service warranted acute level care. b. the quality of follow-up care. c. whether a postoperative infection occurred and how it was treated. d. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

A primary focus of screen format design in a health record computer application should be to ensure that a. data fields can be randomly accessed. b. paper forms are easily converted to computer forms. c. the user is capturing essential data elements. d. programmers develop standard screen formats for all hospitals.

the user is capturing essential data elements.

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the a. lab and diagnostic test results. b. time and means of arrival. c. physical findings. d. instructions for follow-up care.

time and means of arrival

Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data a. timeliness. b. precision. c. reliability. d. validity.

validity

Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? Physician's normal charge = $340 Medicare Fee Schedule = $300 Patient has met deductible ●$228 ●$240 ●$285 ●$300

$228 Nonparticipating provider (nonPARs) do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians) of the Medicare fee schedule (MFS). For example, if the MFS amount is $200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider receives only $152 (95 percent of $160). In this case the physician is Nonparticipating so he/she will receive 95 percent of the 80 percent of the MFS or 80 percent of 300 is $240; 95 percent of the $240 is $228. Medicare will reimburse the physician $240 and the patient's liability is $60

Using the information provided, if this is a participating physician who accepts assignment, how much can he or she expect to be reimbursed by Medicare? _________________________________________________ Physician's normal charge = $340 Medicare fee schedule = $300 Patient has met his deductible ●$140 ●$240 ●$300 ●$340

$240 Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians) of the Medicar Fee Schedule (MFS). For example, if the MFS amount is $200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider receiver only $152 (95 percent of $160). In this case, the physician is participating so he or she will receive 80 percent of the MFS or 80 percent of 300 = $240

The child's prescription drug is not the healthcare plan's formulary. The pharmacist states that the drug's cost is $113.45. Using the information procided on the patient's prescription coverage, how much should the guarantor expect to pay for the prescription? *Tier 1-Generic $10 *Tier 2-Formulary without Generic $25 *Tier 3-Formularty with Generic $35 *Tier 4-Non-Formulary $40 _________________________________________________ ●$10 ●$25 ●$40 ●$113.45

$40 The copayment is a fixed dollar amount or flat fee. The fixed amount may vary by type of service, such as a visit or prescription. In this situation, the child's prescription is not on the healthcare plan's formulary (list of preferred drugs), so it would fall to the tier-4 rate of $40 for the copayment.

Using the information provided if this is a participating physician who accepts assignment, what is the patient's liability to the physician? Physician's normal charge = $340 Medicare Fee Schedule = $300 Patient has met his deductible. ●$60 ●$100 ●$160 ●The patient has no further financial liability

$60 Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare and may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95% (5% less than participating physicians) of the Medicare Fee Schedule (MFS). For example, if the MFS amount is $200, the PAR provider receives $160 (80% of 200), but the nonPAR provider receives only$152 (95% of $160). In this case, the physician is participating so he/she will receive 80% of the MFS or 80% of 300 or $240. Medicare will reimburse the physician $240 and the patient's liability is $60.

What is the correct formula for wage index adjusting a payment? ●(payment rate x nonlabor portion x WI) + (payment rate x labor portion) ●(payment rate x labor portion x WI) + (payment rate x nonlabor portion) ●(payment rate x WI) ●(payment rate x nonlabor portion x WI) + (payment rate x labor rate x COLA)

(payment rate x labor portion x WI) + (payment rate x nonlabor portion) The labor portion is adjusted for the wage index of the geographic area. This adjustment provides for the variations in wages across the country. For example, the wage index for San Francisco, CA, than in the state of Wyoming, so consequenly the salaries are higher too. Therefore, the wage index for San Francisco, CA, is higher than Wyoming's

In a normal distribution, 99.7% of the observations fall within which of the following standard deviations? ●+/- 1 s.d. of the mean ●+/- 2 s.d. of the mean ●+/- 3 s.d. of the mean ●+/- 5 s.d. of the mean

+/- 3 s.d of the mean In the normal distribution, the standard deviation indicates how many observations fall within a certain range of the mean. The areas under the curve corresponding to 1, 2, and 3 standard deviations are 68.3%, 95.4%, and 99.7%

A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code? ●-79, Unrelated procedure or service by the same physician during the postoperative period ●-25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service ●-59, Distinct procedural service ●-24, Unrelated evaluation and management service by the same physician during a postoperative period

-24, Unrelated evaluation and management service by the same physician during a postoperative period Modifier -24 is used unrelated evaluation and management service by the same physician during a postoperative period

Last year, 73,249 people died from diabetes mellitus in the United States. The total number of deaths from all causes was 2,443,387, and the total population was 288,356,713. Calculate the proportionate mortality ratio for diabetes mellitus. ●0.0003 ●10.94 ●0.09 ●0.03

0.03 The proportionate mortality ratio (PMR) is a measure of mortality due to a specific time period. In the formula for calculating the PMR, the numerator is the number of deaths due to a specific disease for a specific time period, and the denominator is the number of deaths from all causes for the same time period. The proportionate mortality ratio for diabetes mellitus = 73,249 / 2,443,387 = 0.03

A 65-year-old woman was admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? *038.11 Methicillin susceptible staphylococcus Aureus septicemia *038.8 Other specified septicemia *038.9 Unspecified septicemia *041.11 Methicillin susceptible staphylococcus aureus *562.11 Diverticulitis of colon (without mention of hemorrhage) *789.00 Abdominal pain, unspecified site ●038.8, 562.11, 789.00 ●038.11, 562.11 ●038.8, 562.11, 041.11 ●038.9, 562.11

038.11, 562.11 Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms. Code 038.11 is for septicemia with Staphylococcus aureus. Because abdominal pain is a symptom of diverticulitis, only the diverticulitis of the colon is coded

Which of the following health record numbers are in correct terminal digit order? ●00-52-84, 07-48-81, 45-58-91, 65-59-87 ●12-25-62, 11-25-68, 18-20-69, 00-24-69 ●01-52-25, 02-53-25, 03-22-35, 35-20-35 ●00-01-10, 52-01-11, 26-00-00, 00-00-12

12-25-62, 11-25-68, 18-20-69, 00-24-69 Terminal digit filing is a common method of paper record filing. Records are filed according to a three-part number made up of two-digit pairs

What is the correct CPT code assignment for electrosurgical removal of three (3) nevi of the arm (size approximately 2.0 cm, 1.5 cm, 0.5 cm)? *11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions *11200 Removal of skin tags, multiple fibrocutaneous tags, any area, up to and including 15 lesions *11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less *11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 cm to 2.0 cm *17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesiong (eg, actinic keratoses); first lesion *17003 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg,actinic keratosis); second through 14 lesions, each (List separately in addition to code for the first lesion) ●11400, 11402, 11402 ●11056 ●11200 ●17000, 17003, 17003

17000, 17003, 17003 The plus symbols (+) indicates the code following the symbol is an add-on code. In this situation, there are three lesion. Therefore, 17000 is coded for the first lesion and then 17003 is coded twice for lesions 2 and 3

Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. The patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. What is the correct CPT code assignment? *188.3 Malignant neoplasm of bladder, anterior wall of urinary bladder *198.1 Secondary malignant neoplasm of other specified sites, other urinary organs *V10.51 Personal history of malignant neoplasm, bladder *57.32 Diagnostic procedure on bladder, other cystoscopy *57.49 Other transurethral excision or destruction or destruction of lesion or tissue of bladder ●188.3, V10.51, 57.49, 57.32 ●198.1, 57.49 ●188.3, 57.49 ●198.1, 188.3, 57.49

188.3, 57.49 If the primary malignant neoplasm previously removed by surgery or eradicated by radiotherapy or chemotherapy recurs, the primary malignant code for the site is assigned, unless the Alphabetic Index directs otherwise

There were 25 inpatient deaths, including newborns, at Community Memorial Hospital during he month of June. The hospital performed five autopsies during the same period. The gross autopsy rate for the hospital for June was: ●0.02% ●0.2% ●5% ●20%

20% A gross autopsy is the proportion or percentage of deaths that are followed by the performance of autopsy. Using this data, five patients had autopsies performed out of the 25 deaths: 5 /25 = 0.2 x 100 = 20%

According to the Pareto Principle, _____ percent of the sources of a problem are responsible for _____ percent of its actual effects. ●20, 20 ●20, 80 ●80, 80 ●80, 100

20, 80 The Pareto chart is based on the Pareto Principle, which state 20 percent of the sources of the problem are responsible for 80 percent of the actual problems. By concentrating on the vital few sources, a large number of actual problems can be eliminated

You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at a. 24 hours after admission. b. 12 hours after admission or prior to surgery. c. 12 hours after admission. d. 24 hours after admission or prior to surgery.

24 hours after admission or prior to surgery

Suppose that you are purchasing shelving units. The department has planned for units that are 5 shelves high, and each shelf is to be 36 inches wide and have 33 inches of actual filing space. From a sampling of records in the current files, you have determined that the average thickness of each record in 2 inches. You are planning too store 10 year's worth of records, and the average discharge rate is 2,000 per year. How many shelving units would you need to purchase? ●165 ●180 ●242 ●243

243 The estimated number of file shelves needed is based on several factors. One consideration is the average size of individual records. The volume of patients and the number of repeat visits or readmissions affect the potential expansion of each individual patient record. The type of facility also affects the size of individual records. For this equation, multiple anticipated discharge by projected number of years (2,000 x 10 years = 20,000). Because records average a 2-inch thickness, 40,000 filing inches are needed (20,000 x 2 = 40,000). Because each 5 -shelf unit will have 165 linear filing inches available (33 x 5 =15), the number of inches needed, 40,000, must be divided by 165 to determine the number of filing units that must be purchased, which will be 243 (242.4)

Patient was admitted to the hospital and diagnosed with diabetic gangrene. What is the correct code assignment? *250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as controlled *250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled *250.71 Diabetes with peripheral circulatory disorders, type II (juvenile type), not stated as uncontrolled *785.4 Gangrene ●250.71, 785.4 ●785.4, 250.70 ●250.70, 250.00, 785.4 ●250.70, 785.4

250.70, 785.4 To assign these codes, documentation in the health record must support his causal relationship. When a casual relationship exists, the principal diagnosis code assigned is a diabetic code from category 250, followed by the code for the manifestation or complication. The diabetes codes and the secondary codes that correspond to them are paired codes that follow the etiology/manifestation convention of the classification

Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0 cm superficial laceration of the left arm; 5.0 laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: x-ray of the ankle which showed a bimalleolar ankle fracture that required closed manipulative reduction and simple suturing of the arm laceration and layer closure of the scalp. Provide CPT codes for the procedures done in the emergency department for the facility bill. *12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm *12004 Simple repair of superficial wounds of scalo, neck, axillae, external genitalia, trunk and/or extermities (including hands and feet); 7.6 cm to 12.5 cm *12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm *27810 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation *27818 Closed treatment of trimalleolar ankle fracture; with manipulation. ●27810, 12032 ●27818, 12004, 12032 ●27810, 12032, 12002 ●27810,12004

27810, 12032, 12002 The closed reduction of the fracture is coded first following principal procedure guidelines. The laceration repair is also coded. When more than one classificaiton of wound repair is performed, all codes are reported, with the code for the most complicated procedure listed first

A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding. *218.9 Leiomyoma of uterus, unspecified *280.0 Iron deficiency anemias, secondard to blood loss (chronic) *285.1 Acute posthemorrhagic anemia *626.8 Disorders of menstruation and other abnormal bleeding from female genital tract, other ●280.0, 626.8 ●285.1, 626.8 ●626.8, 280.0 ●280.0, 218.9

280.0, 626.8 The anemia would be sequenced first based on principal diagnosis guidelines

A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism. __________________________________________________ *291.8 Other specified alcohol-induced mental disorders *291.81 Other specified alcohol-induced mental disorders, alcohol withdrawal *303.00 Acute alcoholic intoxication, unspecified *305.00 Alcohol abuse, unspecified ●291.8, 303.00 ●303.00 ●305.00 ●291.81, 303.00

291.81, 303.00 If the patient is admitted in withdrawal or if withdrawal develops after admission, the withdrawal code is designated as the principal diagnosis. The code for substance abuse/dependence is listed second

Code the following scenario: Patient admitted with major depression, recurrent, severe. *296.30 Major depressive disorder, recurrent episode, unspecified *296.33 Major depressive disorder, recurrent episode, severe, without mention of psychotic behavior *296.89 Other and unspecified bipolar disorders, other *311 Depressive disorder, not elsewhere classified _________________________________ ●296.33 ●296.30 ●311 ●296.89

296.33 Main term: Depression, subterm: recurrent

The rule of thumb in expressing rates less than one is to carry out the division to _____ decimal places and then round to _____ decimal places. ●2, 1 ●3, 2 ●2, 3 ●4, 3

3, 2 Rates of less than 1% are usually carried out to three decimal places and rounded to 2. For rates less than 1%, a 0 should precede the decimal to emphasize that the rate is less than 1%, for example, 0.56%

Aging of accounts is the practice of counting the days; generally in increments, from the time a bill has been sent to the payer to the current day. What is the standard increment, in days that most healthcare organizations use for the aging of accounts? ●7-day ●14-day ●30-day ●90-day

30-day Aging of accounts is maintained in 30-day increments (0-30 days, 31-60 days, and so forth)

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. *31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, diagnostic, with cell washing when performed (separate procedure) *31623 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings *31625 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites *31640 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with excision of tumor ●31622, 31640 ●31622, 31623 ●31623 ●31625

31623 A bronchoscopy with brushings and washings is considered a diagnostic bronchoscopy and not a biopsy. Code 31623 specifies brushings, and 31622 is selected for washings

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital. a. 54% b. 33% c. 32% d. 55%

32%

Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket. ●33223, Revision of skin pocket for cardioverter-delibrillator ●33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) ●33212, Insertion of pacemaker pulse generator only; with existing single lead ●33222, Revision or relocation of skin pocket for pacemaker

33222, Revision or relocation of skin pocket for pacemaker Begin with the main term Revision; pacemaker site; chest

Identifying appropriate users of specific information is a function of: ●Access control ●Nosology ●Data modeling ●Workflow modeling

Access control Access control is a critical function within HIM relative to information security. This function maps the relationship between information and the individuals authorized to use it. It may be established at a variety of levels

Patient is admitted with senile cataract; diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens. *250.00 Diabetes melitus without mention of complication, type II or unspecified type, not stated as uncontrolled *250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled *366.10 Senile cataract, unspecified *366.12 Incipient cataract *13.59 Other extracapsular extraction of lens *13.71 Insertion of intraocular lens prosthesis at time of cataract extration, one-stage _______________________________________ ●366.10, 250.50, 13.59, 13.71 ●250.00, 366.10 ●250.00, 366.12 ●366.10, 250.00, 13.59, 13.71

366.10, 250.00, 13.59 13.71 The patient was admitted for the senile cataract and the procedures were completed for that condition. This follows the UHDDS guidelines for principal diagnosis selection. There is also no causal relationship between the diabetes and the cataract, so 250.50 would be incorrect.

New employee Jan Smith had worked for a manufacturing firm. While working for the manufacturing firm, she was covered under its group healthcare insurance for eight months. Jan terminated her employment with the manufacturing firm on a Friday and began a new position with a computer vendor the following Monday. The computer vendor also offers its employees a group healthcare plan. What is the maximum waiting period Jan should expect for her pre-existing condition? -Preexisting conditions will be covered without a waiting period if: *An employee joins a new healthcare insurance group plan and *The employee had been insured for he previous 12 months under a group plan without a lapse in coverage exceeding 63 days. _____________________________________________________________ -Preexisting conditions will be conditions will be covered with a reduce waiting period if: *An employee joins a new healthcare insurance goup plan and *The employee had previous creditable coverage without a lapse in coverage exceeding 63 days __________________________________________________ The reduction equals the duration of the creditable coverage ●63 days ●4 months ●12 months ●Cannot be predicted

4 months The pre-existing period is a period of time during which healthcare insurance plans may deny coverage for certain conditions. In this situation, her previous employer did not cover that patient for 12 months, so she will have a reduced waiting period of up to four months for any pre-existing conditions

What is the correct CPT code assignment for: destruction of internal hemorrhoids with use of infrared coagulation? ●46255, Hemorrhoidectomy, internal and external, single column/group ●46930, Destruction of internal hemorrhoid(s) by thermal energy (e.g., infrared coagulation, cautery, radiofrequency) ●46260, Hemorrhoidectomy, internal and external, two or more columns/groups ●46945, Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group

46930, Destruction of internal hemorrhoid(s) by thermal energy (e.g., infrared coagulation, cautery, radiofrequency) Begin at main term Destruction, hemorroid, thernal. Thermal includes infrared coagulation

A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension. *401.9 Essential hypertension, unspecified *403.10 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage 1 through stage 4, or unspecified *403.90 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage 1 through stage 4, or unspecified *491.21 Obstructive chronic bronchitis, with (acute) exacerbation *492.8 Emphysema, other *585.9 Chronic kidney disease, unspecified ●492.8, 496, 403.10, 585.9 ●492.8, 585.9, 401.9 ●496, 585.9, 401.9, ●491.21, 403.90, 585.9

491.21, 403.90, 585.9 The patient was admitted for COPD, so this is listed as the principal diagnosis. Code 491.21 is used when the medical record includes documentation of COPD with acute exacerbation. ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, assign code 403.90; however, the code also at category 403 directs the coder to also code the chronic renal failure, 585.9

Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia ●49496, Repair, initial inguinal hernia, full-term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated ●49501, Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or stangulated ●49507, Repair initial inguinal hernia, age 5 years or older; incarcerted or strangulated ●49521, Repair recurrent inguinal hernia, any age; incarcerated or stangulated

49507, Repair inital inguinal hernia, age 5 years or older; incarcerated or strangulated Begin with the main term of hernia repair; inguinal; incarcerated. The age of the patient and the fact that the hernia is not recurrent make the choice 49507

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? *49560 Repair initial incisional or ventral hernia; reducible *49565 Repair recurrent incisional or ventral hernia; reducible *49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft-tissue infection *49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when preformed): reducible ●49565 ●49565, 49568 ●49656 ●49560, 49568

49656 Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope and is reducible make the choice 49656. Notice that the use of mesh is included in the code

Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including death of adults, children, and newborns. The hospital's gross death rate for the month of June was: ●0.05% ●2% ●5% ●20%

5% The gross death rate is the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. The gross death rate is calculated by dividing the total number of deaths occurring in a given time period by the number of discharges, including deaths, for the same time period: 25 / 500 = 0.05 x100 = 5%

Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. A Esophagoscopy and closed esophageal biopsy was performed. *530.10 Esophagitis, unspecified *530.81 Esophageal reflux *530.89 Other specified disorders of esophagus, other *42.23 Other Esophagoscopy *42.24 Closed (endoscopic) biopsy of esophagus *45.16 Esophagogastroduodenoscopy (EGD) with closed biopsy ●530.89, 42.24 ●530.10, 45.16 ●530.81, 42.24 ●530.81, 42.23

530.81, 42.24 Main term for procedure: Esophagoscopy, sub-term: with closed biopsy. Code 45.16 is not correct because the endoscopy was advanced to the level of the esophagus and not the level of the duodenum

Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. ●54401, Insertion of penile prosthesis; inflatable (self-contained) ●54405, Insertion of multi-component, inflatable penile prosthesis, including placement pump, cylinders, and reservoir ●54440, Plastic operation of penis for injury ●54400, Insertion of penile prosthesis, non-inflatable (semi-rigid)

54401, Insertion of penile prosthesis; inflatable (self-contained) Code 54401 is correct because the prosthesis is self-contained

A quarterly review reveals the following data for Springfield Hospital: Springfield Hospital Quarterly Statistics Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 What is the percentage of incomplete records during this quarter? a. 32% b. 33% c. 54% d. 55%

55%

A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? *427.89 Other specified cardiac dysrhythmias, other *553.20 Ventral hernia, unspecified *997.1 Complications affecting specified body systems, not elsewhere classified, cardiac complications *V64.1 Surgical or other procedure not carried out because of contraindication *54.11 Exploratory laparotomy *54.19 Other laparotomy ●553.20, 427.89, V64.1, 54.19 ●553.20, 997.1, 427.89, 54.19 ●553.20, 54.11 ●553.20, 54.11, V64.1

553.10, 427.89, V64.1, 54.19 The repair of the hernia is not coded because it was not performed; however, code 54.19 is assigned to describe the extent of the procedure. The V64.1 is also used to indicate the cancelled procedure due to the contraindication. The code 427.89 is also added for the bradycardia that the patient developed during the procedure

All the patients who present to the emergency department was a suspected acute myocardial infarction (AMI) are expected to receive an EKG within 10 minutes of their arrival. Of the 56 patients who had suspected AMI during the last quarter, 32 had an EKG within the specified time frame. What was the rate of compliance? ●3.2 ●57.1 ●1.75 ●0.571

57.1 Rates are often used to measure events over a period of time. Sometimes they also are used in performance improvement studies. Like ratios and proportions, rates may be reported daily, weekly, monthly, or yearly. This allows for trend analysis and comparison over time. In calculating the rate, the numerator is always included in the denominator. Also, when calculating a facility-based rate, the numerator is first multiplied by 100, and then divided by the denominator. In this case 32 x 100 / 56 = 57.1

The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure? *49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) *58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) *58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) *58940 Oophorectomy, partial or total, unilateral or bilateral *-50 Bilateral procedure ●49000, 58940, 58700 ●58940, 58720-50 ●49000, 58720 ●58720

58720 In the abdomen, peritoneum, and omentum subsection, the exploratory laparotomy is a separate procedure and should not be reported when it is part of a larger procedure. The code of 49000 is often used incorrectly because laparotomy is the approach to many abdominal surgeries. The code 58720 includes bilateral and so the -50 is not necessary

Code the following scenario: Patient with flank pain was admitted and found to have a calculus of the kidney. Ureterscopy with placement of ureteral stents was performed. *592.0 Calculus of kidney *592.9 Urinary calculus, unspecified *788.0 Renal colic *56.0 Transurethral removal of obstruction from ureter and renal pelvis *59.8 Ureteral cauterization ●592.0, 788.0, 59.8 ●788.0, 592.0, 56.0 ●592.9, 59.8 ●592.0, 59.8

592.0, 59.8 Codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related definitive diagnosis has been established. The flank pain would not be coded because it is a symptom of the calculus

Patient admitted with chronic cystitis. A cystoscopy and biopsy of the bladder were performed. What diagnosis and procedure codes would be assigned for this patient? *595.1 Chronic interstital cystitis *595.2 Other chronic cystitis *595.3 Trigonitis *599.0 Urinary tract infection, site not specified *57.32 Diagnostic procedrue on bladder, other cystoscopy *57.33 Closed (transurethral) biopsy of bladder ●595.3, 57.33 ●595.1, 57.33, 57.32 ●595.2, 57.33 ●599.0, 57.32

595.2, 57.33 Mainterm for diagnosis: Cystitis;subterm: chronic. Mainterm for procedure: Cystoscopy; subterm: with biopsy

Assign codes for the following scenario: A female patient is admitted for stress incontinence. A urethral suspension is performed. *625.6 Stress incontinence female *788.0 Renal colic *788.0 Urinary incontinence, unspecified *57.32 Diagnostic procedure on bladder, other cystoscopy *59.5 Retropubic urethral suspension ●625.6, 57.32 ●788.0, 59.5 ●625.6, 59.5 ●788.0

625.6, 59.5 Main term for diagnosis: incontinence, subterm: stress. Main term for procedure: Suspension, subterm: urethra

In January, Community Hospital had 57 discharges from its Medicine unit. Four patients developed a urinary tract infection while in the hospital. What is the nosocomial infection rate for the Medicine unit for January? ●0.07% ●2.17 % ●7% ●217 %

7 % The nosocomial infection rate is (4 x 100) / 57 = 400 / 57 = 7% Hospital-acquired (nosocomial) infection rates may be calculated for the entire hospital. They also may be calculated for the specific types of infections. Ideally, the hospital should strive for an infection rate of 0.0 percent

Patient is admitted with prepatellar bursitis following a crushing injury to the knee as a result hit by a car two years ago. What diagnosis codes would be assigned for this patient? *726.65 Prepatellar bursitis *906.4 Late effect of crushing *928.10 Crushing injury of lower leg *928.11 Crushing injury of knee *E929.0 Late effects of motor vehicle accident _________________________________________________ ●726.65, 928.10, E929.0 ●726.65, 906.4, E929.0 ●726.65, 928.11, E929.0 ●726.65, E929.0

726.65, 906.4, E929.0 The bursitis was the result of the previous crush injury and should be coded as a residual condition that is a late effect of the injury. Use a late effect E code for subsequent visits when a late effect of the initial injury is being treated

Patient - Number of Days A - 1 B - 5 C - 3 D - 3 E - 8 F - 8 G - 8 H - 9 I -9 ●5 days ●6 days ●8 days ●9 days Community Memorial Hospital discharge nine patients on April 1st. The length of stay for each patient is shown in the following table. What is the median length of stay for this group of patients?

8 days The median is the midpoint of a frequency distribution and falls in the ordinal scale of measurement. It is the pont at which 50 percent of the observations fall above and 50 percent below. If an odd number of observations is in the frequency distribution, the median is the middle number, 8 is the middle number

Patient was admitted through the emergency department following a fall from a ladder while painting his house. He had contusions of the scalp and face and an open fraction of the intracapsular section of the left femur. The fracture site was debrided and the fracture was reduced by open procedure, with an external fixation device applied. What is the correct code assignment? *820.00 Fracture of neck of femur, transcervical fracture, closed, intracapsular section, unspecified *820.10 Fracture of neck of femur, transcervical fracture, open, intracapsular section, unspecified *920 Contusion of face, scalp, and neck except eye(s) *E881.0 Fall from ladder *E849.0 Place of occurrence, home *E016.9 Other activity involving property and land maintenance, building and construction *E000.8 External cause status, specified NEC *78.15 Application of external fixtor device, femur *79.25 Open reduction of fracture without internal fixation, femur *79.35 Open reduction of fracture with internal fixation, femur *79.65 Debribement of open fracture site, femur _________________________________________________ ●820.00, E881.0, E849.0 , E000.8, 79.25, 78.15 ●820.10, 920, E881.0, E849.0, E016.9, E000.8, 79.25, 78.15, 79.65 ●820.00, E881.0, 79.35, 79.65 ●820.10, E881.0, E849.0, E016.9, E000.8, 79.25, 78.15, 79.65

820.10, 920, E881.0, E849.0, E016.9, E000.8, 79.25, 78.15, 79.65 The fracture is the principal diagnosis, with contusions is secondary diagnosis. The fracture is what required the most treatment. Procedures for the reduction, debridement, and external fixation device would all need to be coded

Date of service: 1/3/2012. Last date of treatment: 2/12/2011. The patient is seen in the physician\'s office for a cough and sore throat. The physician performs a problem-focused history, expanded problem-focused examination, and medical decision-making is straightforward. What is the correct E/M code for this service? ●99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: expanded problem focused history and expanded problem focused examination, medical decision making of low complexity ●99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: problem focused history and examination, straightforward medical decision ●99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: detailed history and examination, medical decision making of moderate complexity ●99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician

99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: problem focused history and examination, straightforward medical decision Code 99212 is used because the history is problem-focused, the examination is problem-focused, and the medical decision making is straightforward

Which of the following is required in order to prescribe medications? ●Active medical staff membership ●A drug enforcement agency number ●A position on a medical staff executive committee ●A credential from a nationally recognized association

A drug enforcement agency number In order to practice medicine, a physician must graduate from an approved medical school and pass a state-based licensure exam. This exam allows a physician to obtain a drug enforcement agency (DEA) number, required to prescribe medications and practice medicine

What is ISO 9000? ●A set of financial standards of accounting to which all organizations must conform ●A European company that has set the standard for excellence in strategic planning ●The newest information management system allowing decision makers to monitor all organizational databases ●A set of international standards for quality management

A set of international standards for quality management The International Organization for Standardization (ISO) is an example of the drive toward quality improvement. This nongovernmental global organization, established in 1987, provides more than 17,000 qualities for nearly every business, technology, and industry sector. Adopted by than 157 countries, the generic standards can be applied to organizations of any size. It involves defining, executing, auditing best practices in production or service delivery

Which of the following is included in an RFP? ●Preparing and training managers ●General product information ●Establishing an IT infrastructure ●A statement describing the criteria to be used in evaluating proposals

A statement describing the criteria to be used in evaluating proposals An RFP generally includes the following: instructions for vendors; organizational objectives; background information of the organization; system goals and requirements; vendor qualifications; proposed solution; criteria to be used in evaluating the RFP; general contractual requirements; and pricing and support

This PPS has been adopted for use by man third-party payers (for example, Medicaid) for reimbursement for outpatient visits. It is not the methodology used by Medicare. ●ASCs (ambulatory surgical centers) ●APGs (ambulatory patient groups) ●DRGs (diagnosis-related groups) ●APCs (ambulatory payment classifications)

APGs (ambulatory patient groups) The ambulatory patient groups (APGs) have been adopted for use by many third-party payers for reimbursement in the prospective payment system

As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling a. ARRA. b. HIPAA. c. Health Care Quality Improvement Act. d. EMTALA.

ARRA

A 65-year old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The Attending Physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered. The chief complaint was: ●Ruptured appendix ●Exploratory laparoscopy ●Abdominal pain ●Cholelithiasis

Abdominal pain The chief complaint or reason for the visit is the nature and duration of the symptoms that caused the patient's illness

Quality has several components, including appropriateness, technical excellence, _____ and acceptability. ●Accuracy of diagnosis ●Continuous improvement ●Connectivity ●Accessibility

Accessibility Quality has several components, including the following: appropriateness, the right care is provided at the right time; technical excellence, the right care is provided in the right manner; accessibility, the right care can be obtained when it is needed; and acceptability, the patients are satisfied

A number assigned to patients in a cancer registry in the order that the patients were entered in the registry every year (for example, 03-0001) is a(n) _____number. ●Accession ●Reference ●Follow-up ●Tracking

Accession An accession numbers consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year. The first case in, for example, might be 09-0001. The accession number be assigned manually or by the automated cancer database used by the organization. An accession registry of all cases can be kept manually or be provided as a report by the database software

Which of the following must be reported to the medical examiner? ●Burns ●Accidental deaths ●Causes of injury ●Morbidity

Accidental deaths State laws have developed requirements for certain deaths, such as accidental, homicidal, suicidal, sudden, suspicious in nature to be reported, usually to the medical examiner or coroner. In addition, deaths as a result of abortion or induced termination of pregnancy are also reportable

The processes of retention and destruction of health information are subject to specific regulations in may states as well as guidelines found in federal regulations and _____ standards. ●Centers for Medicare and Medicaid ●Accreditation ●Licensure ●HIPAA

Accreditation The retention and destruction processes are subject to specific regulations in many states. Federal regulations and accreditation standards also include specific guidelines on the release and retention of patient-identified health information

Which dimension of data quality is defined as "data that is free of errors"? ●Accuracy ●Granularity ●Precision ●Currency

Accuracy Data that are free of errors are accurate. Typographical errors in discharge summaries or misspellings of names are examples of inaccurate data.

Engaging patients and their families in health care decisions is one of the core objectives for a. the Joint Commission's National Patient Safety goals. b. HIPAA 5010 regulations. c. achieving meaningful use of EHRs. d. establishing flexible clinical pathways.

Achieving meaningful use of EHR's

What type of safeguard is more people-focused in nature? ●Technical ●Administrative ●Physical ●Addressable

Administrative Administrative safeguards are people-focused and include requirement such as training and assignment of an individual responsible for security

What types of information systems were the first to be introduced in healthcare? ●Administrative/financial ●Clinical ●Patient care ●Physician practice management

Administrative/financial Administrative information systems contain primarily administrative or financial data and are commonly used to support the management functions or general operations of a healthcare facility and were the first computerized systems implemented in most healthcare organizations

This function of the utilization management program determines medical necessity and appropriateness of admission. ●Admission review ●Concurrent review ●Discharge palling ●Pre-admission review

Admission review The admission review is done at the time the patient is admitted to the facility. This review is done to determine or verify the medical necessity and appropriateness of admission

The government agency that is developing best practice guidelines and working to improve the quality of care in the United States is the: ●Institute of Medicine ●National Practitioner Data Bank ●Agency of Healthcare Research and Quality ●Centers for Medicare and Medicaid Services

Agency of Healthcare Research and Quality AHRQ began to develop outcome measures and was a resource in outcomes assessment. This agency has worked diligently to provide clinical evidence for best practice. In 2003, the AHRQ, together with Stanford-UCSF (University of California, San Francisco) Evidence-based Practice Center, developed a plan to analyze literature on QI strategies. These analysis focused on translating research into practice, concentrating on what would increase the rate of effective practices as applied to patient care in actual practice settings. The aim of this program is to close the quality gap

Data that are collected on large populations of individuals and stored in databases are referred to as: ●Statistics ●Information ●Aggregate data ●Standards

Aggregate data Aggregate data are used to develop information about groups of patients

What is an advantage of the unit filing system? ●All records for a specific patient, both inpatient and outpatient, are filed together ●The charts have to be split into volumes for filing ●The hospital can accommodate a large outpaiten clinic with many return visits ●Joint Commission approval is automatic because all parts of the record are filed together

All records for a specific patient, both inpatient and outpatient, are filed together One benefit of the unit filing system that all records for a specific patient, both inpatient and outpatient, are filed together

In which stage of the system life cycle would data be collected from system users regarding their needs? ●Implementation ●Design ●Analysis ●Initiation

Analysis Systems analysis is generally the first step in the systems development life cycle after the decision to implement the system that has been made. It helps determine the needs for data, storage, reporting, and functionality

Which of the following are phases of the systems development life cycle (SDLC)? ●Design, analysis and alignment ●Maintenance, implementation, and improvement ●Analysis, design, and implementation ●Analysis, alignment, and improvement

Analysis, design, and implementation Although there are many different models of the SDLC, all generally include a variation of the following four phases: analysis, design, implementation, and maintenance and evaluation. Alignment and improvement are not one of the four phases of the SDLC

The primary objective of quality in healthcare for both patient and provider is to: ●Keeps costs under control ●Reduce death rates ●Reduce the incidence of infectious diseases ●Arrive at the desired outcome

Arrive at the desired outcome Providing the best care in the most effective manner and for the least cost is something every healthcare organization strives to do, and the patient wants the best outcome possible, which may be curative or not when they seek care. This is why the primary objective of quality in healthcare for both the patient is to arrive at the desired outcome

Who is responsible for writing and signing discharge summaries and discharge instructions? ●Attending physician ●Head nurse ●Primary physician ●Admitting nurse

Attending physician The attending physician principally responsible for the patient's hospital care writes and signs the discharge summary

Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This is called: ●Auto authentication ●Electronic signature ●Telecommuting ●Chart tracking

Auto authentication Auto authentication is a policy that allows the physician or provider to state in advance that dictated and transcribed reports should automatically be considered approved and signed when the physician does not make corrections within a certain period of time. Another variation of auto authentication is that physicians authorize the HIM department to send a weekly list of documents needed signatures. The list is then signed and returned to the HIM department

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. a. Baby Boy Doe admitted 1/3/2011, died 1/4/2011 b. Baby Boy Hiltz's mother admitted 1/5/2011, C-section delivery, and discharged 1/7/2011 c. Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011 d. Patient admitted with COPD 1/4/2011 and discharged 1/7/2011

Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011

In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute-care MS-DRGs similar? ●Relative weights ●Based on principal diagnosis ●Categorization of low-volume groups into quintiles ●Classification of short-stay outliers

Based on principal diagnosis Both the MS-LTC-DRGs and the acute care MS-DRGs are based on the principal diagnosis in terms of grouping and reimbursement

One strategy for acquiring EHR components from various vendors and interfacing them is: ●Best-of-breed ●Best-of-fit ●Dual core ●Integration

Best-of-breed Best-of-breed is when an organization has acquired the "best" products from various vendors. The result is that each individual organization unit may happy with its chosen product, but as the organization moves toward adding clinical components that rely on the various other systems as a source of data or to which data must be sent, the challenge to exchange such data can be overwhelming

Which of the following are considered vital records? ●Birth, marriage, and late fetal death ●Birth, registry, and adoption ●Marriage, divorce, and registry ●Late fetal death, passport, and birth

Birth, marriage, and late fetal death Vital records are those concerned with births, deaths, marriages, divorces, abortions, and late fetal deaths. In the United States, states require that certificates be completed verifying the vital event

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the a. CARF manual. b. Joint Commission manual. c. Medical Staff Bylaws, Rules, and Regulations. d. Conditions of Participation for Rehabilitation Facilities.

CARF manual.

Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? ●Case definition ●Case finding ●Follow-up ●Reporting

Case finding Case finding includes the methods used to identify the patients who have been seen and treated in the facility for the particular disease or condition of interest to the registry. After cases have been identified, extensive information from the paper-based patient record into the registry or fed from other databases and entered into the registry database

The principal process by which organizations optimize the continuum of care for their patients is: ●Utilization management ●Services management ●Case management ●Resource management

Case management Case managers review the condition of the patient to identify each patient's care needs and integrate patient data with the patient's course of treatment

In which EHR database model is all of the organization's patient health information stored in one system? ●Distributed ●Centralized ●Hybrid ●Traditional

Centralized In the centralized database model, all the organization's patient health information is stored in one system

Bar coding technology is an example of : ●Character/symbol recognition technology ●Artificial intelligence ●Voice recognition ●Vector graphic data

Character/symbol recognition technology The bar code symbol was standardized for the healthcare industry making it easier to adopt bar-coding technology. Bar-coding applications have been adopted for labels, patient wristbands, specimen containers, business/employee records, library reference material, medication packages, dietary items, paper documents, and more

This data collection tool is used when one needs to gather data on sample observations in order to detect patterns. ●Check sheet ●Ordinal data tool ●Balance sheet ●Nominal data tool

Check sheet A check sheet is used to gather data on sample observations in order to detect patterns. When preparing to collect data, a team should consider the four W questions: Who will collect the data? What data will be collected? Where will the data be collected? When will the data be collected? Check sheets make it possible to systematically collect a large volume of data

In purchasing an EHR system from a vendor, what does due diligence refer to? ●Checking references ●Conducting product demonstrations ●Financing the investment ●Negotiating the contract

Checking references Due diligence can be in the form of site visits, corporate visits, reference checks, credit checks on owners of the vendor company, and other steps needing to be preformed before a final contract is negotiated to ensure that the organization is getting the product it wants

You are the coding supervisor and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer. " What should have been coded as the patient's diagnosis? ●Chronic cough ●Observation and evaluation without need for further medical care ●Diagnosis of unknown etiology ●Lung cancer

Chronic cough Outpatient coding guidelines do not allow coding of possible conditions as a diagnosis for the patient. Do not code diagnoses documented as "probable," "suspected," "questionable," rule out," or "working diagnosis," or similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree or certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit

The physician's office sent a request for payment to Able Insurance Company. The term used in the healthcare industry for this request for payment is a(n): ●Allowance ●Reimbursement ●Block grant ●Claim

Claim A claim lists the fees or charges for each service

The most common architecture used in EHRs in hospitals today is: ●Client/server ●Mainframe ●Network computers ●Web-based

Client/server Client/server architecture is the predominant form of computer architecture used in healthcare associations today. In client/server architecture, certain computers (servers) have been configured to perform most of the processing and resource-intensive tasks, while other computers (clients), which generally are less-powerful computers, capture, view, and perform limited processes on data

All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data: ●Clinical ●Identification ●Secondary ●Financial

Clinical Clinical information is data that the patient's diagnosis or treatment in a healthcare facility

The most common type of health information is : ●Clinical data ●Demographic data ●Coded data ●Epidemiological data

Clinical data Clinical data are the most common type of health information and document the signs, symptoms, diagnoses, impressions, treatments, and outcomes of the care process. They are captured during diagnosis and treatment and stored in the medical record. Clinical data serve a variety of industry needs beyond direct patient care, including reimbursement, planning, and research

A concept that is related to a data warehouse but has different architecture and tends to undergo more changes is a: ●Graphical decision support system ●Data marketplace ●Snowflake schema ●Clinical data repository

Clinical data repository A clinical data repository is a database that has developed using a consistent clinical data model and clinical vocabulary and provides accurate clinical data from the various patient care systems. The clinical repository requires that the other health information and patient care systems be integrated with it to allow data to flow between it and the other systems. Thus, the clinical repository is like the data warehouse in that it serves as a database for storing data from transactional systems

In which form of database would complex data analysis most effectively take place? ●Clinical data repository ●Clinical data warehouse ●Database management system ●Electronic health record

Clinical data warehouse When complex analyses are to be performed on data, a clinical data warehouse (CDW) may be the more appropriate database structure to use. Data warehouses are designed to receive data (often as an extraction to data from a repository) and perform, analytical processes on the data

Dr. Smith orders 500 mg of penicillin by mouth tid. for Jane Doe in the hospital emergency department. The computer sends an alert to Dr. Smith to tell her the patient, Jane Doe, is allergic to penicillin. What type of computer system is Dr. Smith using? ●Clinical data repository ●Data exchange standard ●Clinical decision support ●Health informatics standard

Clinical decision support Clinical decision support systems help physicians and other clinicians make diagnostic and treatment decisions within the electronic record

A drug interaction alert would be a typical function of a: ●Data warehouse ●Data repository ●Data mart ●Clinical decision support system

Clinical decision support system Clinical/medical decision support systems are data driven. They assist clinicians in applying new information to patient care through the analysis of patient-specific clinical/medical variables. Clinical/medical decision support systems can be characterized by providing reminders and alerts, clinical guideline advice, therapy critiquing, or bench marking tools

What term is used in reference to electronically accessed information that provides physicians with pertinent health information beyond the health record itself? ●Core measures ●Advanced decision support ●Clinical practice guidelines ●Enhanced discharge planning

Clinical practice guidelines Clinical practice guidelines are used in reference to electronically accessed information that provides physicians with pertinent health information beyond the health record itself

Which of the following provides step-by-step guidance to physicians and others in making decision related directly to patient care? ●Accreditation standards ●Clinical practice standards ●Conditions of Participation ●Core measures

Clinical practice standards Clinical practice standards define physician practice based on diagnosis. This flow of treatment interventions and the patient's progress are evaluated on the basis of national accepted standards of care for the diagnosis

The process of determining whether healthcare services meet predetermined standards of care is performed in this quality management function. ●Infection control ●Clinical quality assessment ●Utilization management ●Risk management

Clinical quality assessment Clinical quality management involves the evaluation of direct patient care. Clinical performance is often measured around diagnosis, medical condition, or care processes along with outcomes. The relationship between the way care is provided and the outcomes or results of the medical intervention is the focus of clinical management

A list or collection of clinical words or phrases with their corresponding meanings is a: ●Data dictionary ●Clinical classification ●Nomenclature ●Clinical vocabulary

Clinical vocabulary Clinical vocabulary is a formally recognized list of preferred medical terms. The definition for the vocabulary is similar to clinical terminology except that it includes the meanings or definitions of words. Because of their very similar meanings, the terms clinical terminology are often used interchangeably in practice

In today's healthcare organization, physicians use the _____ to access multiple sources of patient information within the organization's network. ●Data repository ●Clinical information system ●Data warehouse ●Clinician portal

Clinician portal The clinician/physician web portals first were seen as a way for clinicians to easily access (via a web browser) the healthcare provider organizations' multiple sources of structured and unstructured data from any network-connected device. Like clinical workstations, clinician/physician web portals evolved into an effective medium for providing access to multiple applications as well as the data

Data that have been grouped into meaningful categories according to a classification system are referred to as _____ data. ●Research ●Reference ●Coded ●Demographic

Coded Coded data that have been translated into a standard nomenclature or classification so they can be aggregated, analyzed, and compared. To facilitate the analysis of large amounts of information, coded data frequently are grouped into meaningful categories. The categories may be as simple as M for male and F for female or as extensive as those used to code diagnosis and procedures. The grouping may be simplistic, as in age range, or as complex as the methodology used in prospective payment systems

What is the unique impact HIM professionals have on coded data? ●Understanding the clinical context of cost and the rules for reimbursement improves organizational decision-making ●Attention to data quality provides unique identification of patient in a healthcare enterprise ●Providing current literature and research outcomes enhance clinical knowledge at the point of care ●Combining knowledge of the clinical content, documentation principles, and data use provide accurate information for the industry

Combining knowledge of the clinical content, documentation principles, coding systems, and data use provide accurate information for the industry One role of the HIM professional is to code data, which is to translate diagnosis and procedures into a standard nomenclature or classification or classification so they can be aggregated, analyzed, and compared

What third-party payer does the figure represent? *********ABC Premiere Health Plan********** *Member - Jane B. White *Policy Number - HS 123456 7890 *Group - State *Type - Employee-only EFFEC 01012005 *SEND ALL BILLS TO: ABC Premier Health Plan 1500 Primrose Path Flowervilles, xx 12345 ●Medicaid ●Medicare ●Blue Cross and Blue Shield ●Commercial healthcare insurance

Commercial healthcare insurance The third-party payer is not Medicare, Medicaid or Blue Cross/Blue Shield so it is considered a commercial healthcare insurance company

If a child was admitted to a hospital with a fever and within 24 hours developed measles, the measles would be classified as: ●Healthcare-associated infection ●Hospital sickness ●Community-acquired infection ●Community sickness

Community-acquired infection An infection that was present in the patient before he or she was admitted to the facility is called community-acquired. In this situation, measles has an incubation period of at least 14 days, so it was community-acquired

Mobile professionals in a hospital are most likely to use which form of human-computer interface? ●Computer on wheels ●Desktop computer ●Personal digital assistant ●Terminal

Computer on wheels Healthcare organizations find it effective to mount a notebook computer to a cart and move it with the user. These sometimes are affectionately called computers on wheels (COWS) or wireless on wheels (WOWs)

Technology that electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted is called: ●Business process management (BPM) technology ●Automated forms processing technology ●Computer output laser disk (COLD) technology ●Digital signature management technology

Computer output laser disk (COLD) technology Computer output laser disk/enterprise report management (COLD/ERM) technology electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print-steam originated. COLD/ERM technology not only electronically store the report-formatted documents but also distributes them with fax, email, web, and traditional hard-copy print processes

What does entity authentication mean? ●Prevents rebooting to deactivate a log-off system ●Computer reads a predetermined set of criteria to determine if a user is who he or she claims to be ●Allows rebooting to activate a sign-in process ●Computer rejects multiple log-ins

Computer reads a predetermined set of criteria to determine if a user is who he or she claims to be Authenticity is the verification of a record's validity. It confirms that it is the record of the individual in question and it is what it purports to be, and therefore, its reliability and truthfulness as evidence

As a preliminary step in designing an IS strategy, it is important for the steering committee to conduct a scan of the external environment and to: ●Build security and privacy constraints ●Contact vendors for system bids ●Purchase hardware and software components ●Conduct an internal environmental assessment

Conduct an internal environmental assessment An environmental assessment should be performed to explore emerging technologies and their potential impact on the ways the healthcare organization delivers its services. This assessment should include both the external and internal environment

If a nurse uses the abbreviation CPR to mean cardiopulmonary resuscitation one time and computer-based patient record another time, leading to confusion if the chart were audited would be concern when applying this dimension of data quality? ●Accuracy ●Consistency ●Precision ●Currency

Consistency Data quality needs to be consistent. A difference in the use of abbreviations provides a good example a good example of how the lack of consistency can lead to problems

In the LTCH PPS, what is the standard federal rate? ●Constant that converts the MS-LTC-DRG eight into a payment ●Relative weight based on the market basket of goods ●Geographic wage index ●Adjustment mandated by the Benefits Improvement and Protection Act (BIPA) of 2000

Constant that converts the MS-LTC-DRG eight into a payment In the long-term care prospective payment system (LTCH PPS), the standard federal rate is the national base payment amount in the prospective payment system for long-term care hospitals

The medical report that documents the response of one member of the medical staff to a request of one member of the medical staff to a request by another member of the medical staff to review a patient's history, examination of the patient, and written findings giving recommendations is: ●History and physical exam ●Pathology report ●Discharge report ●Consultation report

Consultation report A consultation report is the documented findings and/or recommendation for further treatment by a physician or specialist. Consultations are usually performed at the request of the attending physician

A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is: ●Continuity of Care Record ●Minimum Data Set ●Ambulatory Care Data Set ●Uniform Hospital Discharge Data Set

Continuity of Care Record Continuity of Care Record (CCR) is documentation of care delivery from one healthcare experience to another

Which of the following is a concept designed to help standardize clinical content for sharing providers? ●Continuity of care record ●Interoperability ●Personal health record ●SNOMED

Continuity of care record The continuity of care record (CCR) helps standardize clinical content for sharing between providers. A CCR allows documentation of care delivery from one healthcare experience to another

This type of data assumes an infinite number of possible values in measurements that have decimal values as possibilities. ●Nominal data ●Ordinal data ●Discrete data ●Continuous data

Continuous data Examples of continuous data include weight, blood pressure, and temperature. Continuous data are displayed on histograms

This type of chart is used to focus attention on any variation in the process and helps the team to determine whether that variation is normal or a result of special circumstances. ●Pareto chart ●Pie chart ●Control chart ●Line chart

Control charts Control charts can be used to measure key processes over time. Using a control chart focuses attention on any variation in the process

The director of the health information department wanted to determine the level of physicians' satisfaction with the departmental services. The director surveyed the physicians who came to the department. What type of sample is this? ●Direct ●Positive ●Guided ●Convenience

Convenience Researchers use convenience samples when they "conveniently" use any unit that is at hand. For example, HIM professionals investigating physician with departmental services could interview physicians who came to the department

It is the year 201x. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? ●Conversion factor ●RVU ●GPCI ●Weighted discount

Conversion factor The conversion factor is the national dollar multiplier that sets the allowance for the relative values-a constant

Standardized set of valid, reliable, and evidence-based measures implemented by the Joint Commission are called: ●Sentinel events ●Indicator monitoring systems ●Core (performance) measures ●Technical reporting requirements

Core (performance) measures Core performance measures are considered tools - standardized metrics - that provide an indication of an organization's performance. Core measures are defined as standardized sets of valid, reliable, and evidenced-based measures implemented by the Joint Commission

Which of the following is a common resource used in hospitals for the evaluation of outcomes management to improve the clinical performance? ●OSHA standards ●Core measures ●OASIS data set ●Marketing plan

Core measures As a method of improving the quality of care, outcomes management looks for the best treatment process. A treatment process is determined and used, and then data are collected and entered into a database. The data are analyzed and the treatment process altered as necessary. The goal is to find the best treatment possible to benefit patient care. These identified best practices can be considered guidelines to help clinicians make the best decisions possible for their patients. Outcomes research has changed clinical practice. Being able to collect meaningful data, and then analyze the types of treatments and the resulting outcomes, clinicians are able to provide better patient care more uniformly. Core measures, statement of outcomes, and clinical practice guidelines are all names of tools that can be used to measure the performance of an organization

The process of reviewing and validating a physician's education and experience prior to granting medical staff membership is called: ●Outcomes management ●Credentialing ●Utilization review ●Surveillance

Credentialing Credentialing is the process of reviewing and validating qualifications, granting professional or medical staff membership, and awarding delineated privileges. Specific policies and procedures are used by healthcare organizations to accomplish this process. The credentialing process verifies the education, training, experience, current competence, and ability to perform the privileges requested or any other background information pertinent to an individual requesting membership on the medical staff

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 ●OASIS

DEEDS The purpose of the Data Elements for Emergency Department Systems (DEEDS) is to support the uniform collection of data in hospital-based emergency departments and to substantially reduce incompatibilities in emergency department records. DEEDS recommend the collection of 156 data elements in hospital that offer emergency care services. As with the UHDDS and UACDS, this data set contains recommendations on both the content and structure of the data elements to be collected

What term is used in reference to objective descriptions of processes, procedures, people, and other observable objects and activities? ●Information ●Data ●Knowledge ●Notices

Data Objective descriptions of process, procedures, and other observable objects and activities are all considered data.

By querying the organizational data, you find that patients admitted on a weekend have a mean length of stay that is 1.3 days longer than patients who are admitted Monday through Friday. This method of finding information is called: ●Structuring query language ●Data mining ●Multidimensional data structuring ●Satisfying

Data Mining Data mining is the process of sorting through the organization's data to identify unusual patterns or to apply analytical models that will assist predicting future events. Current applications of data-mining activities in healthcare include models to support fraud detection, utilization review, and clinical pathways

A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): ●Accreditation manual ●Core content ●Continuity of care record ●Data dictionary

Data dictionary Data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure-consistency of terminology

Ensuring that data have been accessed or modified only by those authorized to do so is a function of: ●Data integrity ●Data quality ●Data granularity ●Logging functions

Data integrity Databases contain rules know as integrity constraints that must be satisfied by the stored data. Data integrity happens when all of the data in the database conform to all integrity constraint rules. These constraints help ensure that the originally entered data and changes to these data follow certain rules. After the parameters for the types of integrity have been set within the database, users cannot violate them

Which of the following is the process of probing and extracting business data and information from a data warehouse and then quantifying and filtering the data for analysis purpose? ●Application systems analysis ●Multidimensional OLAPs ●Data mining ●Clinical data repositories

Data mining Data mining is the process of probing and extracting business data and information from a data warehouse and then quantifying and filtering the data for analysis purposes

The computer-based process of extracting, quantifying, and filtering discrete data that reside in a relational database is called: ●Intelligent character recognition ●Data mining ●Autocoding ●Bar coding

Data mining Text mining and data mining are the term commonly used to describe the process of extracting and then quantifying and filtering free-text and discrete data, respectively

Online/real-time transaction processing (OLTP) is a functional requirement for a: ●Data repository ●Data mart ●Data warehouse ●Data dictionary

Data repository Data repositories in healthcare organizations require tools designed to perform intricate data searches and retrievals using online/real-time transaction processing (OLTP)

Copying data onto tapes and storing the tapes at a distant location is an example of: ●Data backup ●Data mapping ●Data recovery ●Data storage for recovery

Data storage for recovery Managing data storage has become an increasingly important issue. Where in the past data were retained online for, at most, a matter of days after discharge or a visit, and a backup was made daily and stored on tape, an EHR virtually demands that data be retained online forever, be instantaneously retrievable, and be backed up continuously - both locally and in a remote environment for disaster recovery

A collection of data that is organized so its contents can easily be assessed, managed, and updated is called a: ●Spreadsheet ●Database ●File ●Data table

Database The structure of the database must be designed carefully. In a well-designed database, data is entered once and stored in one place. Anyone who accesses the data gets the most updated version. A poorly designed database can lead to redundant data and information errors, which in turn can lead poor management or patient care decisions

Define a fetal death. ●Death of a fetus of 500 g or more ●Death of a fetus of 22 or more weeks of gestation ●Death of a fetus declared a fetal death by the physician ●Death of a fetus of a weight and week gestation determined by state law

Death of fetus of a weight and week gestation determined by state law A fetal death refers to the death of a fetus of a particular weight gestation frequently 500 g or more or 22 or more completed weeks of gestation

Which activity would typically occur during the analysis phase of the systems development life cycle (SDLC)? ●Researching vendor qualifications ●Building interfaces ●Definition of functional requirements ●Submission of RFI to vendors

Definition of functional requirement In the analysis phase it is important to examine the current system to identify opportunities for improvement or enhancement. Typically the existing system is evaluated by asking routine users to identify the strengths and limitations. Completion of this task can help ensure that the organization does not make a significant investment in a new system only to later discover what was needed was better communication, training, and more extensive technical support and not a new information system

The patient belonged to a managed care plan. The patient had an elective surgery. Prior approval for the elective surgery had not been obtained. What should the patient expect? ●Delay in scheduling the post-operative visit ●Reduction in future coverage of surgical services ●Denial of reimbursement for the surgery ●Increase in premium for next enrollment period

Denial of reimbursement for the surgery In a managed care plan, prior approval for elective surgery must be obtained in order for services to be reimbursed

A use case: ●Confirms user needs against CCHIT criteria ●Describes an EHR's behavior in response to a user process ●Diagrams the flow of information throughout an EHR ●Documents the federal government initiatives for EHR

Describes an EHR's behavior in response to a user process Use cases are another tool that may be used to describe workflows and processes. Although use cases can easily be used in process at all stages in the EHR project, they typically have been more closely aligned with defining functional requirements

The most important information to include in an informed consent in biomedical research is the: ●Name of the sponsor ●Description of risk ●Specific names of drugs and substances used ●Timeline for the project

Description of risk Federal regulations require that certain information be provided each human subject. The subjects must be given a description of reasonably foreseeable risks or discomforts. The description must be accurate and reasonable, and subjects must be informed of previously reported adverse events

When the institute of Medicine and other authors talk about the "quality gap," this can best be described as the: ●Time between data analysis and implementation of an improved process ●Difference between the patient care protocols belonging to a variety of healthcare providers ●Difference between average care and best care ●Difference between what is written in a procedure and how the procedure is actually carried out

Difference between average care and best care Finding ways to increase the rate of effective practice as applied to actual patient care are being analyzed. Many reasons for the gaps between best, evidence-based practice and current treatment choices include a gap in the dissemination of knowledge from research to practitioners; failure to implement best practice due to skepticism surrounding the cost effectiveness, environment, or organizational culture of practice setting; and research setting effectiveness not equating to an individual's practice setting

What technology creates images of handwritten and printed documents that are then stored in health record databases as electronic files? ●Clinical data repository ●Data exchange standards ●Central processor ●Digital scanner

Digital scanner A digital scanner creates images of handwritten and printed documents that are the stored in health record databases as electronic files

What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document? ●Digital signature ●Electronic validation ●Electronic signature ●Electronic authorization key

Digital signature A digital signature is a digitized version of a handwritten signature. The author of the documentation signs his or her name on a pen pad, and the signature is automatically converted to a digital signature that is affixed to the electronic document

Clinical quality management focuses on the evaluation of: ●All healthcare industry processes ●Direct care and treatment of patients ●Business processes in healthcare ●A combination of demographic, financial, and patient care areas

Direct care and treatment of patients Clinical performance is often measured around diagnosis, medical condition, or care processes along with outcomes. The relationship between the way care is provided and the outcomes or results of the medical intervention is the focus of clinical management

In this case management step, the case management plans continued care after the healthcare facility services end. ●Preadmission care planning ●Care planning at the time of admission ●Review the progress of care ●Discharge planning

Discharge planning As the patient's requirements for care decrease and the patient moves toward discharge, the case manager undertakes final discharge planning. In this step, the patient's continues care after discharge is planned

An assessment of a patient's readiness for placement in a non-acute setting is what function of utilization management? ●Admission review ●Concurrent review ●Discharge planning ●Pre-admission review

Discharge planning Discharge planning ensure that a patient is ready for placement in a non-acute setting when he or she leaves the facility. This process often begins either at pre-admission or upon admission to ensure that the patient is placed or receives needed at the time of discharge

James Walker, an 85-year-old male, is admitted with a hip fracture that is repaired with a closed reduction and stabilization During his hospital stay, a social worker assess his situation and determines that long-term care placement is necessary when he is ready to leave the hospital. This process is called: ●Preadmission review ●Continued stay review ●Ancillary services review ●Discharge planning

Discharge planning Discharge planning occurs during the patient's hospitalization and is conducted by a case manager or social worker in conjunction with the attending physician, patient, and patient's family and/or significant others. This planning process involves an assessment of the care level that the patient will need upon discharge from the current care setting. It may involve the placement of a patient in a skilled nursing facility or home care

Which of the following are basic functions of the utilization management process? ●Preadmission review, claim management, and retrospective review ●Discharge planning, review for potentially compensable events, and loss prevention ●Discharge planning, retrospective review, and preadmission review ●Retrospective review, discharge planning, and review for potentially compensable events

Discharge planning, retrospective review, and preadmission review Utilization management (sometimes referred to as case management) is a formal review of patient resource use. Data collected during this formal review help determine the appropriateness of the services provided. UM ensures the medical necessity of treatment provided and the cost-effective use of resources and identifies overuse or underuse of available services. Preadmission review, discharge planning, and retrospective review are all basic functions of the utilization management process. Claims management, review of potentially compensable events, and loss prevention are not basic functions of the utilization management process

Dr. Jones comes into the HIM department and requests the HIM director to pull all of his records from the previous year in which the principal diagnosis of myocardial infarction was indicated. Where would the HIM director begin to pull these record? ●Disease index ●Master patient index ●Operative index ●Physician index

Disease index A disease index is a listing diagnosis code number order for patients discharged from the facility during a particular time period. Each patient's diagnoses are converted from a verbal description to a numerical code, usually using a coding system such as the ICD-9-CM

Using the following data, what conclusion can you draw about Dr. Jones' outcomes compared to the OB/GYN practice group? Category/ Dr. Jones / OB-GYN Group Cesarean section rate / 15.2% / 11.5% Hospital-acquired infection / 1.7% / 1.5 % Surgical wound infection rate / 3.8% / 0.36% Mortality rate / 0.57% / 0.07% ●Dr. Jones performed better in all four categories than the OB/GYN group ●Dr. Jones performed poorer in all four categories than the OB/GYN group ●Dr. Jones performed better in all categories except Mortality Rate than the OB/GYN group ●Dr. Jones performed poorer in all categories except the Mortality Rate than the OB/GYN group

Dr. Jones performed poorer in all four categories than the OB/GYN The data shows that Dr. Jones outcomes are all higher than the OB/GYN group. This data indicates that Dr. Jones should be monitored for continued poor performance compared to his peer group

Which term is used to describe the device that runs secondary storage medium? ●Central processing unit ●Drive ●Magnetic disk ●Storage network

Drive Secondary storage may be available continuously (online) to the CPU for real-time access to data or physically separated (offline) and require only loading to be connected to the CPU. The term drive is often to describe the device that runs a secondary storage medium

In designing an input screen for an EHR, which of the following would best to capture structured data? ●Drop-down menus ●Speech recognition ●Natural language processing ●Document imaging

Drop-down menus Structured data entry from pick lists or pull-down menus is an important data capture technique. Most EHR systems use a combination of structure data entry and free text. When using structured data entry, it is important that the data options be clearly defined, comprehensive, and up to data

Medicare Part B covers which item(s)? ●Eyeglasses and hearing aids ●Durable medical equipment ●Custodial care ●Dentures and dental care

Durable medical equipment Medicare Part B insurance covers physician services, medical services, and medical supplies not covered by Part A (durable medical equipment, mental healthcare, occupational, physical, and speech therapy, clinical laboratory services, and home health. It should be noted that the following healthcare services are usually not covered by Medicare Part A or B and are only covered by private health plans under the Medicare Advantage program: long-term nursing care, dentures and dental care, eyeglasses, and hearing aids

The personal health record model that maintains provider control on content while allowing access to the authorized patient is the: ●Shared data record model ●EHR extension model ●Provider-sponsored information management model ●Smart card model

EHR extension model The EHR extension model of the PHR extends the EHR cyberspace so an authorized patient can access the provider's record and check the record's content. Often this model allows an authorized patient to extract data from the healthcare provider's record. The record is still maintained by the provider but is available to the patient in an online format

The technology that allows a healthcare organization to logically (or conceptually) link multiple physical data repositories is: ●MPI ●OLAP ●OLTP ●EMPI

EMPI Online/real-time transaction processing (OLAP) is a technology that allows an organization to logically link their physical data repositories. The data are entered into the repositories by the organizations' various "feeder" applications, and the users must be able to manipulate, update, retrieve, and otherwise act on the data in real time while the data are stored in the repositories. This requires data repositories to include tools like OLTP, which are designed to perform intricate data searches and retrievals

HIPAA allows what form of signature? ●Digital ●Digitized ●Electronic ●Wet

Electronic The Federal Electronic Signatures in Global and National Commerce Act of 2000 (ESIGN) permits an electronic signature to be any electronic sound, symbol, or process, attracted to or logically associated with a contract or other record and executed or adopted by the person with the intent to sign the record

The distinguishing feature of a results management application is that it: ●Provides diagnostic study information in viewable form ●Enables diagnostic study results to be compared and displayed with other data ●Captures charges for diagnostic studies and send them to a billing system ●Directs the work of the departments that produce diagnostic studies results

Enables diagnostic study results to be compared and displayed with other data The result management application enables diagnostic studies results to be compared and displayed with other data

A statewide cancer data system is an example of: ●Reference data ●Epidemiological data ●Coded data ●Demographic data

Epidemiological data Epidemiological data are used to describe health-related issues or events, such as disease trends found in specific populations or general analytics of population health. The information then may be used to inform the public or generate actions that could affect a trend

Data used to describe a specific health-related population are called: ●Reference data ●Financial data ●Clinical data ●Epidemiological data

Epidemiological data Epidemiological data is used to describe health-related issues or events such as disease trends found in specific populations or general analytics of population health

The financial manager of the physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart faiure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group receiving? ●Traditional ●Episode-of-care ●Per diem ●Fee-for-service

Episode-of-care Episode-of-care reimbursement is a healthcare payment method in which providers receive one lump sum for all the services they provide related to a condition or disease

Which of the following activities is likely to occur in the analysis phase of the systems development life cycle? ●Examine current system and identify opportunities for improvement ●Send out RFPs to prospective vendors ●Negotiate contract with vendor ●Install necessary hardware and software

Examine current system and identify opportunities for improvement In the analysis phase of the SDLC, it is important to examine the current system and identify for improvement or enhancement. Even though an initial assessment would be completed as part of the strategic information planning process, the analysis phase of the SDLC involves a more extensive evaluation

Healthcare organizations and practitioners throughout the country need a common terminology that is integrated into the electronic health record to: ●Read tests more accurately ●Exchange and use information reliably ●Prepare secondary records ●Track population mortality

Exchange and use information reliably It is vitally important to be able to compare data for outcomes measurement, quality improvement, resource utilization, best practices, and medical research. These tasks can be accomplished only when healthcare has a common terminology that is easily integrated into the EHR

The field of artificial intelligence is most closely related to: ●Expert decision support systems ●Geographic information systems ●Executive information systems ●Medical decision support systems

Expert decision support systems Expert decision support systems (also referred to as systems that use principles of artificial intelligence) use a set of rules or encoded concepts to construct a reasoning process. Such rules or concepts are based on knowledge developed from consultation with experts on a problem and the processing or formalized of this knowledge in such a manner that the problem can be solved

A network made accessible to trusted individuals outside of the organization is called a(n): ●Extranet ●Intranet ●VPN ●LAN

Extranet Extranets are networks that connect a given organization to its customers and business partners or suppliers (business associates in healthcare). Although extranets send information over public networks, requiring a greater level of security, access to them is still restricted to the services and persons authorized

In which type of health information exchange architectural model does the organization operate much like an application service provider (ASP) or bank vault? ●Consolidated ●Federated-consistent database ●Federated-inconsistent database ●Switch

Federated-consistent database The Federated-consistent database model is essentially the same as the consolidated model of data being stored in separate data vaults, yet is it still managed centrally

The security devices situated between the routers of a private network and public network to protect the private network from unauthorized users are called: ●Audit trails ●Passwords ●Firewalls ●Encryptors

Firewalls Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders. However, they also can be used to protect entities within a single network, for example, to block laboratory technicians from getting into payroll records. Without firewalls, IT departments would have to deploy multiple-enterprise security programs that would soon become difficult to manage and maintain

Which of the following statement about a firewall is false? ●It is a system or combination of systems that supports an access control policy between two networks ●The most commonplace to find a firewall is between the HealthCare organization's internal network and the internet ●Firewalls are effective for preventing all types of attacks on a healthcare system ●A firewall can limit internal users from accessing various portions of the Internet

Firewalls are effective for preventing all types of attack on a healthcare system As important as firewalls are to the overall security of health information systems, they cannot protect a system from all types of attacks. Many viruses, for example, can hide within documents that will not be stopped by a firewall

To which of the following authorities do hospitals report vital statistics? ●World Health Organization ●National Vital Statistics System ●Centers for Disease Control ●The designated state authority

National Vital Statistics System Hospital vital statistics are reported to the National Vital Statistics System

If an HIM employee act in deliberate ignorance or in disregard to official coding guideline, it may constitute: ●Abuse ●Fraud ●Malpractice ●Kickbacks

Fraud Fraud is a false representation of fact or failure to disclose a fact that is material (relevant) to a healthcare transaction that results in damage to another party that reasonably relies on the misrepresentation or failure to disclose

In data capture terminology, data entry as narrative data via keyboarding, dictation, voice recognition, and handwriting recognition is known as: ●Free text ●A graphical user interface ●Natural language processing ●Structured data

Free text Free text is the entry of narrative data, primarily via keyboarding, although dictation, voice recognition, and handwriting recognition are possible. Dictation uses a third party to transcribe the data, so there will always be a delay factor in seeing the results

Which one of the following is a characteristic of an organized medical staff as recognized by the Joint Commission? ●Peer review activities are optional unless requested by a physician ●Fully licensed physicians are permitted by law to provide patient care services ●Delineation of clinical privileges is not necessary ●The medical staff is not subject to medical staff bylaws/rules, regulations, and policies; and is subject to their professional code of ethics

Fully licensed physicians are permitted by law to provide patient care services Like any organization, the medical staff, as a self-governing entity, needs to have structure. The medical staff bylaws provide an organizational structure to ensure communication with the governing body and high-quality patient care. Committees are use to help most medical staffs function. This committee structure is used to make credentialing and clinical privilege decisions

In a decision support system, rule-based systems that mimic human though and enable computers to think in inexact terms are based on: ●Fuzzy logic ●Genetic algorithms ●Symbolic reasoning ●Problem analytics

Fuzzy logic Fuzzy logic is a rules-based system that mimics human thought and enables a computer to "thing" in exact terms rather than in a definitive, either-or-manner. Expert systems "learn" based on the continual addition of data to the system

What is the term for an index based on relative differences in the cost of a market basket of goods across areas? ●Bundle ●CPI ●GPCI ●Cost-to-charge

GPCI The adjustment component is called Geographic Practice-Cost Index (GPCI). This index is based on relative differences in the cost of a market basket of goods across geographic areas

Dr. Smith, an OB-GYN, is granted membership on the Medical Center Hospital medical staff, where she may offer care and treatment related to obstetrics and gynecology including performing deliveries and doing gynecological surgery. The process of defining what services she may perform is called: ●Outcomes management ●Care mapping ●Granting privileges ●Retrospective review

Granting privileges Granting clinical privileges refers to the authorizing of a practitioner to provide specific patient care services within well-defined limits. The criteria for awarding clinical privileges must be detailed in the medical staff bylaws/rules and regulations

A key element on the structure of a decision support system (DSS) that assists in presenting the results to the user is called the: ●Brain of the DSS ●Graphical user interface ●Inference engine ●Knowledge base

Graphical user interface A graphical user interface (GUI) is a style of computer interface in which typed commands are replaced by images that represent tasks. For example, this would allow the user to point, click, drag, and drop icon objects on the computer screen to accomplish desired tasks. Input devices include the standard keyboard and the computer mouse

A consumer interested in comparing the performance of health plans should review data from: ●HEDIS ●OASIS ●ORYX ●UHDDS

HEDIS Health Plan Employer Data and Information Set (HEDIS) is a set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need for comparing the performance of managed healthcare plans

Which of the following conditions would be the most likely to fall into the category of notifiable diseases as defined by the National Notifiable Diseases Surveillance System? ●Diabetes mellitus ●Coronary artery disease ●Fracture of major bones ●HIV infection

HIV infection A notifiable disease is one for which regular, frequent, and timely information on individual cases is considered necessary to prevent and control disease. The list of notifiable diseases varies over time and by state, however, HIV/AIDS would be notifiable disease anywhere

Which organization has created a standard for EHR system functions? ●AHIMA ●Federal government ●HL7 ●IOM

HL7 HL7 is a standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or application level, of healthcare system interconnections

The most commonly used data source during quality improvement activities is the: ●Health record ●Pathology report ●Operative index ●Patient bills

Health record The scope of performance measurement activities requires clarity. The important areas of service are usually based on volume, risk, or known problem. The population targeted must be clearly identified and defined, and the sample size must be representative and allow for valid statistical measurement. Descriptions of the raw data and data sources must be identified precisely so that everyone understands what the data elements will tell them. The medical record remains as the main data source

Which national database includes data on all discharged patients regardless of payer? ●Healthcare Cost and Utilization Project ●Medicare Provider Analysis and Review file ●Unified Medical Language System ●Uniform Hospital Discharge Data Set

Healthcare Cost and Utilization Project Healthcare Cost and Utilization Project (HCUP) uses data collect at the state level from either claims data from the UB-04 or discharge-abstracted data, including UHDDS items reported by individual hospitals and, in some cases by freestanding ambulatory care centers, regardless of payers

The application of information science to the management of healthcare data and information through computer technology is referred to as: ●Data definitions ●Data resource management ●Healthcare informatics ●Clinical information systems

Healthcare informatics Healthcare informatics is the field of information science concerned with the management of all aspects of health data and information through all application of computers and computer technologies

Which of the following statements regarding quality management in healthcare is true? ●The healthcare industry has exhibited leadership in quality management efforts ●Healthcare quality improvement methods have been adopted from the business sector ●Healthcare quality improvement methods have been adopted from the education sector ●The implementation of quality improvement methods in healthcare has been relatively smooth and seamless

Healthcare quality improvement methods have been adopted from the business sector The experts of managing the change process (for example, Deming, Juran, and Crosby) have developed methods to measure and monitor systems in organizations. Their theories give managers methods to use in bringing about measured, focused change before crisis occurs. These methods were developed first in the business industry, and healthcare has struggled to adopt them

A patient admission for treatment of an intervertebral disk injury developed a urinary tract infection with fever several days undergoing surgery. In this situation the urinary tract infection would be classifies as: ●Healthcare-associated infection ●Hospital sickness ●Community-acquired infection ●Community sickness

Healthcare-associated infection A healthcare-associated infection is one that occurs in a patient in a hospital or healthcare setting in whom it was present or incubating at the time of the admission, or the remainder of an infection acquired during previous admission

What classification of medical staff membership denies admitting privileges but recognizes the contributions and reputations of its members? ●Active ●Honorary ●Courtesy ●Affiliate

Honorary The six classification categories of medical staff membership are as follows: active (regular), associate, courtesy, consulting, honorary, and affiliate. The honorary classification category is intended for those medical staff who practice very little and may not admit patient, but their reputation and previous service to the hospital is such that the hospital wants to recognize their contribution

Mary Smith, RHIA, Director of HIM, at Central Hospital is in the process of training staff and employees on the move from a paper record to an electronic record. As she continues this transition, what health record format would she most likely use? ●Hybrid records ●Integrated records ●Problem oriented records ●Clinical decision records

Hybrid records Hybrid records have functional component in both paper and electronic documents

What are LOINC codes used for? ●Identifying test results ●Reporting test results ●Identifying tests unique to a specific company ●Reporting a code for reimbursement

Identifying test results LOINC is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results. The Regenstrief Institute in Indianapolis using a semantic data model manages it. LOINC codes are widely acceptable and included in the consolidated health informatics standards. LOINC vocabulary is maintained as a single table structure; the database and supporting materials are available for download

Which of the following basic services provided by an HIE organization provides the authentication? ●Identify management ●Person identification ●Registry and directory ●Secure data support

Identity management Identity management is a process that operates to ensure individuals who have been identified are who they say they are, that they have authority to do what they want to do, and that their actions are tracked. This process is essentially the typical security functions, of authorization, authentication, access control, and audit control

In which phase of the systems development life cycle does initial training on a new information system generally occur? ●Analysis ●Design ●Implementation ●Maintenance and evaluation

Implementation During the implementation phase of the SDLC, a comprehensive plan for implementing the new system is developed. This plan would include all plans for training managers, technical staff, and other end-users

In which of the following examples does the gender of the patient constitute information rather than a data element? ●As an entry to be complete on the face sheet of the health record ●In the note "50-year-old" in the patient history ●In a study comparing the incidence of myocardial infarctions in black males as compared to white females ●In a study of the age distribution of lung cancer patients

In a study comparing the incidence of myocardial infarctions in black males as compared to white females Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information is data that have been combined to produce, and enhance that information with experience and trial-and-error that produces knowledge

During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These cases represent 30 percent of the nursing home's population. This rate represents the: ●Prevalence ●Incidence ●Frequency ●Distribution

Incidence An incidence rate is used to compare the frequency of disease in populations. Populations are compared using rates instead of raw numbers because rates adjust for differences in population size. The incidence rate is the probability or risk of illness in a population over a period of time

What must be in place to enhance the retrieval process for scanned documents? ●Electronic signature ●Indexing system ●RFID device ●Table of contents

Indexing system To enhance retrieval of scanned documents, some form of indexing needs to take place in order to organize the documents for easy retrieval. Ideally, each form that is scanned or otherwise created should have a bar code or some other forms recognition feature, or features, associated with it

In assessing the quality of care given to patients with diabetes mellitus, the CQI group collects data regarding blood sugar levels on admission and on discharge. This data is called a(n): ●Indicator ●Measurement ●Assessment ●Outcome

Indicator An indicator is a performance that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugar on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay

One technology used for computer-assisted coding is: ●Logic-based encoding ●Natural language processing ●Artificial intelligence ●Coder intervention

Natural language processing Natural Language Processing (NLP) uses a technology based on artifical intelligence that extracts pertinent data and terms from a text-based document and converts them into medical codes. The natural language processing technology used might be algorithmic (rules-based) or statistical

According to the figures, what type of coverage does the third-party payer provide Jane B. White? _____________________________________________________ *****ABC Premiere Health Plan***** *Member - Jane B. White *Policy Number - HS 123456 7890 *Group - State *Type - Employee-only EFFEC 01012005 *SEND ALL BILLS TO: ABC Premiere Health Plan 1500 Primrose Path Flowerville, XX 12345 ●Family ●Dependent ●Individual ●Premiere

Individual The policy information provided states this is an employee-only or individual policy so the dependents of Jane E. White would not be covered

On his first day of work, the new clerk in release of information processed three requests for information. He observed that all three requests were from law firms. He concluded that all requests for information come from law firms. What type of reasoning did the clerk use? ●Clinical ●Inductive ●Deductive ●General

Inductive Within both the quantitative and qualitative approaches, researchers use inductive reasoning and deductive reasoning. Inductive reasoning, or induction, involves drawing conclusions based on a limited number of observations

The process of preventing the spread of communicable disease in compliance with applicable legal requirements is performed in this quality management function. ●Infection control ●Clinical quality assessment ●Utilization management ●Risk management

Infection control The medical staff and the healthcare organization should work together to provide an environment that reduces the risk of infections in both patients and healthcare providers. The healthcare organization should support activities that look for, prevent, and control infections. As infection review is done with the involvement of the medical staff. Information is collected regularly on endemic and epidemic healthcare-associated infections. As appropriate, the healthcare must report significant information to both internal groups and public health agencies

What is the outcome of analyzing data for a specific purpose? ●Facts ●Numbers ●Charts ●Information

Information Information is the result of analyzing data for a specified purpose

The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of healthcare describes: ●Patient health records ●Information capture ●Report generation ●Patient safety reports

Information capture Information capture is "the process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of healthcare" (MRI 2002, 2). Some means of information capture in healthcare organizations are handwriting, speaking, word, processing, touching a screen, pointing and clicking on words or phrases, videotaping, audio recording, and generating digital images through x-rays and scans

A transmission medium commonly used to connect portable medical devices to information systems is: ●Cable ●Infrared light ●Microwave ●Radio waves

Infrared light Infrared light (for example, Bluetooth) is used to carry information between devices in a network. It is popularly used between PDAs and cell phones to "beam" data from one device to another, and in healthcare between medical devices and information systems

Diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? ●Outpatient ●Emergency room ●Physician office ●Inpatient

Inpatient If the diagnosis is documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," or "still to be ruled out," or similar terms indicating uncertainty, code the condition as if it existed or was established

A director of a health information services department plans to do a research project on motivation that involves rewarding some employees for achieving specified goals. A control group will not be rewarded for achieving the same goals. Which entity will need to approve this study? ●Institutional review board ●Administrative team ●Accreditation organization ●Medical staff

Institutional review board The Institutional Review Board (IRB) is a committee established to protect the rights and welfare of human research subjects involved in research activities. The IRB determines whether research that is conducted is appropriate and protects human subjects as they participate in this research. The primary focus of the IRB is not on whether they type of research is appropriate for the organization to conduct but upon whether or not human subjects are adequately protected

Which type of record is arranged in strictly chronological order? ●Sectional ●Integrated ●Consolidated ●Source-oriented

Integrated The content of the integrated health record is arranged in strict chronological order. Different types of information and sources of information are mixed together according to the dates on the entries.

Which one of the following is a characteristic of managed care organizations? ●Uncoordinated care across the continuum ●Integration of financing and delivery of health ●Cost containment and unlimited access to healthcare providers ●Freedom of choice and autonomous decision making

Integration of financing and delivery of health Managed care organizations focus on providing quality patient care. They achieve this by coordination of care across the continuum, integration of financing and delivery of health, and management of costs and outcomes

Computer-based recognition of handwritten, free-text characters is known as: ●Optical character recognition ●Intelligent character recognition ●Voice recognition ●Natural language processing

Intelligent character recognition The recognition of unconstrained, handwritten, English language free-text (print or cursive, upper- or lowercase, characters or symbols) typically stored on paper-based, analog documents is known as intelligent character recognition (ICR) technology

What is the most common type of security threat to a health information system? ●External to the organization ●Internal to the organization ●Environmental in nature ●Computer viruses

Internal to the organization As within any type of setting, the most common security threat to a health information system is an internal threat within the organization by employees

The term that describes the ability of one information system to exchange data with another information system is: ●Certified ●Deterministic ●Integrated ●Interoperable

Interoperable Many healthcare organizations have used a closed-system approach to designing healthcare information systems, which has resulted in a lack of interoperability among systems. Interoperability refers to the capability of one IS to exchange data with another

One of the roles of the health information professional in clinical quality management is: ●Performing safety check on new equipment ●Training physicians on new surgical procedures ●Making judgments about the quality of clinical care ●Interpreting data in a meaningful way

Interpreting data in a meaningful way An HIM professional can be involved in quality management in a variety of ways, including: collecting data and information; organizing, interpreting, and reporting data in a meaningful way; knowing data sources; and understanding clinical processes. In addition to the preceding ways of providing direct quality management involvement, the HIM professional role includes bringing basic guiding principles of solid information management to the attention of his or her organization. HIM professionals however do not make judgment about the quality of care given; this is left to the clinical staff.

To ensure quality of data, the Cancer Committee reviews the abstracting done by the cancer registry personnel. This is a method of _____ reliability. ●Precision ●Recheck ●Interrater ●Construct

Interrater Reliability is frequently checked by having more than one-person abstract data for the same case. The results are then compared to identify any discrepancies. This is called an interrater reliability method of checking. Several different people may be used to do the checking. In the cancer registry, physician members of the cancer committee are called on to check the reliability of the data

An internal link that allows only the employees of a particular organization to navigate and communicate in a web-based environment is a(n): ●Internet ●Repository ●Intranet ●Access code

Intranet Intranet link every employee within an organization via an easy-to-navigate, comprehensive network devoted to internal business operations. Intranets are designed to enhance communication among an organization's internal employees and facilities. Web-based intranets offer better security than use of the "public" Internet and are less expensive to implement and easier to use than most private networks proprietary mail and messaging software products

Which of the following statements is true of data quality management? ●It affects the collection, application, warehousing, and analysis of data to improve information quality ●It analyzes and interprets disease and procedure classifications and terminologies ●It includes system design, screen design, and report and forms design ●It involves appropriately responding to requests for information based on laws and policy

It affects the collection, application, warehousing, and analysis of data to improve information quality Data quality management is the collection, application, warehousing, and analysis of data to improve information quality

Which of the following statements is true of structured query language (SQL)? ●It is both a data manipulation and data back-up mechanism ●It defines data elements and manipulates and controls data ●It is the computer language associated with document imaging ●Users are not able to query a relational database

It defines data elements and manipulates and controls data SQL includes both Data Dictionary Language and Data Manipulation Language components and is used to create and manipulate relational databases

Which of the following is true of the median? ●It is a measure of variability ●It is difficult to calculate ●It is based on the whole distribution ●It is sensitive to extreme values

It is base on the whole distribution The median offers the following three advantages: relatively easy to calculate; based on the whole distribution and not just a portion of it, as is the case with the mode; and unlike the mean; it is not influenced by extreme values or unusual outliers in the frequency distribution

What is the biggest problem with using mean length of stay as a facility statistic? ●It is not accurate ●It is influenced by outlier values ●It is mathematically incorrect ●It is a dependent variable

It is influenced by outlier values The mean is sensitive to extreme measures. That is, it is strongly influence by outliers

Which of the following is a function of a data warehouse? ●It provides the most recent transaction data available within the organization ●It stored print-outs from the system is organized filed ●It is organized around specific business functions or requirements ●It limits access to business data for analysis or data mining (in other words, decision support)

It is organized around specific business functions or requirements A data warehouse is a database that has the following functions: serves as a neutral storage area for data extracted from an organization's transactional systems, serves as a storage area around specific business functions or requirements, and provides easy access to business data for analysis or data mining (that is, decision support)

From the figure, determine the subscriber. _________________________________________________ *****ABC Premiere Health Plan***** *Member - JANE B, WHITE *Policy Number - HS 123456 7890 *Group - State *Type - Employee-only EFFEC 01012005 *SEND ALL BILLS TO: ABC Premiere Health Plan 1500 Primrose Path Flowerville, XX 12345 ●STATE ●ABC Premiere Health Plane ●JANE B. WHITE ●Cannot be determined

JANE B. WHITE The subscriber of the insurance policy is the member or person for which the policy is provided for

A decision support system (DSS) in which the key element in its architecture often consists of rules in the form of an IF, THEN, ELSE format is called a(n) ●Data-based DSS ●Knowledge-based DSS ●Model-based DSS ●Ontology-based DSS

Knowledge-based DSS Knowledge-based DSS are often referred to as rule-based systems because the knowledge is stored in the form of rules. For example, a simple rule system is the familiar IF, THEN, ELSE format - if a certain condition is true, then this is an indication of a certain other condition, else the condition is not indicated. By applying general rules of this form to a given situation, a decision is suggested to the user

Which of the following is an example of clinical information systems? ●Laboratory information system ●Staff scheduling system ●Patient registration system ●Material management system

Laboratory information system Clinical information systems (or applications) contain primarily clinical or health-related data that are used to diagnose, treat, monitor, and manage patient care. Examples of clinical applications include ancillary departmental systems (such as pharmacy, radiology, and laboratory medicine) as well as EMR systems, CPOE, medication, administration, and nursing documentation

Which one of the following is an example of a clinical information system? ●Laboratory information system ●Human resource management system ●Patient registration system ●Staff management system

Laboratory information system Clinical information systems (or applications) contain primarily clinical or health-related data that are used to diagnose, treat, monitor, and manage patient care. Examples of clinical applications include ancillary departmental systems (such as pharmacy, radiology, and laboratory medicine) as well as EMR systems, computerized provider order entry, medication administration, and nursing documentation

Today, to practice medicine, medical school students must pass a test before they can obtain a: ●Degree ●Residency ●Specialty ●License

License A license is required in order for medical students to practice medicine

Before Central Hospital is permitted to open and provide medical services in a particular state, the organization must first go through which of the following processes? ●Accreditation ●Licensure ●Qualification ●Certification

Licensure Licensure is required prior to a hospital's opening and providing medical services

This type of data display tool is a plotted chart of data that shows the process over time. ●Bar graph ●Histogram ●Pie chart ●Line graph

Line graph A line graph may be used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the values of the variable being plotted.

This data mining technique discovers relationships between attributes within data sets and displays them in a linked network graph to enable the user to better visualize the patterns. ●Machine learning ●Linkage analysis ●Neural networks ●Logistic regression

Linkage analysis Linkage analysis portrays relationships discovered within data sets by a linked network graph. Many healthcare organizations as well as government agencies are investigating linkage analysis as a DSS tool for containing the increasing cost of healthcare due to fraud and abuse

The Omnibus Budget Reconciliation Act of 1980 amended the SSA to specify which procedures would be covered under the prospective payment system for ambulatory surgical centers. This PPS is officially named the ASC_______. ●List of Covered Procedures ●List of Covered Surgeries ●Fee Schedule ●PPS

List of Covered Procedures The Omnibus Budget Reconciliation Act of 1980 amended sections 1832(a)(2) an 1833 of the Social Security Act (SSA) to specify procedures that would be covered under the prospective payment system called the ASC List of Covered Procedures (ASC list)

A group of computers connected within a relatively small geographic area such as an office building or hospital is what type of network? ●Local area network ●Wide area network ●Wireless local area network ●Virtual private network

Local area network A local area network (LAN) is a group of computers typically connected within a relatively small geographic area, such as an office, building, or campus. Connectivity is generally achieved through dedicated cable

A health record that maintains information thought the lifespan of the patient, ideally from birth to death, is known as a: ●Problem-oriented health record ●Patient- centric record ●Longitudinal health record ●Health record

Longitudinal health record A longitudinal health record maintains information throughout the lifespan of the patient, ideally from birth to death

Anywhere Hospital has mandated that the social security number be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a: ●Wildcard ●Mask ●Truncation ●Data definition

Mask The data dictionary may also control if a mask is used and if so, what form it takes. The social security number 123456789 could be entered and it appears in the system as 123-45-6789. The use of the mask tells the database what format to use to display the number

Often considered the most important resource in a healthcare facility, this index is a database of patient within a facility or associated group of facilities. ●Facility-specific index ●Master patient index ●Disease index ●Disease and operation index

Master patient index The master patient index (MPI) is a database of patients and individuals for which healthcare services are delivered or completed

Which of the following indexes and databases includes patient-identifiable information? ●MEDLINE ●Clinical trials database ●Master patient/population index ●UMLS

Master patient/population index The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. Without the information contained in the MPI, it would be almost impossible to locate a patient's health record in most organizations that use a numeric filing system. The MPI is the permanent record of every patient ever seen in the healthcare entity. The amount of information contained on each patient in the MPI varies from facility to facility. However, the basic information usually includes patient's last, first, and middle names; patient's health record number(s); patient's gender; and dates of encounter. Additional information such as address, telephone number, and attending for each encounter also may be recorded

Which of the following indexes and databases includes patient-identifiable information? ●MEDLINE ●Clinical trials database ●Master population/patient index ●UMLS

Master population/patient index Master population/patient index (MPI) contains patient-identifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physician, and health record

Which documents give detailed information about all substances and material used at a facility, including any hazards associated with them? ●Disaster cleanup plan ●Hazard vulnerability plan ●Material safety data sheets ●Substance exposure instruction sheets

Material safety data sheets The material safety data sheets (MSDSs) give detailed information about a material, including any hazards associated with the material. MSDSs must be available immediately to employees at locations where hazardous materials are used

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for: ●Veterans of the Armed Forces ●Spouses or widow(er) of veterans meeting specific criteria ●Active-duty service members ●Spouses of active duty service members

Spouses or widow(er) of veterans meeting specific criteria The Department of Veterans Affairs provides covered healthcare services and supplies to eligible beneficiaries through the Civilian Health and Medical Program of the Departmet of Veterans Affairs (CHAMPVA)

Medicaid coverage is not identical in New Jersey, California, or Idaho. Which of the following reasons is correct? ●Federal funds allocated to each state are based on the size of the state ●The program must cover infants born to Medicaid-eligible pregnant women ●States that offer an SCHIP program do not have a Medicaid program ●Medicaid allows states to maintain a unique program adapted to state residents needs and average incomes

Medicaid allows states to maintain a unique program adapted to states residents needs and average incomes. Coverage differs among these states because Medicaid allows states to maintain a unique program adapted to state residents needs and average incomes. Although state programs must meet coverage requirements for groups such as recipients of adoption assistance and foster care, other types of coverage, such as vision and dental services, are determined by the states Medicaid agencies.

Which of the following generally describes a coroner and a medical examiner, both of who examine suspicious deaths? ●Medical examiner is usually a non-physician elected official; coroner is appointed ●Medical examiner is a pathologist; coroner is not a physician ●Medical examiner is appointed by the court; coroner is a physician ●Medical examiner is usually a physician; coroner is appointed or elected and may or may not be a physician

Medical examiner is usually a physician; coroner is appointed or elected and may or may not be a physician A medical examiner is typically a physician with pathology training given the responsibility by a government, such a county or state, for investigating suspicious deaths. A coroner is typically an appointed or elected official, who may or may not be a physician, with responsibility for investigating suspicious deaths

Medical staff bylaws are legally binding and any changes must be approved by a vote of which of the following? ●Hospital staff ●Administrative Staff ●Hospital attorney ●Medical staff

Medical staff The medical staff is governed by bylaws that are typically votes on by the medical staff and executive committee and then approved by the facility's board. The organized medical staff operates under the direction of the medical staff officers typically consist of a president, president-elect, chief of staff, and vice chief of staff with the president-elect transitioning to president and the vice chief of staff transitioning to the chief of staff position

Which of the following govern(s) the operation of a hospital medical staff? ●Medical staff classification ●Medical staff bylaws ●Medical staff credentialing ●Medical staff committees

Medical staff bylaws The medical staff is governed by bylaws that are typically voted on by the medical staff and executive committee and then approved by the facility's board

Blood and blood component usage review, medication usage review, and surgical case review are all examples of: ●Activities used in appointing to the medical staff ●Medical staff clinical QI activities ●Infection control data ●Data available through the National Practitioner Data Bank

Medical staff clinical QI activities The medical staff must lead the way in improving clinical and nonclinical processes used in organizations. Involvement of the medical staff in patient care review is critical. This means the medical staff is involved in measuring, assessing, and improving processes that depend on licensed physicians or other practitioners credentialed and privileged through the medical staff process. The use of blood and blood components, medication use, and surgical case are examples of these clinical QI activities

Long-term acute care is paid under which of the following Medicare systems? ●SNF Resource Utilization Groups (RUGS) ●Medicare Inpatient Rehabilitation Facilities (IRF) ●Medicare prospective payment systems (PPS) ●Medicare Severity Diagnostic-Related Groups (MS-DRGs)

Medicare Severity Diagnostic-Related Groups The Medicare reimbursement for LTCHs is under a PPS based on the Medicare Severity diagnosis-related groups (MS-DRGs) systems used by short-term, acute-care MS-DRGs are used, but have been weighted to reflect the resources required to treat the medically complex patients treated at LTCHs

Protocols that support communication between applications are often referred to as: ●Application program ●Interface code ●Messaging standards ●Source code

Messaging standards Within healthcare, standard protocols that support communication between nonintegrated applications are often referred to as messaging standards, also called interoperability standards or data exchange standards. Messaging standards provide the tools to map proprietary formats to one another and more easily accomplish the exchange of data

The _____ is/are used to gather information about specific health status factors and include(s) information about specific risk factors in the resident's care. ●Resident Assessment Protocols (RAP) ●Resident Assessment Instrument (RAI) ●Utilization Guidelines ●Minimum Data Set (MDS)

Minimum Data Set (MDS) The MDS is the first component of the RAI and is used to collect information about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long-term care facility

Which of the following is a database from the National Health Care Survey that uses the 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 The National Ambulatory Medical Care Survey includes data collected by a sample of office-based physicians and their staffs from the records of patients seen in a one-week reporting period. Data included are demographic data, the patient's reason for visit, the diagnoses, diagnostic and screening services, therapeutic and preventive services, ambulatory surgical procedures, and medications and injections, in addition to information on the visit disposition and time spent with the physician

You are working in the credentialing office at the hospital and need to check if a physician applying for medical staff privileges has had privileges denied at any other facility. You would check the: ●Healthcare Integrity and Protection Data Bank ●MEDPAR file ●National Practitioner Data Bank ●Volunteer Mutual Association

National Practitioner Data Bank The National Practitioner Data Bank maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the a. Health Plan Employer Data and Information Set. b. risk manager. c. National Practitioner Data Bank. d. peer review organization.

National Practitioner Data Bank.

For a hospital planning to open a portal for its physicians to access their transcribed reports, lab results, and potentially other applications, an important element of technology that should be considered is: ●Document imaging ●Network capacity ●Provider interest ●Telecommunications fees

Network capacity Network and infrastructure capability are obviously major requirement for an EHR. Many times, decisions about new network structures such as wireless, more remote access, and web-based architectures are made at the time an EHR is considered. These can play an important role in ease of use, response time and reliability of the system as well as the ubiquity of the EHR functionality. Telecommunications capability may well need to be enhanced

From the figure, determine whether the plan covers Gill F. White, Jane's spouse. __________________________________________________ *****ABC Premier Health Plan***** *Member - JANE B. WHITE *Policy Number - HS 123456 7890 *Group - State *Type - Employee-Only EFFEC 01012005 *SEND ALL BILLS TO: ABC Premiere Health Plan 1500 Primrose Path Flowerville, XX 12345 ●No; the card states "Employee-Only." ●Yes; the policy number includes "S" ●Yes; the group is "State." ●Cannot be determined

No; the card states "Employee-Only The policy information provided states this is a single policy or employee-only policy, so the member's spouse is not covered

A QI technique that allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended circular discussions is called: ●Brainstorming ●Benchmarking ●Decision-making technique ●Nominal group technique

Nominal group technique The nominal group technique gives each member of the team the opportunity to select which ideas identified from the affinity diagram process are the most important. This technique allows groups to narrow the focus of discussion or make decisions without getting involved in extended, circular, which more vocal members dominate

The term used to describe breaking data elements into the level of detail to retrieve the data is: ●Normalization ●Data definitions ●Primary key ●A database management system

Normalization When developing the data elements that go into a database, the fields should be normalized. Normalization is breaking the data elements into the level of detail desired by the facility. For example, last name should be in separate field as should city, state, and zip code

The generic formula for calculating rate of occurrence is used to calculate hospital-acquired infections in an intensive care unit in a given month. If the number of hospital-acquired infections is the numerator, the denominator would be the: ●Number of patients who died of an infection ●Number of deaths in the ICU ●Number of discharges (including deaths) of ICU patients ●Total number of hospital discharges

Number of discharges (including deaths) of ICU patients Hospital-acquired (nosocomial) infection rates may be calculated for the entire hosptial or a specific unit in the hospital. They also may be calculated for the specific types of infections. Ideally, the hospital should strive for an infection of 0.0 percent. The formula for calculating the hospital-acquired, or nosocomial, infection rate is: Total number of hospital-acquired infections for a given period / Total number of discharges, including deaths, for the same period x 100

Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? ●Unit secretary working on the unit where the patient is located ●Nurse working on the unit where the patient is located ●Health information director ●Admissions registrars

Nurse working on the unit where the patient is located Because of the risks associated with miscommunication, verbal orders are discouraged. When a verbal order is necessary, a clinician should sign, give his or her credential (for example, RN, PT, or LPN), and record the date and time the order was received. Verbal orders for medication are usually to be given to, and to be accepted only by, nursing or pharmacy personnel

In the HHPPS system, which home healthcare services are consolidated into a single payment to home health agencies? ●Home health aide visits, routine and nonroutine medical supplies, durable medical equipment ●Routine and nonreoutine medical supplies, durable medical equipment, medical social services ●Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits ●Nursing and therapy services, durable medical equipment, medical social services

Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits Under the HHPPS, CMS has accounted for nonroutine medical supplies medical social services, and nursing and therapy services

What data set provides the underpinning of the Home Health PPS? ●UHDDS ●MHDS ●OASIS ●HAVEN

OASIS The case-mix system for the HHPPS combines 20 data elements from the OASIS to measure the three domains of the case mix: clinical severity, functional status, and service utilization

In addition to bar codes on health record documents, what other forms of recognition characteristics enhance the accuracy of forms indexing features? ●Access controls ●COLD ●OCR ●Workflow

OCR The capability to retrieve documents from an electronic document management system (EDMS) is determined by the underlying technology used to store the documents. In addition to bar codes on medical record documents, optical character recognition (OCR) may be available to enhance the accuracy of indexing features on forms

As the Director of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency. a. CMS b. OSHA c. ONC d. CDC

ONC

The basic component of a(n) _____ is an object that contains both data and their relationships in a single structure. ●Object-oriented database ●Relational database ●Access database ●Structured database

Object-oriented database An object-oriented database is derived from object-oriented programming and has no single inherent structure. The structure for any given class or type of object can be anything a programmer finds useful - a linked list, a set, an array, etc. An object may contain different degrees of complexity, making use of multiple types and multiple structures

Which TRICARE program offers services to active duty family members (ADFMs) with no enrollment, deductible, or copayment fees for covered services? ●TRICARE Prime ●TRICARE Standard ●TRICARE for Life ●TRICARE Plus

TRICARE Prime TRICARE Prime is also available for military retirees under age 65 and their families

Which of the following items are fundamental parts of a Quality Improvement plan? ●Vision, mission, and community outreach ●Objectives, values, and performance measures ●Values, performance measures, and community outreach ●Objective, mission, and accreditation status

Objectives, values, and performance measures Key to the implementation of an effective PI program is a written plan that systematically describes the structure and approach the organizations will follow in the continuous assessment and improvement of its important systems, processes, and outcomes of care. Items commonly found in a plan include statement of mission, and vision, objectives, values, leadership, organizational structure, methodologies, performance measures, communication, and annual plan appraisal

Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care-acute-care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of an MCO in an integrated delivery system, how should Phil expect that his healthcare billing will be handled? ●Bills for each service from each physician, each facility, and each other healthcare provider from every encounter ●Bills for each service from each physician, each facility, and each other healthcare provider at the end of the 10-month period ●Consolidated billing for each encounter that includes the bills from all the physicians, facilities, and other healthcare providers involved in the encounter ●One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers

One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers Integrated delivery system is a term referring to the collaboration integration of healthcare providers

OLAP is the acronym used for: ●On-time linear analysis program ●Online linear analytical program ●Online analytical processing ●One-time leftover analysis predicament

Online analytical processing Online analytical processing (OLAP) is an application that was developed to explore the multidimensional aspects of such business data. OLAP stores in a multidimensional data structure and enables the user to examine and view the data along dimensions that may be specific to the context and will be defined by the business rules of the organization

The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing, are included in what area of performance measurement? ●Outcomes ●Processes ●Systems ●Benchmarks

Outcomes Healthcare performance improvement philosophies most often focus on measuring performance in systems, processes, and outcomes. The results of care, treatment, and services are examples of outcomes

In healthcare, one of the primary uses for data warehouses is: ●Utilization review ●Accounts receivable management ●Outcomes management ●Materials/inventory management

Outcomes management In healthcare, data warehouses have been used primarily for the following applications: clinical management, operations management, outcomes management, population management, and revenue management. For example, data mining is conducted to study patient health status or other factors, such as satisfaction, that contribute to clinical outcomes

Which of the following stores a clinical image in a computer? ●CDA ●FDA ●PACS ●XML

PACS A picture archiving and communication system (PACS) is used to store radiology and other clinical images

An attempt to contain hospital inpatient costs and improve quality by restructuring services is called: ●Continuous quality improvement ●Patient-focused care ●Managed care ●Acute care

Patient-focused care Patient-focused care attempts to contain hospital inpatient costs and improve quality by restructuring services so that more of them take place in nursing units (patient floors) and not in specialized units in dispersed hospital locations,. The emphasis is on cross-training in the nursing units to perform a variety of functions for a small group of patients rather than one set of functions for a large number of patients

Which of the following is an example of an M:M relationship? ●Patients to hospital admissions ●Patients to consulting physicians ●Patients to hospital medical records ●Primary care physicians to patients

Patients to consulting physicians A many-to-many relationship occurs only in a data model developed at the conceptual level. In this case, the relationship between PATIENTS and CONSULTING PHYSICIANS is many-to-many. For each instance of PATIENT, there could be many instances of CONSULTING PHYSICIAN because patients can be seen by more than one consulting physician. For each instance of CONSULTING PHYSICIAN, there could be many PATIENTS because the physician sees many patients

Which of the following is an example of a 1:M relationship? ●Patients to hospital admissions ●Patients to consulting physicians ●Patients to hospital health records ●Primary care physicians to patients

Patients to hospital admissions The one-to-many relationship exists when one instance of an entity is associated with many instances of another entity. In this case, the relationship between PATIENT and HOSPITAL ADMISSIONS is one-to-many. For each instance of PATIENT in the database, there could be many instances of HOSPITAL ADMISSION. In other words each patient may have many hospital admissions, but each hospital admissions, but each hospital admission is associated with only one patient

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for: ●Performance improvement programs ●Billing and claims data processing ●Developing hospital discharge abstracting systems ●Developing individual care plans for residents

Performance improvement programs In 1997, the Joint Commission introduced the ORYX initiative to integrate outcomes data and other performance measurement data into its accreditation processes

Which of the following basic services provided by an HIE organization matches identifying information to an individual? ●Consent management ●Person identification ●Record locator ●Identify management

Person identification Because there is not mandated unique identifier, ensuring that the HIE organization can identify the right patient as it seeks to exchange information is a process of identify matching

Verbal orders by telephone or in person are discouraged. In cases where verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened? ●Person receiving the order should it read it back to ensure the order is correct ●Order should be signed after the patient is discharged from the facility ●Order should be signed by another provider ●Person receiving the order should authenticate the order after it is entered into the record

Person receiving the order should it read it back to ensure the order is correct Because of the risks associated with miscommunication, verbal orders are strongly discouraged. To reduce miscommunication, the person receiving the order should read it back to ensure the order is correct. Verbal orders should be authenticated as soon as possible after they are given

This EHR implementation strategy identifies the sequence of implementing the EHR with regard to various inpatient units, departments, physicians, or other categories of users or sites. ●Phased roll-out ●Big bang roll-out ●Pilot ●Straight turnover

Phased roll-out Implementation of an EHR component, or functions of a component, in one or a few organizational units at a time with full roll-out in the same manner is called a phased roll-out

Electronic prescribing is used in: ●Computerized provider order entry ●Hospital order entry systems ●Physician office prescription writing ●Pharmacy systems

Physician office prescription writing E-prescribing is the protocol used for physician office to send prescriptions electronically to a retail pharmacy. When a provider writes a prescription in an e-prescribing system to be sent to a retail pharmacy, the prescription must be written in the NCPDP SCRIPT protocol for the retail pharmacy to receive it

The computerized analysis of heart functioning, blood sugar levels, and brain wave activity are examples of: ●Point-of-care documentation ●Artificial intelligence ●Online analytical processing ●Physiological signal processing

Physiological signal processing Physiological signal processing systems measure biological signals, examples include ECG, EEG, EMG and fetal trace systems. These systems store data based on the body's signals and create output based on the lines plotted between the signals' points

A system that monitors a patient's cardiac activity and alerts the provider to readings outside normal parameters is an example of a(n): ●Point-of-care information system ●Clinical pathway ●Physiological signal processing system ●Telehealth system

Physiological signal processing system Physiological signal processing systems measure biological signals (for example, ECG, EEG, EMG, and fetal trace systems). They help to integrate the medical science of analyzing the signals with such disciplines as biomedical engineering, computer graphic, mathematics, diagnostic image processing, computer vision, and pattern recognition

A health information professional is preparing statistical information about the third-party that reimburse care in the facility. She find the following information: Medicare reimburses 46 percent; Medicaid reimburses 13 percent; Blue Cross reimburses 21 percent; workers' compensation reimburses 1 percent; commercial plans reimburse 15 percent; and other payers or self-payers reimburse 4 percent. What is the best graphic tool to use to display this data? ●Histogram ●Pie chart ●Line graph ●Table

Pie chart A pie chart is an easily understood chart in which the sizes of the slices of the pie show the proportional contribution of each part. Pie charts can be used to show the component parts of a single group or variable. In this case, the intent is to show the proportion of each payer to the whole payer mix

A barrier to effective computer-assisted coding is the: ●Resistance of physicians ●Resistance of HIM professionals ●Poor quality of documentation ●Reduction of consistency without human coders

Poor quality of documentation Computer-assisted coding (CAC) cannot address the major obstacle facing today's human coder: the lack of accurate, complete clinical documentation

A risk manager is called in to evaluate a situation in which a visitor to the hospital slipped on spilled water, fell, and fractured his femur. This situation was referred to the risk manager because it involves a: ●Medical error ●Claims management issue ●Potentially compensable event ●Sentinel event

Potentially compensable event Risk management systems today are sophisticated programs that function to identify, reduce, or eliminate potentially compensable events (PCEs), thereby decreasing the financial liability of injuries or accidents to patients, staff, or visitors

Mobile input devices are primarily limited in their use by: ●Navigational support concerns ●Network connectivity support ●Portability ●Power supply issues

Power supply issues Portable devices require a battery for their power, which is perhaps one of their main drawbacks for use in a 24/7 environment, or even in an 8-hour day. Most portable computers do not have sufficient battery power to the last 8 hours

Which of the following clinicians would use the DSM-IV-TR system to assist with establishing a diagnosis? ●Registered nurses ●Physical therapists ●Practicing psychiatrists ●Registered dietitians

Practicing psychiatrists DSM-IV-TR is a multi-axial coding system with five axes. Axis 1 includes the mental disorders or illnesses comparable to general medical illnesses. Axis 2 includes personality disorder. Axis 3 includes general medical illnesses. Axis 4 covers life events or social problems that affect the patient. Axis 5 is the overall level of the patient's functioning, usually as determined by the Global Assessment of Functioning (GAF). The American Psychiatric Association (APA) states two general uses for DSM: as source of diagnostic information that enhances clinical practice, research, and education

This function of the utilization management program identifies patients who are unsuitable for a particular procedure or admission. ●Admission review ●Concurrent review ●Discharge planning ●Pre-admission review

Pre-admission review The pre-admission review is done prior to the patient's admission. It is required by most managed care plans. Its purpose is to determine if the admission and procedure are medically are medically necessary and appropriate in an acute care setting. The pre-admission review identifies patients who are unsuitable for admission or for a particular procedure and then directs them to the appropriate care setting to obtain healthcare services

When the patient's physician contacts a healthcare organization to schedule an episode of care service, the healthcare organization begins which step in the case management process? ●Preadmission care planning ●Care planning at the time of admission ●Review the progress of care ●Discharge planning

Preadmission care planning Preadmission care planning is initiated when the patient's physician contacts a healthcare organization to schedule an episode of care service. The case manager reviews the patient's projected needs with the physician. Admission criteria are established based on a suggested diagnosis. The manager also may contact the patient directly to obtain further information

Which of the following conditions are included on the hospital-acquired condition provision list? ●Pressure ulcers, staphylococcus infections, gunshot wounds ●Staphylococcus infections, air embolism, physical and substance abuse ●Catheter associated urinary tract infections, gunshot wounds ●Pressure ulcers, catheter associated urinary tract infections, falls and fractures

Pressure ulcers, catheter associated urinary tract infections, falls and fractures Gunshot wounds, physical abuse, and substance abuse are not hospital-acquired conditions an therefore are not listed under the hospital-acquired condition provision list

Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time? ●Prevalence ●Incidence ●Frequency ●Distribution

Prevalence The prevalence rate is the proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time. The prevalence rate describes the magnitude of an epidemic and can be an indicator of the medical resources needed in a community for the duration of the epidemic

The _____ is the procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition. ●Chief procedure ●Principal treatment ●Principal procedure ●Comorbidity

Principal procedure The principal procedure is the procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition

The SOAP format is an example of a structured progress note commonly used with the _____ health record. ●Patient-oriented ●Problem-oriented ●Source-oriented ●Integrated system

Problem-oriented The subjective, objective, assessment and plan (SOAP) format is an example of a structure progress note commonly used with the problem-oriented health record

The percent of antibiotics administered immediately prior to open reduction and internal fixation (ORIF) surgeries or the percent of deliveries accomplished by cesarean section are examples of what type of performance measure? ●Outcome measure ●Data measure ●Process measure ●System measure

Process measure A process measure has a scientific basis for it. In this example, the percentage of antibiotics administered before surgery has been proved through evidence-based medicine so it is scientifically based

An effective tool for implementing a new information system is: ●Project management software ●Entity relationship diagrams ●User documentation ●Structured query languages

Project management software Throughout the implementation process, many tasks or activities may occur simultaneously; others will need to be completed before other activities can begin. Because of the number of different tasks occurring. It is generally a good idea for the project manager to use Gantt chart or project management software that identifies the major tasks, their estimated start and completion dates, the individuals responsible for performing them, and the resources needed to complete them

A ratio in which x is portion of the whole is called a(n): ●Index ●Chart ●Proportion ●Distribution

Proportion A proportion is a particular type of ratio in which x is a portion of the whole (x + y). In a proportion, the numerator is always included in the denominator

The best reason for implementing IS technology in healthcare is to: ●Provide effective and efficient patient care services ●Keep up with rapid technological change ●Provide a competitive edge in marketing the organization ●Support all identified IS initiatives identified by managers in the organization

Provide effective and efficient patient care services Healthcare organizations are under increased pressure to control costs and improve efficiency. At the same time, they are experiencing increased demands to ensure patient safely, reduce medical errors, improve the quality of care, promote access, and ensure compliance with privacy and security regulations, Many healthcare organizations are looking to information system (IS) technology to help them respond to these pressures and provide high-quality services in a more cost-effective manner

An RFP serves two important purpose: It solidifies the planning information and organizational requirements into a single document, and it: ●Allows one vendor an advantage over the other potential vendors ●Enables the organization to make decisions quickly ●Provides valuable insights into someone's operations and products and levels the playing field in terms of asking all the vendors the same questions ●Delineates the organization's system requirements in such a way that a vendor is selected without review of the entire RFP pool

Provides valuable insights into the vendors operations and products and levels the playing field in terms of asking all the vendors the same questions A well-constructed RFP serves two important purposes. One is to solidify the planning information and organizational requirements into a single document and the other is to provide valuable insights into the vendor's operations and products and to level the playing field in terms of asking all the vendors the same questions. This process requires skill and time

Which of the following is an external user of hospital data? ●Public health department ●Medical staff ●Hospital administrator ●Director of the clinical laboratory

Public health department External users of patient data are individuals and institutions outside the facility, Examples include state data banks and federal agencies. States have laws that mandate cases of patients with diseases such as tuberculosis and AIDS be reported to the state department of health. Moreover, the federal government collects data from the states on vital events such as births and deaths

A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This process addresses the data quality element of: ●Validity ●Granularity ●Timeliness ●Reliability

Validity The quality of coded clinical data depends on a number of factors, including validity. Validity is ensuring that the coded data is a correct representation of the patient's diagnosis and procedures

The following performance standard, "Complete five birth certificates per hour" is an example of a: ●Quality standard ●Quantity standard ●Joint Commission standard ●Compliance standard

Quantity standard Quantity standards (also called productivity standards) and quality standards (also known as service standards) are generally used to monitor individual employee performance and the performance of a functional unit or the department as a whole. To properly communicate performance standards, managers need to make the distinction between quantitative and qualitative standards and identify examples of each for the HIS functions

Which of the following would be used to determine what the users need in an information system? ●Questionnaire ●Trouble ticket ●Source code ●Weighted system

Questionnaire Questionnaires allow for a large number of users to provide input about the needs of the system

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from a. indicator monitoring program. b. R-ADT system. c. disease index. d. generic screens used by record abstractors.

R-ADT system.

An example of storage technology used to achieve redundancy in the event of a server crash is: ●CPU ●DVD ●RAID ●USB

RAID One configuration that is commonly used is called redundant arrays of inexpensive (or independent) disks (RAID). RAID comes in different levels; although the names of the levels are not standardized, there are typically from two to five levels

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's a. CPOE. b. expert system. c. EDMS system. d. RHIO.

RHIO

While the focus in inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the: ●Reason for admission ●Reason for encounter ●Discharge diagnosis ●Activities of daily living

Reason for encounter The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care such as the reason for the encounter with the healthcare provider

The primary purpose of a minimum data set in healthcare is to: ●Recommend common data elements to be collected in health records ●Mandate all data that must be contained in a health record ●Define reportable data for federally funded programs ●Standardize medical vocabulary

Recommend common data elements to be collected in health records The need for standardized data definitions was recognized in the 1960s, and the National Committee on Vital and Health Statistics took the lead developing uniform minimum data sets for various sites of care. As technology has driven the development of the data/information systems, the early data sets have been supplemented with healthcare information standards that focus on EHR systems. A number of standards-setting organizations are involved in developing uniform definitions, data fields, and views for health record content and structure

The ______ is/are used to complete comprehensive assessment and collect information for the Minimum Data Set for Long-term Care (MDS). ●Resident Assessment Protocols ●Resident Assessment Instrument ●Utilization guidelines ●Minimum Data Set

Resident Assessment Instrument Every long-term care facility must complete a comprehensive assessment of every resident's needs by using the Resident Assessment Instrument (RAI) specified by the state in which the facility operates

In the long-term care setting, these problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions). ●Resident Assessment Protocols (RAP) ●Resident Assessment Instrument (RAI) ●Utilization Guidelines (UG) ●Minimum Data Sets (MDS)

Resident Assessment Protocols (RAP) RAPs form a critical link to decisions about care planning and provide guidance on how to synthesize assessment information within a comprehensive assessment

A researcher fails to inform a study participant of the reasonable risks in a study of the effectiveness of a new chemotherapy agent. What ethical principle was violated? ●Beneficence ●Ethical treatment ●Justice ●Respect for persons

Respect for persons Respect for persons requires that individuals be treated as autonomous human beings and not used as a means to an end. Elements of autonomy include the ability to understand and process information and the freedom to volunteer for research without coercion or undue influence from others. Respect for persons requires informed consent and respecting the privacy of research subjects

Which of the following is the first step in a generic approach to developing a strategic IS plan? ●Identify the organization's IS needs and prioritize current and future IS projects ●Gain approval from the organization's leaders for the prioritized plan for completing IS projects ●Review the organization's strategic plan and assess the organization's current external and internal environment ●Evaluate the organizations existing information systems and assess its current internal environment

Review the organization's strategic plan and assess the organization's current external and internal environment To begin the planning process, the IS Steering Committee should review the organization's current strategic plans, goals, and objectives and evaluate its current external environment. The overall strategic plan should include an environmental assessment that analyzes the external forces that may affect the organization. External forces include changes in reimbursement methodologies, new government regulations, and changes in the demographics or healthcare needs of the community

Which of the following is a systematic process of identifying security measures to afford protections given an organization's specific environment? ●Gap analysis ●Operations review ●Readiness assessment ●Risk analysis

Risk analysis Risk analysis is a systematic process of identifying security measures to afford protections given an organization's specific environment, including where the measures are located, what level of automation they have, how sensitive the information is that needs protection, what remediation will cost, and many other factors

Which of the following processes would investigate a medical error that resulted in the death of a patient? ●Security management ●Risk management ●Diagnostic review ●Accreditation

Risk management One purpose of risk management is to investigate a medical error that resulted in the death of a patient

The systematic investigation of both the clinical administrative reasons for sentinel events is called: ●Concurrent review ●Outcomes assessment ●Qualitative analysis ●Root-cause analysis

Root-cause analysis When a sentinel event occurs, organizational leadership must support the process of investigation, analysis, and improvement. The expectation is that the organization will respond to all sentinel events. Root-cause analysis is the process used to identify the cause of the event. The organization looks for ways to decrease the likelihood of such an even happening again. The focus should be on organizational and clinical systems and processes, not on the person or people involved in the sentinel event

Which terminology provides a common language that enables a consistent way of capturing, sharing, and aggregating health data across specialities and sites of care for EHR ●SNOMED CT ●ICD-10-CM ●DEEDS ●OTLP

SNOMED CT As a core terminology for the EHR. SNOMED CT provides a common language that enables a consistent way of capturing, sharing, and aggregating health data across specialities and sites of care. SNOMED CT has several components: concept, description, and relationship tables.

From the figure, determine who is the entity that has purchased the insurance policy. __________________________________________________ *****ABC Premiere Health Plan***** *Member - JANE B. WHITE *Policy Number- HS 123456 7890 *Group - State *Type - Employee-only EFFEC 01012005 *SEND ALL BILLS TO: ABC Premiere Health Plan 1500 Primrose Path Flowerville, XX 12345 ●1234567890 ●STATE ●ABC Premiere Health Plan ●Jane B. White

STATE The insured is the organization that has purchased the insurance policy. In this case, STATE has purchased the insurance coverage for subscriber Jane B. White

The researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? ●Content analysis ●Effect size review ●Psychometric assay ●Secondary analysis

Secondary analysis Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file

Which of the following basic services provided by an HIE organization ensures that information can be retrieved as needed? ●Consent management ●Person identification ●Registry and directory ●Secure data transport

Secure data transport A basic service provided by an HIE organization must be the actual transmission of the data. This is technical networking service that provides appropriate bandwidth, latency, availability, ubiquity, and security

What is the principal function of health records? ●Provide information for performance improvement activities ●Support billing and reimbursement processes ●Serve as the repository of clinical documentation relevant to the care of individual patients ●Determine appropriate resource allocation

Serve as the repository of clinical documentation relevant to the care of individual patients The principal function of the health record is to serve as the repository of clinical documentation relevant to the care of individual patients

To reduce the effect of a server crash in an EHR environment, it is advisable to: ●Have an inventory of all systems ●Have a storage area network ●Store data in RAID ●Set up redundant systems

Set up redundant systems When a paper health record backup no longer exists in a paperless EHR environment, there must be assurance that the computer system is available to users at all times. To achieve such availability, an EHR must have full redundancy, as well as backup and network redundancy. This means that as data are entered and processed by one server, they are simultaneously being entered and processed by a second server. Should the primary server crash, the system fails over to the second server and can continue processing as if (at least from the user's point of view) nothing had happened

A database established to identify the level of resource consumption based on clinical evidence is best described as: ●Utilization review ●Severity index ●Risk management ●Credential review

Severity index Severity index is the process of identifying the level of resource consumption based on factors of clinical evidence. The more complications and comorbid conditions present, the sicker the patient and the higher the resource consumption. This method of trying to judge the level of illness for reimbursement, utilization, and quality of care programs

Electronic document management system (EDMS) would enable which of the following changes to occur in an HIM department? ●Change record retention schedule to one year ●Eliminate transcription ●Reduce coding errors ●Shift release of information to point of service

Shift release of information to point of service EDMS allows the ROI function to be shifted into decentralized areas including off-site clinics

What is the traditional format for a hospital patient care record? ●Integrated ●Practice-oriented ●Chronological ●Source-oriented

Source-oriented Source-oriented is a system of health record organization in which information is arranged according to the patient care department that provided the care.

According to the UHDDS definition, ethnicity should be recorded on a patient record as: ●Race of mother ●Race of father ●Spanish origin/Hispanic, non-Spanish origin /non-Hispanic, unknown ●Free-text descriptor as reported by patient

Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown According to the UHDDS definition, ethnicity should be recorded on a patient record as non-Spanish/Hispanic or Spanish/non-Hispanic, unknown. The UHDDS has been revised several times since 1986

Which of the following are considered input devices? ●Keyboard, printer, and mouse ●Touch pad, speech recognition, and printer ●Optical character recognition, printer, and mouse ●Speech recognition, touch pad, and mouse

Speech recognition, touch pad, and mouse Input/output devices are considered peripheral devices because they are separate from the central processing unit of the computer, even if they are housed in the single casing like a notebook computer. Examples of input devices are keyboards, mouse, touch pad, light pen, optical recognition, etc.

Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff? a. physician index b. master patient index c. procedure index d. disease index

physician index

To be successful, a regional health information network is dependent on: ●Stakeholder consensus on local regional needs ●Federal funding ●Enabling legislation by the state ●Fees paid by consumers

Stakeholder consensus on local regional needs Regional health information organizations (RHIOs) developed and maintained HIE standards in an attempt to share information and make it available where needed. These organizations bring together healthcare stakeholders within a defined region and govern the HIE process for the purpose of improving care in that community. As sophistication and utility of the Internet (based on standards) increases, there will be a number of new standards development activities emerging that affect health information management in all settings. The concept of a national health information infrastructure (NHII) is designed to bring information to and aid communication among all stakeholders in the process. The infrastructure requires technology investment for success but also requires fundamental change in business process, information sharing, and adoption of standards

A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the: ●Mean ●Mode ●Standard deviation ●Standard variance

Standard deviation The standard deviation is the most widely used measure of variability in descriptive statistics. The standard deviation is easy to interpret and is the most preferred measure of dispersion for frequency distributions

In this type of network configuration, individual computers are connected through a central hub that serves as a traffic cop for the data. ●Star topology ●Ring topology ●Bus topology ●Logical topology

Star topology Star topology is one physical topology of a network and uses a central hub as a traffic cop

This EHR implementation strategy stops its paper processing shortly after the go-live of the system. ●Phased roll-out ●Big bang roll-out ●Pilot ●Straight turnover

Straight turnover Straight turnover refers to having everyone in the designated group go-live, with paper processes ceasing virtually immediately after go-live. This is the most typical form of turnover for EHRs because most organizations find that any reliance of former paper processing not only ends up being too-time-consuming but also sends a message that the system is not to be trusted

Quality improvement focuses on the three performance measures of _____, _____, an _____. ●Process, results, mortality ●Training, process, results ●Structure, process, outcome ●Surgery, outcomes, admission

Structure, process, outcome Performance measures are quantifiable indicators used over time to determine whether structure, process, or outcome supports quality performance. They usually represent important aspects of care provided by the organization, department, or unit of service. Performance measure development has been linchpin for clinical quality improvement

In this type of interview, a predetermined list of questions is used: ●Structured interview ●Unstructured interview ●Planned interview ●Unplanned interview

Structured interview When using a structured interview you know exactly what questions to ask and understand the purpose and goal of each question so that a meaningful response can be recognized.

Which communication system allows a user to request data from a decision support system? ●Graphical user interface ●Structured query language ●Data mine ●Linkage analyzer

Structured query language The decision support system uses its knowledge system to translate the user's requests into a query format acceptable to the database component. A typical implementation of this system allows the user to specify queries in a pick-and-click or drop-down manner via the graphical user interface (GUI). The system then translates those requests into the database language structured query language (SQL). The SQL is submitted to the database system containing the various data sources, and a report is sent back to the user

Today, _____ refers to the level of skilled care needed by patients with complex medical conditions, typically Medicare patients who have multiple medical problems. ●Acute care ●Ambulatory care ●Subacute care ●High-quality care

Subacute care In the past, the term "subacute care" was used in reference to the services to hospitalized patient who did not meet the medical criteria for needing acute care. Today it refers to the level of skilled care needed by patients with complex medical conditions, typically Medicare patients who have multiple medical problems

Which of the following items are packaged underthe Medicare hospital outpatient prospective payment system (HOPPS)? ●Recovery room and medical visits ●Medical visits and supplies (other than pass-through) ●Anesthesia and ambulance services ●Supplies (other than pass-through) and recovery room

Supplies (other than pass-through) and recovery room Under the Medicare hospital outpatient prospective payment system (HOPPS), outpatient services such as recover room supplies (other than pas-through), and anesthesia are included in this reimbursement method.

A research instrument that is used to gather data and information from respondents in a uniform manner through the administration of a predefined and structured set of question and possible responses is called a(n): ●Survey ●Interview ●Process measure ●Affinity diagram

Survey A survey is a common tool used in performance improvement to assess the level of satisfaction with a process by its customers. When designing a survey, the PI team must define the goal of the survey in clear and precise terms

What is the most commonly used means to transmit data across a wide area network today? ●Frame relay ●ISDN ●POTS ●T-lines

T-lines Trunk line (T-lines) are the backbone of long-distance, packet-switched network transmission that transmit data in digital form. They come in a variety of peers and may also carry voice

In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed? ●Initial Study ●Design ●Testing ●Operation

Testing Running a mock query would be part of application testing that ensures every function of a new computer system works. Application testing also ensures the system meets the functional requirements and other required specifications in the RFP or contract

Which of the following examples illustrates data that have transformed into meaningful information? ●45% ●3,567 units of penicillin ●$5 million ●The average length of stay at Holt Hospital is 5.6 days

The average length of stay at Holf Hospital is 5.6 days. Data are the raw elements that make up our communications, Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combinded to produce value) and enhance that information with experience and trial-and-error that produces knowledge.

What factor is medical necessity based on? ●The beneficial effects of a service for the patient's physical needs and quality of life ●The cost of a service compared with beneficial effects on the patient's health ●The availability of a service at the facility ●The reimbursement available for a given service

The beneficial effects of a service for the patient's physical needs and quality of life Medical necessity is based on the effects of a service for the physical needs and quality of life

What is the formatting problem in the following table? See Medical Center Hospital Table ●Variable banes are missing ●The title of the table is missing ●The column headings are missing ●The column totals are inaccurate

The column headings are missing A table is an orderly arrangement of values that group into rows and columns. It should have specific, understandable headings for every column and row

In the APC system, an outlier payment is paid when which of the following occurs? ●The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount ●The LOS is greater than expected ●The charges for the services provided are greater than the expected payment ●The total cost of all the services is greater than the sum of APC payments by a fixed ratio and exceeds the sum of APC payments plus a threshold amount

The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount An outlier payment is paid when the cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount

The researcher's informed consent form stated that the patient's information consent form stated that the patient's information would be anonymous. Later, the application form IRB approval, the researcher described a coding system to track respondents and non-respondents. The IRB returned the application to the researcher with the stipulation that the informed consent must be changed. What raised the red flag? ●The description of the use of a coding system to track respondents and non-respondents ●The application form for the IRB approval ●The researcher's informed consent form ●The description of the use of a coding system to track respondents

The description of the use of a coding system to track respondents and non-respondents The discrepancy is between the researcher's use of the term "anonymous" in the informed consent and the researcher's intent to track respondents. Anonymity demands that the researchers cannot link the response and the responder. The code would link the respondents to their data, so their data would no longer be anonymous

A possible justification for building an information system in-house rather than purchasing one from a vendor is that: ●It is cheaper to buy than to build ●The facility has unique information needs ●Integration of systems will be easier ●Vendor products are not comprehensive enough

The facility has unique information needs An organization's decision to build or buy should be based on a careful review of the marketplace because currently is it generally more expensive to undertake self-development. Self-developed systems also can be a drawback when attempting to integrate with commercial products as the organization grows. The primary reason to build would be the desire to develop their own, "perfect" system based on your unique needs and characteristics

To be successful, any information system technology initiative must align with: ●Current hardware in use in the facility ●The organization's strategic plan ●IS department strategies ●Health information management initiatives

The organization's strategic plan It is critical that the organization's IS plans be well aligned and integrated with to overall organizational strategic plans. To develop a blueprint for IS technology, the healthcare organization should engage in strategic IS planning

Using the admission criteria provided, determine if the following patient meets severity of illness and intensity of service criteria for admission. *****Severity of Illness***** ◆Persistent fever ◆Active bleeding ◆Wound dehiscence *****Intensity of Service***** ◆Inpatient-approved surgery/procedure within 24 hours of admission ◆Intravenous medications and/or fluid replacement ◆Vital signs ever 2 hours or more often John Smith presents to the emergency room at 1,500 hours with a fever of 101 degrees F, which he has had for the last three days. He was discharged 6 days ago following a colon resection. X-rays show a bowel obstruction and the plan is to admit him to surgery in the morning. ●The patient does not meet both severity of illness and intensity of service criteria ●The patient does meet both severity of illness and intensity of service criteria ●The patient meets intensity of service criteria but not severity of illness ●The patient meets severity of illness criteria but not intensity of service

The patient does meet both severity of illness and intensity of service criteria The patient meets severity of illness with the persistent fever and intensity of service with the inpatient-approved surgery scheduled within 24 hours of admission

A physician performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy on his patient at Community Hospital. His office billed the following: *58150 Total abdominal hysterectomy with or without salpingo-oophorectomy *58720 Bilateral salpingo-oophorectomy Why was this claim rejected? ●Billed hysterectomy with wrong CPT code ●Not a covered procedure ●Unbundled procedures ●Covered procedure but insurance company requires additional information

Unbundled procedures These procedures have been unbundled. Unbundling is the practice of coding services separately that should be coded together as a package because all the parts are included within one code and, therefore, one price. Unbundling done deliberately to obtain a higher reimbursement is misrepresentation of services and can be considered fraud

Using the admission criteria provided, determine if the following patients meets severity of illness and intensity of service criteria for admission. *****Severity of Illness***** ◆Persistent fever ◆Active bleeding ◆Wound dehiscence *****Intensity of Service***** ◆Inpatient-approved surgery/procedure within 24 hours of admission ◆Intravenous medications and/or fluid replacement ◆Vital signs every 2 hours or more often Sue presents with vaginal bleeding. An ultrasound showed a missed abortion so she is being admitted to the outpatient surgery suite for a D&C. ●The patient does not meet both severity of illness and intensity of service criteria ●The patient does meet both severity of illness and intensity of service criteria ●The patient meets intensity of service criteria but not severity illness ●The patient meets severity of illness criteria but not intensity of service

The patient meets severity of illness criteria but not intensity of service The patient meets the severity of illness with the vaginal bleeding but does not meet intensity of service because the surgery is not being performed as an inpatient. She would not meet the admission criteria provided

The patient belongs to a managed care plan. The patient wants to make an appointment with an out-of-network specialist. The plan has approved the appointment as "out-of-plan." What should the patient expect? ●The front office of the out-of-network specialist will delay and obstrct the making of the appointment ●The patient's out-of-pocket costs for the out-of-plan appointment will be equal to the out-of-pocket costs for in-plan care because the prior notification was completed ●The patient's out-of-pocket cost will be increased ●The patient can permanently transfer his or her care to the out-of-plan specialist because the initial appointment was approved

The patient's out-of-pocket cost will be increased As financial incentives to members, managed care organizations (MCOs) set varying rate of cost-sharing. For example MCOs, require higher out-of-pocket payments when members use out-of-plan providers than in plan providers

Assume you are the manager of a 10-physician group primary care practice. The physicians are interested in contracting with an application service provider to develop and manage patient records electronically. Which of the following statements is an indication that an ASP may be a good idea for this practice? ●The practice does not have the upfront capital or IT staff needed to purchase and implement a system from a health information systems vendor ●The practice wants an electronic medical record system and wants to get into the IT management business as well ●The practice would like to have the system up and running in a relatively short period of time (less than four months) ●The practice is not looking to purchase any additional hardware needed for an electronic medical system

The practice does not have the upfront capital or IT staff needed to purchase and implement a system from a health information systems vendor In an ASP model, there is much less upfront outlay and fewer IT staff required in-house. In fact, the ASP acquisition strategy may be considered essentially a financing model

Which one of the following statements accurately describes the optimal relationship between strategic planning and strategic IS planning in a healthcare organization? ●There is no relationship. The two processes should occur separately and independent of one another; otherwise, the "waters can get murky" ●The strategic IS planning process should be done first. The organization's overall strategic directions should then emerge from the IS planning process ●The two processes are clearly related. It is important for the CIO to be involved in both processes to ensure that IS priorities are congruent with the overall strategic plans of the organization ●The two processes are clearly related. However, the CIO should not be involved in the overall strategic planning process. Having the CIO there might steer the discussion to the technology and that should not occur at this stage in the process

The two processes are clearly related. It is important for the CIO to be involved in both processes to ensure that IS priorities are congruent with the overall strategic plans of the organization As the senior leadership team engages in strategic planning discussions, they should ensure that IS leadership is also engaged in these discussions. In particular, they should examine the organization's view of the role that IS technology will play in the organization's future

Which of the following statements about information systems (IS) technology in healthcare is false? ●There is pressure to demonstrate return on investment for IS technology ●There are unlimited funds for IS technology in the healthcare industry ●A great deal of capital investment has been made in healthcare IS technology ●There is increased emphasis is on strategic use of IS technology in healthcare organizations

There are unlimited funds for IS technology in the healthcare industry Acquiring an EMR (or other IS) system is a significant investment of time, resources, and people. Besides the up-front capital needed to acquire the systems, significant costs are associated with implementing and maintaining the system, as well as the time, effort, and personnel resources devoted to redesigning processes and incorporating the system into the care process

Which of the following statements does not pertain to paper-based health records? ●They are kept in locked storage areas that are accessible only to authorized staff ●They are logged out according to the organization's prescribed procedure ●They are forwarded to the appropriate service area when needed for patient care purposes ●They have built-in access control mechanism

They have a built-in access control mechanism One disadvantage of paper-based health records is the inability of an access control mechanism

Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis for medical information was listed along with her rehabilitation potential. This information is documented on the: ●Transfer or referral form ●Release of information form ●Patient's rights acknowledgment form ●Admitting physical evaluation form

Transfer or referral form Transfer or referral forms provide document communication between care-givers in multiple healthcare setting. It is important that a patient's treatment plan be consistent as the patient moves through the healthcare delivery system

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. What is the first resource she should use? ●UHDDS ●UACDS ●MDS ●ORYX

UHDDS In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms

A hospital is undergoing a major reconstruction project and a new director of nursing has been hired. At the same time, the nursing documentation component of the EHR has been implemented. The fact that nurse staffing satisfaction score have risen is: ●A result of anecdotal benefits of EHR ●A result of qualitative benefits of EHR ●A result of reconfiguration of the nursing units ●Uncertain due to existence of confounding variables

Uncertain due to existence of confounding variables In this situation there are too many changes occurring at the same time to determine what is improving the nursing satisfaction scores. Any one item could be the reason for the improvement. To evaluate the impact of the EHR nursing documentation component, a benefits realization study should have been utilized. This would have studies the impact of the EHR component before and after implementation

At Medical Center Hospital, the master patient index system is not meeting facility needs. There are duplicate numbers and errors in patient identification information. This IS director replaces the system with a newer system from a different vendor. After several months, the new system is exhibiting many of the same problems as the old system, and the facility staff is frustrated and angry. What is the most likely cause of the problem? ●The new system has the same design flaws as the previous system ●The old system was not properly disabled and has infected the new system ●Underlying human and process problems were not identified and corrected prior to making a system change ●Human error is the cause of all the problems with both systems

Underlying human and process problems were not identified and corrected prior to making a system change Conversion to a new system often requires major changes in the workflow and organizational structure. These changes in workflow patterns, noise, space, telephone lines, and electrical power should all take place as part of the implementation phase of the SDLC

What type of patient information, when used in the aggregate, allows hospitals to draw comparisons across multiple health record sources? ●Administrative information ●Progress notes ●Demographic information ●Uniform data sets

Uniform data sets The two purposes of uniform data sets are as follows: they ensure the same types of data collected for the patient, and they provide standardized definitions of the data to be collected

In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? ●Unit numbering ●Index unit numbering ●Serial-unit numbering ●Serial numbering

Unit numbering Unit numbering storage is a health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters

Which of the following is a system in which the patient health record is kept in the same order on the nursing station and in complete record? ●Standard ●Universal ●Source-oriented ●Patient-centered

Universal A universal chart order system is one in which the patient health record is kept in the same format/order while the patient is in the facility and after discharge

In this type of interview the sequence of questions is not planned in advance and is conducted in a friendly, conversational manner. ●Structured interview ●Unstructured interview ●Planned interview ●Unplanned interview

Unstructured interview An unstructured interview is not preplanned and flows with the conversation. This type of interview is helpful when the interviewer is trying to uncover preliminary problems that may need in-depth analysis and investigation

Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? a. Establish critical pathways for complex, high-dollar cases b. Appropriate use of HL-7 standards c. Smoking cessation counseling for MI patients d. Use CPOE for medication orders

Use CPOE for medication orders

Which RFP component would fit the following description? Describe how your product supports the ability to register a patient in the clinic, admit the patient using the same health record number and demographic information, and share medication list for medication reconciliation with the nursing home to which the patient is discharged. ●Application support ●Operational requirements ●Technical specifications ●Use case

Use case The use of case or script scenario is based on the organization's redesigned processes and asks the vendor how its products would perform the inherent functions. The approach is useful for avoiding yes and no responses

. In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the a. flagrant use of specialty-specific abbreviations. b. use of prohibited or "dangerous" abbreviations. c. prohibited use of any abbreviations. d. use of abbreviations in the final diagnosis.

Use of prohibited of "dangerous"abbreviations

The most common reason given for information system failure is: ●Lack of training ●No-increased benefits gained ●Technical failure of hardware and/or software ●User resistance

User resistance The three primary barriers are the high cost of acquiring and supporting systems, a lack of sufficient standards and interoperability concerns, and organizational and behavioral resistance

The director of Health Information Services is allowed access to the health record tracking system when providing the proper log-in and password. Under what access security mechanism is the director allowed access to the system? ●Role-based ●User-based ●Context-based ●Situation-based

User-based User-based access is a security mechanism used to grant users of a system access based on the identity of the user

Which one of the following are discounted fee-for-service healthcare payment methods? ●Clinical Risk Groups (CRG) ●Customary, Prevailing, and Repeatable (CPR) ●Regulatory-Based Relative Variable Scale (RBRVS) ●Usual, Customary, and Reasonable (UCR)

Usual, Customary, and Reasonable (UCR) To begin to control cost, the third-party payers negotiated reduced fees for their members or insured. The payment method using these reduced fees are known as a discounted fee-for-service. Versions of the discounted fee-for-service payment methods are UCR, the CPR and the RBRVS

This type of network uses a private tunnel through the Internet as a transport medium. ●Virtual privacy network ●Local area network ●Wide area network ●Intranet

Virtual privacy network A virtual private network (VPN) is a special kind of wide area network (WAN) that uses a private tunnel through the Internet as the transport medium between locations rather than privately owned cable or leased lines. A VPN reduces networking costs significantly because much of the maintenance is performed by an Internet service provider

In data quality management, the processes and systems used to archive data and data journals are called: ●Collection ●Warehousing ●Application ●Analysis

Warehousing The third key process of data quality management is warehousing, which includes the processes and systems used to archive data and data journals

HTML and XML are programming languages used to create: ●Web-enabled applications ●Expert decision support systems ●Web browser-based applications ●Artificial intelligence systems

Web browser-based applications Web browser-based or web native systems where companies have either written or rewritten their systems' code using HTML, SGML, XML, or Java and it derivatives

Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical? ●When the patient is readmitted a second time for the same condition ●When the patient is readmitted within 30 days for the initial treatment for a different condition ●When the patient is readmitted a third time for the same condition ●When the patient is readmitted within 30 days of the initial treatment for the same condition

When the patient is readmitted within 30 days for the initial treatment for the same condition An interval may be used for the patient's history and physical when the patient is readmitted within 30 days of the initial treatment for the same condition.

A group of computers that connect across relatively large geographic distance using telephone or cable services is what type of network? ●Local area network ●Wide area network ●Wireless local area network ●Virtual private network

Wide area network A group of computers that connect across great geographical distances, often using telephone or cable services for connectivity is a wide area network (WAN)

Under RBRVS which elements are used to calculate a Medicare payment? ●Work value and extent of the physical exam ●Malpractice expenses and detail of the patient history ●Work value and practice expenses ●Practice expenses and review of systems

Work value and practice expenses Each RBRVU comprises of three elements, physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register

All but which of the following are examples of unusual events that healthcare facilities typically must report? ●Falls resulting in fractures ●Wrong site surgery ●Workers' compensation cases ●Medical errors

Workers' compensation cases Most states require the reporting of unusual events or other public health prevention and control programs. Any unusual event, unexpected occurrence, or accident resulting in death or life-threatening or serious injury to the patient that is not related to a natural course of the patient's illness or underlying condition is usually reported

In an acute care hospital, a complete history and physical may not be required for a new admission when a. the patient's stay is less than 24 hours. b. the patient has an uneventful course in the hospital. c. the patient is readmitted for a similar problem within 1 year. d. a legible copy of a recent H&P performed in the attending physician's office is available.

a legible copy of a recent H&P preformed in the attedning physician's office is available

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the LaTour and Eichenwald-Maki, p 214 a. attending physician. b. HIM director. c. chief of staff. d. risk manager.

attending physician

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to a. signature line for authentication. b. use of box design. c. placement of hospital logo. d. bar code placement.

bar code placement

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is a. discharged on antithrombotic. b. early administration of aspirin. c. blood culture before first antibiotic received. d. beta blocker at discharge.

blood culture before first antibiotic received.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be a. cognitive patterns. b. procedures and dates. c. principal diagnosis. d. personal identification.

cognitive patterns

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data a. security. b. comprehensiveness. c. accuracy. d. timeliness.

comprehensiveness

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) ________ will be added to his health record. a. consultation report b. advance directive c. interval summary d. interdisciplinary care plan

consultation report

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case? a. data granularity b. data precision c. data comprehensiveness d. data accuracy

data accuracy

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient." a. clinical laboratory report b. admission note c. physical exam d. discharge summary

discharge summary

Which of the following is least likely to be identified by a deficiency analysis technician? a. x-ray report charted on the wrong record b. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist c. need for physician authentication of two verbal orders d. missing discharge summary

discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation? a. technical interpretation of electrocardiogram b. interpretation of a radiologic study c. impressions of a cardiologist asked to determine whether patient is a good surgical risk d. tissue examination done by the pathologist

impressions of a cardiologist asked to determine whether patient is a good surgical risk

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the a. integrated progress notes. b. incident report. c. doctors' progress notes. d. nurses' notes.

incident report

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing a. SOAP notes. b. source-oriented records. c. interdisciplinary treatment plans. d. integrated progress notes.

integrated progress notes.

Joint Commission requires the attending physician to countersign health record documentation that is entered by a. business associates. b. consulting physicians. c. interns or medical students. d. physician partners.

interns or medical student

One record documentation requirement shared by BOTH acute care and emergency departments is a. problem list. b. advance directive. c. time and means of arrival. d. patient's condition on discharge.

patient's condition on discharge.

Based on the following documentation in an acute care record, where would you expect thisexcerpt to appear? "The patient is alert and in no acute distress. Initial vital signs: T 98, P 102 and regular, R 20 and BP 120/69..." a. chief complaint b. social history c. past medical history d. physical exam

physical exam

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing a. point-of-care documentation. b. concurrent record analysis. c. clinical pertinence review. d. quantitative record review.

point-of-care documentation.

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a a. data retrieval portal group. b. continuum of care. c. regional health information organization. d. data warehouse.

regional health information organization.

Discharge summary documentation must include a. a note from social services or discharge planning. b. significant findings during hospitalization. c. a detailed history of the patient. d. correct codes for significant procedures.

significant findings during hospitalization.

Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? a. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court b. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record c. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital d. when the record is taken to a physician's private office for a follow-up patient visit postdischarge

when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog, which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should a. request that administration hire more transcriptionists. b. write a detailed operative note in the record. c. request a "stat" report. d. provide the dictated tape to his staff.

write a detailed operative note in the record