HIT 110

The length of stay (LOS) for an outpatient is limited to

23 hours, 59 minutes, 59 seconds

Critical access hospitals (CAHs) are those located more than ____ miles from any other hospital or another CAH, or they are state certified as being a necessary provider of health care to area residents.

35

Which of the following organizations certifies privacy officers?

AHIMA

The Administration on ________ supports a nationwide aging network, providing services to the elderly to enable them to remain independent.

Aging

Which association grants the Registered Health Information Technician (RHIT) credential?

American Health Information Association (AHIMA)

The process of authenticating a dictated report prior to its transcription is called

Auto-Authentication

Privacy officers oversee the development of, implementation of, maintenance of, and adherence to an organization's policies and procedures covering the privacy of and access to protected health information (PHI) in compliance with which law?

Both federal and state laws

Which certification is sought by a cancer registrar?

Certified Tumor Registrar (CTR)

A lowercase or an uppercase letter, numeric digit, or special character is also known as (a)

Character

What is the process used to report diagnoses, procedures, and services to third-party payers and government programs?

Coding

A hospital's quality management department has determined that 10% of the medical staff is noncompliant regarding documentation issues related to the appropriate assignment of diagnosis and procedure codes. Which professional would best provide in-service training in this area?

Coding Specialist

What was a 1970 - 1980 term to describe early medical record automation attempts?

Computerized Medical Records

The patient's date of birth and mother's maiden name are considered what type of information?

Demographic information

"I've had a fever for 3 days" is an example of an objective SOAP note entry.

False

A VISN is associated with the Bureau of Prisons.

False

A long term care facility provides services to patients who have experienced a recent decline in function, often due to a stroke or a head or spinal cord injury.

False

A patient with an urgent problem would most likely be treated in a physician's office.

False

A risk manager coordinates the communication, contract, data, financial, human resource, health information, insurance, marketing, and risk management operations of a provider's office.

False

A technical control created by an electronic health record (EHR) system that lists all transactions and activities on the system is called access trail.

False

Ambulatory surgery patients are limited to a 12-hour stay.

False

An RHIA usually earns a master's degree in health information prior to certification.

False

An assisted-living facility (ALF) provides non-medical custodial care, which can be provided in a single-family residence, a retirement residence, or in any appropriate care facility including a nursing home.

False

Incident reports are filed in the medical record.

False

Incident reports are subject to disclosure upon receipt of a subpoena.

False

Internal medicine physicians provide care to the entire family and focus on general medicine, obstetrics, pediatrics, and geriatrics.

False

Neighborhood health centers allow people who are seriously ill or dying to remain at home and receive treatment from nurses, social workers, therapists, and other licensed health care professionals who provide skilled care in the home.

False

Outpatient services have steadily decreased since the 1980s.

False

Professional practice experience is paid, on-the-job training arranged by the educational program.

False

Qualitative analysis is the process of reviewing medical records for completeness.

False

Skilled services such as injections and colostomy care are provided in residential care facilities

False

The Certified Health Data Analyst credential is offered by AAPC.

False

The S in a SOAP format progress note stands for summary.

False

The goal of hospice care is curative.

False

The primary responsibility of the cancer registrar is to provide educational cancer programs.

False

To be eligible to take the national certification exams offered by AHIMA, a person must graduate from a program approved by the National Council on Education.

False

Training for an RHIT is the same as the training for an RHIA.

False

When a patient is discharged from the hospital, the attending physician dictates a final history and physical.

False

X-ray films and scans are considered secondary records.

False

The organization of reports in the inpatient and discharged record is determined by the

Health Care Facility or Provider

Which type of health care facility provides inpatient medical, nursing, and other health-related services to patients for surgical and nonsurgical conditions?

Hospitals

Which association is an insurance claims organization?

Medical Association of Billers (MAB)

Diagnosis related groups (DRGs) were first used by which payer to reimburse inpatient hospital care?

Medicare

The organization that administers health care for active members of the uniformed services (and their dependents) is called the

Military Health System (MHS)

An organization in which two or more hospital, long-term care, rehabilitation, or psychiatric facilities are owned, managed, or leased by a single organization is called a(n)

Multihospital System

Which organization was established in the 1970s to provide external peer review for correctional institutions?

National Commission on Correctional Health Care (NCCHC)

While the patient is in the hospital, the record is typically located at the

Nursing station

Which is an electronic or paper medical record maintained and updated by an individual for his or her own personal use?

Personal Health Record

What is an accident or medical error that results in personal injury or loss of property?

Potentially Compensable Event (PCE)

The database, problem list, initial plan, and progress notes are components of which medical record format?

Problem-Oriented Medical Record

This application creates a centralized database of patient demographic information and has replaced the paper master patient index in the virtual world.

Registration-Admission-Discharge-Transfer System (RADT)

With the universal chart order, medical record reports are filed in what order?

Reverse Chronological Date

The prospective payment system was implemented as part of which federal legislation?

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

What is the main reason coding specialists ensure that all diagnoses, services, and procedures documented in patient records are coded accurately?

To ensure proper reimbursement and for research and statistical purposes.

Risk managers investigate incident reports for what reason?

To recommend appropriate corrective action.

A HIT earns an associate degree in health information.

True

A chemical dependency program provides 24-hour medically directed evaluation and withdrawal management in an acute care inpatient setting.

True

A consultant provides assistance, advice, and information.

True

A health information manager plays an important role in educating physicians about proper documentation practices.

True

A professional is considered credentialed when he or she passes an exam offered by a professional organization and maintains the required number of continuing education credits.

True

A professional who is not an employee of a hospital but offers assistance, advice, and information is a consultant.

True

A referred outpatient is the type of outpatient who receives diagnostic or therapeutic care because such care is unavailable in the primary care provider's office.

True

Academic programs are required to place students in professional practice experiences to comply with accreditation requirements.

True

Administrative data includes patient demographics.

True

An intermediate care facility (ICF) provides developmentally disabled people with medical care and supervision, nursing services, occupational and physical therapies, activity programs, educational and recreational services, and psychological services.

True

An x-ray is considered a primary source of patient information.

True

Another name for professional practice experience is an externship.

True

Authentication of both manual and computerized record entries is required by state and federal laws.

True

Breach of patient confidentiality during a professional practice experience can result in failure of the course.

True

CTRs are required to submit proof of continuing education hours every two years.

True

Electronic, rubber stamp, and handwritten signatures are forms of authentication.

True

Insurance number and guarantor are considered a financial type of patient data.

True

Occupational, physical, and speech therapy are types of care administered to patients in rehabilitation facilities.

True

Once a professional is certified, most professional organizations require maintenance of the credential through continuing education.

True

Patient record entries should be signed or authenticated as soon as possible after care is provided.

True

Physicians who have delinquent records receive a suspension letter from the HIM department.

True

Physicians who spend most of their time in hospitals admitting patients from local primary care providers are known as hospitalists.

True

Respite care is care provided by specially trained individuals at a setting other than the patient's home to offer relief and rest to primary caregivers.

True

Students are often able to join professional associations at reduced membership dues.

True

The Centers for Disease Control and Prevention is the organization that provides a system of health surveillance to monitor and prevent outbreak of disease.

True

The Food and Drug Administration (FDA) assures the safety of foods and cosmetics as well as the safety and efficiency of pharmaceuticals, biological products, and medical devices.

True

The Military Health System (MHS) administers health care for active members of the uniformed services (and their dependents) as provided by military treatment facilities.

True

The Public Health Service Commissioned Corps is led by the surgeon general.

True

The agreement between an academic institution and a hospital to host students is known as an articulation or affiliation agreement.

True

The day of admission is counted when computing LOS.

True

The primary purpose of the patient record is to promote continuity of care.

True

The primary responsibility of the tumor registrar is to ensure the timely, accurate, and complete collection and maintenance of cancer data.

True

When responsible providers authenticate entries that they did not originally document, they do so with a countersignature.

True

Health Level Seven (HL7) is a standards development organization that develops EHR standards under the direction of what department?

U.S. Department of Health and Human Services

Which is the calculation for the total number of inpatient beds for which a facility is licensed by the state?

bed count

Which of the following addresses the admissibility of copies of records in court?

c. Uniform Business Records as Evidence Act

Reviewing the medical record during inpatient hospitalization for quality documentation is called

concurrent analysis

Digitized images of handwritten signatures and biometric identifiers are examples of a(n)

electronic signature

When a page is _____, it means it is identified according to a unique identification number, which is commonly the patient's medical record number.

indexed

What type of record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters?

longitudinal patient record

Which system collects and monitors patient physiological data and records the information?

patient monitoring system

The nonpaid, on-the-job work experience prior to graduation, which is arranged through an academic health information management program, is called

professional practice experience

Which piece of equipment is used to capture paper record images onto electronic storage media?

scanner

Regional Health Information Organizations (RHIOs) focus on what key function?

sharing information

The readability of a medical record entry is known as legibility.

true