1301 Final

Overlay

Two people assigned one health record number

What are components of an electronic health record? (5)

-Data warehouses -Human-computer interface -Data repository -Rules engine -Knowledge sources

The annual volume statistics for New Town Hospital are noted below. How many shelving units will be required to store this year's inpatient discharge records? Average inpatient discharges = 12,000 Average inpatient record thickness = ¾ inch Shelving units shelf width = 36 inches Number of shelves per unit = 6

42

Who is primarily responsible for setting the overall direction of an acute-care hospital? A. Board of directors B. Chief executive officer C. Organization's stockholders D. Medical staff

A. Board of directors

In a medical record, the following statement is an example of what type of documentation: "I have this terrible pain in my hip" A. CC B. ROS C. SH D. FH

A. CC

Which of the following is true of computer-based records? A. Can be accessed by multiple end users simultaneously B. Is usually supported by all healthcare providers C. Permits minimal risks to healthcare privacy and security D. Uses clear, consistent content standards

A. Can be accessed by multiple end users simultaneously

The attending physician is responsible for which of the following types of acute- care documentation? A. Discharge summary B. Laboratory report C. Consultation report D. Pathology report

A. Discharge summary

Members of the AHIMA House of Delegates are: A. Elected by members in state component organizations B. Elected by the AHIMA Nominating Committee C. Elected by the AHIMA Board of Directors D. Appointed by the AHIMA Board of Directors

A. Elected by members in state component organizations

Which of the following information systems is considered an administrative information system? A. Financial information system B. Laboratory information system C. Nursing information system D. Radiology information system

A. Financial information system

Which of the following forms should never be a permanent part of the patient's medical record? A. Incident report B. Radiological examination C. Informed consent D. Physician's order

A. Incident report

The master patient index: A. Is the most important index maintained by the HIM department. B. Contains basic demographic information about the patient. C.Is commonly part of the admission, discharge, and transfer computer system. D. All of the above

A. Is the most important index maintained by the HIM department.

Which of the following indexes is considered to be the authoritative key to locating a health record? A. Master patient index B. Disease index C. Physician index D. Operation index

A. Master patient index

The services provided by HIM departments in acute care hospitals usually include all the following except: A. Medical billing B. Release of information C. Clinical coding D. medical transcription

A. Medical billing

Which of the following dictates how the medical staff operates? A. Medical staff bylaws B. Medical staff classification C. Medical staff credentialing D. Medical staff committees

A. Medical staff bylaws

The content requirements for death and birth certificates vary according to what law? A. State B. County C. City D. Federal

A. State

Which governmental entity (entities) administer(s) the Medicaid program? A. State governments B. Peer review organizations C. County governments D. Federal government

A. State governments

Licensure tests to practice medicine are admnistered by: A. State licensure boards B. Medical schools C. Federal licensure board D. Department of Health and Human Services

A. State licensure boards

Which of the following is a disadvantage of alphabetic filing? A. Uneven expansion of file shelves or cabinets B. No reliance on an index or authority file C. Easy to train new personnel to file D. Ease of creation

A. Uneven expansion of file shelves or cabinets

Which of the following best describes data accessibility? A. data are easy to obtain B. data are reliable C. data include all required elements D. data are correct

A. data are easy to obtain

What is the difference between data and information? A. data represent basic facts, while information represents meaning B. information is about people, while data are about things C. information must be kept confidential, while data are meant to be shared D. data are expressed in numbers, while information is expressed in words

A. data represent basic facts, while information represents meaning

What health record format is arranged in chronological order and documentation from various sources are intermingled? A. integrated B. source-oriented C. problem-oriented D. electronic

A. integrated

What is the difference between patient's consent and patient's authorization?

Authorization - patient grants permission to release information Consent - permission for treatment, payment, or healthcare operations

The admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? A. data completeness B. data consistency C. data accessibility D. data comprehensiveness

B. data consistency

The promotion of good for others or the provision of helpful services for others A. Bioethics B. Beneficence C. Justice D. Nonmaleficence

B. Beneficence

The application of ethical principles to decisions that affect human lives A. Autonomy B. Bioethics C. Justice D. Beneficence

B. Bioethics

I am looking to purchase a system that will be used by the physicians to order medications, tests, and other treatment. This system must use alerts and reminders. I must be looking to purchase what type of system? A. Clinical order entry results reporting B. Clinical provider order entry C. Patient registration system D. Clinical knowledge and treatment support system

B. Clinical provider order entry

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review. A. Peer B. Concurrent C. Prospective D. Retrospective

B. Concurrent

What is the general name for Medicare standards impacting healthcare organizations? A. Regulations for Licensure B. Conditions of Participation C. Terms of Accreditation D. Requirements for Service

B. Conditions of Participation

The three sets of standards that should influence most of the decisions made by a Health Information Department Director in an acute care facility are: A. state licensing regulations, TJC standards, AMA regulations B. Conditions of participation, TJC standards, state licensing regulations C. TJC standards, state health department rules, AMA regulations D. Conditions of participation, TJC standards, state health department rules

B. Conditions of participation, TJC standards, state licensing regulations

Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? A. Laboratory report B. Operative report C. Pathology report D. Anesthesia report

B. Operative report

The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the: A. Patient care unit B. Patient registration department C. Billing department D. HIM department

B. Patient registration department

When a hospital accredited by the Joint Commission is considered to be in compliance with Medicare 's Conditions of participation, this is called: A. dual accreditation B. deemed status C. conditional accreditation D. adjuvant accreditation

B. deemed status

A final progress note may substitute for a discharge summary for a patient: A. admitted for overnight observation following a trauma to the head B. admitted for a normal obstetric labor and delivery C. admitted for gastroplasty whose surgery is canceled because of an episode of hyperthermia following induction of anesthesia D. admitted for colonoscopy who dies 36 hours after admission

B. admitted for a normal obstetric labor and delivery

Which health record format is being used when documents are grouped together according to their point of origin? A. electronic B. source-oriented C. problem-oriented D. integrated

B. source-oriented

The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma CHEST: Good bilateral chest sounds." In which of the following would this documentation appear? A. operative report B. history C. physical examination D. physician orders

C. physical examination

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _____ systems. A. CDC B. ABC C. ADT D. MIS

C. ADT

The _______makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA. A. Board of Directors B. House of Delegates C. Communities of Practice D.Commission on Certification for Health Informatics and Information Management

C. Communities of Practice

In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility? A. Terminal digit filing system B. Alphabetic filing system C. Serial numbering system D. Unit numbering system

C. Serial numbering system

Which of the following filing methods is considered the most efficient? A. Alphanumeric filing B. Straight numeric filing C. Terminal digit filing D. Alphabetical filing

C. Terminal digit filing

In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters? A. Alphabetic filing system B. Serial numbering system C. Unit numbering system D. None of the above

C. Unit numbering system

Which of the following is an example of clinical data? A. data and time of admission B. health record number C. admitting diagnosis D. insurance information

C. admitting diagnosis

In which department/unit does the health record typically begin? A. HIM department B. nursing unit C. patient registration (admitting) D. billing department

C. patient registration (admitting)

A health record that uses both manual and electronic processes is described as a: A. traditional health record B. computerized health record C. hybrid health record D. electronic health record

C. hybrid health record

By signing a consent for treatment, the patient agrees to: A. take all medications prescribed and dispensed by health care providers B. allows the hospital to dispose of property and values in the case of death C. treatments and procedures to be performed by health care providers D. allow the hospital to release information to his/her third party payer

C. treatments and procedures to be performed by health care providers

What is the function of a consultation report? A. Concisely summarizes the patient's treatment and stay in the hospital. B. Documents the physician's instructions to other parties involved in providing care to a patient C.Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care D.Provides a chronological summary of the patient's medical history and illness

C.Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

Master Patient Index (MPI)

Contains pertinent demographic data on patient

Which of the following can be defined as a voluntary system of institutional review in which a quasi independent body periodically evaluates the quality of the services provided by healthcare organizations against written criteria? A. Professionalization B. Standardization C. Licensure D. Accreditation

D. Accreditation

HIPAA permits all covered entities to use and disclose patients' protected health information for what purposes? A. Treatment B. Payment C. Healthcare operations D. All of the above

D. All of the above

In making job-related decisions, HITs must consider a number of ethical factors, including: A. The rights and interests of healthcare patients and providers B.Their employer's policies, rules, and regulations as well as cost and technological feasibility C.Federal and state laws, medical staff bylaws, and accreditation and licensing standards D. All of the above

D. All of the above

What are some of the primary purposes of the health record? A. Patient Care Delivery B. Patient Care Management C. Financial and Other Administrative Processes D. All of the above

D. All of the above

Which of the following factor(s) may be considered in classifying the various types of hospitals? A. Type of services provided B. For-profit or not-for-profit status C. Type of ownership D. All of the above

D. All of the above

Which of the following accredits academic programs in health information management? A. CCHIIM B. House of Delegates C. AHIMA Board of Directors D. CAHIIM

D. CAHIIM

Which of the following information systems is used to assist healthcare providers in the actual diagnosis and treatment of patients? A. Laboratory information system B. Management information system C. Pharmacy information system D. Clinical decision support system

D. Clinical decision support system

Which of the following is not an example of a long-term care setting? A. Subacute care organizations B. Assisted living facilities C. Nursing homes D. Community mental health centers

D. Community mental health centers

What was the main result of the publication of the Flexner report? A. Nursing school standards were established. B. Hospital standards were established. C. Health information management standards were established. D. Medical school standards were established.

D. Medical school standards were established.

Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long roll? A. Microfiche B. Document scanning system C. Microfilm jacket D. Microfilm roll

D. Microfilm roll

Which accrediting organization has instituted core measurements and uses tracer methodology during survey visits? A. Accreditation Association of Ambulatory healthcare B. Commission on Accreditation of Rehabilitation Facilities C. American Osteopathic Association D. The Joint Commission

D. The Joint Commission

Which of the following is an example of administrative information? A. An admitting diagnosis B. Blood pressure records C. Medication records D. The patient's address

D. The patient's address

Critique this statement: Security involves physical and electronic mechanisms that protect health information from accidental or intentional damage, loss, or unauthorized access. A. This is not a true statement as security does not include loss. B.This is not a true statement as security only addresses intentional problems. C.This is not a true statement as security addresses only electronic mechanisms—not physical. D. This is a true statement.

D. This is a true statement.

When correcting erroneous information in a paper health record, which of the following is not appropriate? A. Print "error" above the entry. B. Add the reason for the change. C. Enter the correction in chronological sequence. D. Use black pen to obliterate the entry.

D. Use black pen to obliterate the entry.

What type of information can be found on the face sheet, registration record, admission/discharge record? A. demographic information B. admitting diagnosis C. insurance information D. all of the above

D. all of the above

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. operative report. B. recovery room record. C. discharge summary. D. pathology report.

D. pathology report.

Preprinted/preplanned orders that are placed on/in the patient's record (e.g., upon admission) are called: A. pre-approved B. process orders C. automatic orders D. standing orders

D. standing orders

FH

Family History

HIPAA

Health Insurance Portability and Accountability Act

What does HPI represent?

History of Present Illness

I/O

Input/Output

MAR

Medication Administration Record

Overlap

More than one health record number exists for the same patient within an enterprise

NPP

Notice of Privacy Practice

PHI

Protected Health Information

Duplicate

Same person assigned two different health record numbers

TPO

Treatment, Payment, Healthcare Operations

VO/TO

Verbal order/Telephone order

The final disciplinary action that AHIMA can take against a member for a violation of the AHIMA Code of Ethics is: a. revocation of credential b. loss of voting privileges c. censure d. termination of employment

a. revocation of credential

This federal mandates guarantees the security and privacy of health information: a. HIPAA b. BBA c. P.L. 89-97 d. P.L. 92-603

a. HIPAA

The first hospital in the United States was: a. The Pennsylvania Hospital b. Belleview Hospital c. Massachusetts General Hospital d. National Institutes of Health

a. The Pennsylvania Hospital

When individuals or departments who need access to the patient's health record have the ability to receive instant access and view the record at the same time in an electronic health record system, this is called: a. accessibility b. timeliness c. reliability d. security

a. accessibility

A face-to-face contact between a patient and a provider who has primary responsibility for assessing and treating the patient is called: a. encounter b. occasion of service c. episode of care d. availability

a. encounter

A healthcare organization that provides a full range of healthcare services along a continuum of care (for example, an organization that provides acute care services, long term care services, and home health services) is called a(n): a. integrated delivery system b. public health system c. managed care system d. hospital system

a. integrated delivery system

To retain the RHIA or RHIT credential, an HIM professional must: a. maintain a file of documentation of all continuing education (CE) activities and produce it audited b. have documentation of all CE activities verified by his or her employer c. report all CE activities to AHIMA every two years d. do nothing because the RHIA or RHIT credential is a lifetime credential without a CE requirement e. a and c

a. maintain a file of documentation of all continuing education (CE) activities and produce it audited

This organization developed the first hospital standardization program. a. TJC b. ACS c. AOA d. AMA

b. ACS

This can be defined as a voluntary system of institutional review by an independent external agency. a. licensure b. accreditation c. certification d. credentialing

b. accreditation

Which of the following statements most accurately describes the Medicare program? a. a state program that finances healthcare services for the elderly b. a federal program that finances healthcare services for the elderly c. a state program that finances healthcare services for low-income families d. a federal program that finances healthcare services for low-income families

b. a federal program that finances healthcare services for the elderly

Who is primarily responsible for determining the overall mission of an acute care hospital? a. CEO b. board of directors c. medical staff d. organization's stockholders

b. board of directors

This department is responsible for assisting patients and their families in addressing emotional, social, and economic stresses of illness or injury: a. occupational therapy b. social service c. physical therapy d. respiratory therapy

b. social service

Medical staff bylaws are legally binding and any changes must be approved by a vote of the Boardof Directors and the: a. employees of the facility b. medical staff c. administrative team d. only active members of the medical staff

b. medical staff

Who is responsible for implementing the policies and strategic direction of a healthcare organization on a day-to-day basis? a. board of directors b. CIO c. CEO d. medical director

c. CEO

The committee that has the responsibility for taking action on recommendations from other committees of the MSO and making recommendations to the governing body is the: a. credentials committee b. joint conference committee c. executive committee d. quality assessment committee

c. executive committee

This govern(s) the operation of a hospital medical staff. a. medical staff classification b. medical staff credentialing c. medical staff bylaws d. medical staff committees

c. medical staff bylaws

Who bears the ultimate responsibility for the quality of care in a hospital? a. CEO b. medical staff c. board of directors d. medical director

c. board of directors

Which of the following statements most accurately describes funding for the Medicaid program? a. funding comes from the federal government b. funding comes from each state government c. funding is a joint federal and state initiative d. funding is from private sources

c. funding is a joint federal and state initiative

Not-for-profit hospitals differ from for-profit hospitals because they: a. do not bill for services b. pay dividends to stockholders c. reinvest excess funds in services and education d. provide free medical education to medical students and residents

c. reinvest excess funds in services and education

What factor is most important in determining the durability of a file folder? a. scoring b. printed information c. weight (points) d. tabs

c. weight (points)

The total number of inpatients that can potentially be treated in a hospital is determined by the: a. size of the medical staff b. complexity of care c. number of clinical services d. bed capacity

d. bed capacity

The process by which an HIM professional gains recognition for professional competence is called: a. licensure b. accreditation c. bonding d. certification

d. certification

This is an example of demographic data. a. procedure code b. diagnosis c. payer information d. patient's age

d. patient's age

These type of healthcare organizations pay out their excess revenues in the form of bonuses and dividends to owners, investors, and managers. a. not-for-profit b. government c. voluntary d. proprietary

d. proprietary

Certification is: a. mandatory for all hospitals b. mandatory for all healthcare facilities c. mandatory for all hospitals and voluntary for other healthcare facilities d. voluntary for all healthcare facilities

d. voluntary for all healthcare facilities

Medicare will provide reimbursement for treatment in a(n): a. home healthcare b. hospice care c. skilled nursing facilities d. b and c e. all the above

e. all the above