HS 422: Midterm

The maximum range for incentive payments among Medicare and Medicaid incentive programs for the electronic health record is:

$44,000-$63,750.

Following patient discharge, what is the time frame after which a medical record is considered delinquent?

15-30 days

The term "medical informatics" became widely used in the United States during the:

1980s.

How is the inpatient census tracked?

ADT system

Which of the following is NOT considered to be an identifier of PHI?

Age 33

The roles of which information professionals are core to the success of a health information exchange? Programmers Interface specialists Health informatics specialists

All of these

AHDI was formerly known as what association?

American Association for Medical Transcription

Continuing education units (CEUs) are earned by doing which of the following?

Attending education seminars and workshops

The first hospital in the United States was founded by Dr. Thomas Bond and:

Benjamin Franklin

Which of the following is NOT an accreditation agency?

CMS

Who requires a facility to retain records and gives guidelines as to how long they need to be kept?

CMS

Mary Smith is to have vital signs taken every 4 hours, and NPO after midnight for total knee arthroscopy according to Dr. Blume. What is Dr. Blume doing?

CPOE

Which credential is held by a cancer registrar?

CTR

A patient arrives at a hospital to have a pre-operative consultation with an ENT. The information mailed to the patient stated that the patient should report to the registration department on arrival before going to the department of otolaryngology. This is an example of what type of registration process?

Centralized

A patient is admitted with symptoms of fever and abdominal pain. These presenting symptoms are an example of what type of data?

Clinical data

Which of the following accredits home health agencies?

Community Health Accreditation Program

Which report does not have specific regulations by state or CoP, but a facility may have policies and procedures?

Consultation report

Charging a set fee for an office visit, a vaccination encounter by the nursing staff, or a telephone consultation would be an example of what type of healthcare reimbursement?

Fee-for-service

Mary Smith is admitted to the hospital by her primary care physician; he documents the following in the history and physical: patient complaining of abdominal pain for the last 48 hours with nausea and vomiting. What part of the history and physical is this called?

History of Present Illness (HPI)

What information might the pharmacist be looking for when reviewing a patient's record?

If a physician ordered a medication and the dosage

Which of the following is NOT a benefit of EHRs?

Instant, automated coding

Terminal digit filing begins with use of which two numbers first?

Last two

If a HIM director wanted to locate the licensing regulations for the state the hospital was located in, how would the information be accessed on the Internet?

Licensure regulations hospitals (then state name)

Health information professionals, previously known as "record librarians," were first organized where?

Massachusetts General Hospital

Which federal program, established in 1965, provides financial assistance for healthcare for persons 65 years of age and over and to disabled persons?

Medicare

The written notification that must be signed by the patient or legal representative that was established by HIPAA is the:

Notice of Privacy Practices.

A patient goes to what area immediately following surgery for monitoring of vital signs and condition post-surgery?

PACU

A voluntary pay-for-performance incentive program is:

PQRI.

A research facility is tracking HIV cases and is asking General Hospital for the information of patients with HIV. Which of the following would NOT be included in the information General Hospital sends the research facility?

Patient name

Which tool enhances patient engagement by providing a web-based location for patients to view and retrieve their personal health information?

Patient portal

Ginny Jones has been missing work frequently, so her boss has Sally, his assistant, call Ginny's doctor and ask for a copy of Ginny's medical records. Which of the following is the INCORRECT procedure for the HIM staff at the doctor's office to follow?

Pull the record and send it to Sally

Which three tenets have guided governmental officials as they have worked to improve healthcare in the United States over the past decade?

Quality, positive outcomes, and access

________ is an organization funded by the HITECH Act to assist providers by extending EHR adoption training and support services, as well as providing guidance with the implementation, trouble-shooting, and technical use of the EHR, while meeting Meaningful Use incentives.

REC

The Joint Commission standards that relate directly to health information are:

Record of Care, Treatment and Services.

Which part of the hospital revenue cycle is coding a part of?

Reimbursement

What type of care is covered and reimbursed by Medicare?

Skilled care

Legislation that resulted in a shift from retrospective to prospective payment for hospital inpatients is:

TEFRA.

Which of the following is a FALSE statement concerning the Affordable Care Act?

The Act will restrict the types of insurance coverage available

Which of the following has been accrediting hospitals for over 60 years?

The Joint Commission

Why is it necessary to be able to retrieve a document if it does not belong in a patient chart?

The patient chart is a legal health record.

What is the retention period for the Master Patient (Person) Index?

There is no retention period. It's permanent.

What was the purpose for establishing the professional organization ARLNA in 1928?

To elevate the status of individuals who processed medical records

A common barrier to employment of information technicians in healthcare is limited:

accountable care organization.

Medicare requirements state that the history and physical of inpatients must:

be done within 24 hours of admission or no longer than 30 days prior to admission

One of the ways that disaster recovery might be supported for a smaller facility is by using

cloud services.

Several different types of data are gathered during the registration process. Administrative data include all of the following EXCEPT:

diagnosis.

ADT plays an important role in Meaningful Use in all of the following ways EXCEPT:

files are large and can be transmitted easily.

HCPCS Level II codes are used for:

inpatients and outpatients.

Programs that allow two or more similar or different devices to communicate are known as an:

interface.

Increasingly, payment to providers will be linked to quality based on

outcome measurements.

The physical location where a healthcare professional delivers services to a patient is known as the:

point of care.

HIPAA is NOT a rule concerning:

professional licensing.

A staff member who compiles and sends requested information to other facilities is often called a:

release of information coordinator.

Documentation is done in several departments, such as an emergency room, laboratory, or radiology, and this complicates the use and sharing of health information. This process is referred to as:

silos.

Cloud-based servers are those servers that are able to:

store software and data offsite.

In the United States, the current reimbursement scheme is shifting

towards pay-for-performance

The health record provides a basis for:

transforming diagnoses and procedures into numerical format.

An order given to a nurse either in person or over the phone and later authenticated by the physician or physician extender is called a(n):

verbal order.

Which website would the HIM director of an ambulatory surgical center look at for accrediting information on other ambulatory surgery centers?

www.aaahc.org