Final exam study cards

The ARRA and HITECH Act encouraged many IT vendors to start designing EHRs for various types of facilities, such as hospitals, physician's office, and dentists. While this was a positive trend, new issues were created relating to A. great variability of EHRs but limited knowledge in selecting the right one. B. minimal availability of competent staff to lead the transition from paper files. C. lack of support in implementation. D. All the choices are correct.

D. All the choices are correct.

Typical parameters for scheduling patients include A. available providers. B. available days. C. available times. D. All the choices are correct.

D. All the choices are correct.

Which of the following patient engagement criteria is required for compliance with meaningful use? A. clinical summaries B. appointment recalls C. timely access to health information D. All the choices are correct.

D. All the choices are correct.

Which of the following is not true about the Documents function? A. It allows the user to view pending reports. B. It allows the user to view signed reports. C. It allows the user to add documents. D. It allows the user to delete documents.

D. It allows the user to delete documents.

Which of the following statements is not true? A. NCVHS core data elements can be used in a variety of settings. B. NCVHS core data elements include definitions for all 42 elements. C. NCVHS core data elements encourage information exchange among providers. D. NCVHS core data elements were replaced by the core data set developed by AHIMA.

D. NCVHS core data elements were replaced by the core data set developed by AHIMA.

The HIPAA Privacy and Security Rule complaint process includes all of the following except A. review of complaint. B. investigation. C. corrective actions. D. case transfer.

D. case transfer.

An example of clinical input is a A. patient's cumulative radiology report. B. laboratory summary. C. transcribed consultation report. D. diagnosis code.

D. diagnosis code

Which of the following is an example of primary data? A. patient's vital signs B. provider registry C. UHDDS D. disease index

D. disease index

All of the following can be guarantor account types except A. third party liability. B. personal/family. C. worker's compensation. D. next of kin.

D. next of kin.

What is the difference between data and information?

Data represents attributes of variables; information represents data that is collected and analyzed.

If an EHR does not have a scheduling feature, it should at least have an external application that provides the scheduling component. For this to work, a(n) _____ is needed.

Health Level Seven interface

Which of the following is not true about interoperability? A. Interoperability is designed specifically for healthcare. B. Healthcare organizations cannot exchange information without interoperability. C. Interoperability is what makes an EHR successful. D. With interoperability, it is possible to improve communication among healthcare providers, and thus improve patient care.

Interoperability is designed specifically for healthcare.

Which of the following is not true about the de-identified health information?

It can be shared with medical device companies.

The ______________ form includes information about the patient's rights and responsibilities:

Notice of Privacy Practices

In an acute care setting, HIPAA regulations require the following form(s) to be given to the patient during the registration process:

Notice of Privacy Practices and Advance Directive Notice.

Estephania works in a hospital and receives a request for copies of 50 records that will be reviewed by an audit company working for Medicare. What should she do?

She should comply with the request.

Clinical inputs include structured and unstructured data. What is the difference between these two types of data?

Structured data is stored in fixed database fields; unstructured data is mostly narrative.

Templates are a popular feature of an EHR system, and users are required to use them when available or even create new ones when needed. Why?

Templates prompt the user to provide more complete documentation.

In the process of transitioning from paper to electronic records, a primary physician's office is faced with time-consuming tasks, such as scanning old records and dealing with duplicate records. As a consultant, what do you tell the disappointed staff to help them through the process?

This is temporary. The EHR will improve patient care by providing better access and involving the patient

What health conditions are targeted by CDC's 6/18 initiative?

Unintended Pregnancy High Blood Pressure Tobacco Use Asthma Antibiotic Use Type 2 Diabetes

A cloned progress note differs from a progress note in that it is

a partial or total copy of a progress note.

An Assignment of Benefits form is

a patient authorization allowing the payor to send reimbursement directly to the healthcare provider.

What kind of document gives the patient permission or a recommendation to be seen by another provider?

a referral

The term "meaningful use" refers to:

a set of standards for using EHRs, defined by CMS.

To be compliant with meaningful use requirements, an EHR must have A. a way to schedule patients directly in the EHR. B. a way to allow patients to see their schedule. C. a scheduling module. D. a scheduling tab.

a way to schedule patients directly in the EHR.

It is the responsibility of the healthcare facility to make sure that the documentation in the medical record is

accurate and complete.

When a patient is no longer able to make their own decisions, what document helps the provider make the right decisions?

advance directives

Shwetha has recently relocated from another county and has found out that the physician she used to see is now part of a larger group practice. She locates the nearest office within the group practice and calls to schedule an appointment. Her last visit at her prior location was about two years ago. How should the admission and registration staff process her case?

an established patient

Following HIPAA regulations, privacy and security of patient information is at the forefront of health information professionals. All of the following are best practices to increase EHR security except A. encrypting passwords. B. changing passwords every 90-120 days. C. establishing user permissions. D. changing usernames every 12 months.

changing usernames every 12 months.

Patient bills are checked for errors via a process called

claim scrubbing.

New Hope hospital has created a new coding position that requires the coder to start coding the patient's medical record while the patient is still receiving treatment. What type of coding are they using?

concurrent coding

The process of searching and examining large amounts of patient data with the intention of identifying trends or patterns is called

data mining.

A data dictionary

describes the content, format, and structure of data elements in a database.

An HIM professional is analyzing the report of incomplete patient records over the last quarter to identify types of documents that continue to be incomplete, the responsible user, and whether the situation has improved since the last quarter. In this scenario, what type of data analytics are in use?

descriptive analytics

Which report is monitored daily by health information managers, coders, and others in a healthcare organization?

discharged not final billed (DNFB)

An itemized form that allows charges to be captured from a patient visit is called a(n)

electronic superbill.

Which of the following tasks is not part of the general guidelines for documentation? A. identifying the patient B. ensuring complete and accurate documentation C. identifying the provider D. ensuring that there is no corrected documentation

ensuring complete and accurate documentation

In what documentation would you most likely find the patient's vital signs?

flowsheets

The legal entitlement to payment or reimbursement for healthcare costs is known as

health coverage

When do healthcare facilities initiate the billing process for patient visits or admissions?

immediately following a patient's visit or patient's admission

When a prescriber enters a medication order and the system does not correctly warn them that the patient is allergic to it, this indicates that the data ________ is compromised.

integrity

When an organization ensures that information entered into the electronic health record is authenticated, accurate, timely, and complete, it is in fact ensuring data

integrity.

Some of the patient identifiers that are part of the master patient index are

patient Social Security number, name, date of birth, and address.

The challenges of EHRs present opportunities for health information professionals in many areas, especially:

privacy, security, and training.

Kaiser Foundation Group is an example of a(n)

private payer plan.

Coding accuracy is mostly affected by

quality of documentation

In order to clarify confusing documentation in the medical record and code the record accurately, a coder should do the following

query the physician.

A chief complaint is part of the history and physical, which consists of the patient's

reporting the reason for their admittance to the ER.

An ambulatory care facility experiencing many no-shows should ________ in order to determine the rate of no-shows.

run a report

Manual data collection is accomplished by

staff members who type it directly into the computer.

Which type of communication allows a patient and a provider to discuss the condition and plan of treatment in real time?

synchronous communication

The office manager at Northstar Medical Center has just hired a new biller and is setting her up with a new EHR account and selecting the EHR functions she can use. The office manager is most likely using

the Permissions submenu.

The difference between acute care and ambulatory care pertains to:

the length of time the patient is in the facility.

Setting up a facility template means that

the overall schedule of operations is included in the scheduling system

Final bills are typically held in a suspended status for ________ after patient discharge to allow for final charge entry, documentation, insurance verification, and final coding

three days

What was the main reason the disease classification system was originally developed?

to study infant mortality

The Patient Tracker feature enables the user to

update the status of the patient while in the facility.

When a report is transmitted from the transcriptionist's computer to the patient's EHR, the report is ________ into the EHR.

uploaded

An EHR must follow security protocols which means

-applying standards to prevent unauthorized access. -having a backup plan. -following data loss prevention protocols.

Which of the following contains skilled nursing home data? A. MDS B. UACDS C. OASIS D. UHDDS

A. MDS

Which of the following is an example of a data standard? A. EHR B. HL7 C. data dictionary D. data integrity

B. HL7

Which of the following is not true about the de-identified health information? A. It can be used by a hospital marketing department for outreach purposes. B. It can be used by a nursing home administrator to order new wheelchairs. C. It can be shared with public health offices to determine the flu vaccines needed. D. It can be shared with medical device companies.

D. It can be shared with medical device companies.

Which of the following contains data from an inpatient encounter? A. MDS B. UACDS C. OASIS D. UHDDS

D. UHDDS

What is a drawback of ICD-9-CM?

It does not reflect the updated codes for reporting diagnoses or inpatient hospital procedures.

A _____ allows computers within a small geographical area to connect with one another.

LAN

Which of the following Medicare programs helps pay for prescription drugs? Medicare Part A Medicare Part B Medicare Part C Medicare Part D

Medicare Part D

Shwetha has recently relocated from another county and has found out that the physician she used to see is now part of a larger group practice. She locates the nearest office within the group practice and calls to schedule an appointment. Her last visit at her prior location was about two years ago. How should the admission and registration staff process her case

an established patient

Mobile devices present many opportunities for healthcare providers except

automated HIPAA security.

Which type of EHR makes it possible to share the information among multiple providers and facilities?

networked

A subscriber is

the person who usually pays for the cost of the insurance.

Which of the following best describes a registry? A. A registry contains clinical information about a disease. B. A registry is automatically created as part of an EHR. C. A registry is a database. D. A registry is part of a data warehouse

A. A registry contains clinical information about a disease.

Which of the following must comply with HIPAA's requirements to protect the privacy and security of health information? A. a business associate working with Medicaid B. a worker's compensation carrier C. a vendor working with a pharmaceutical manufacturer D. a pharmacy benefits management program

A. a business associate working with Medicaid

Which of the following is an example of a third-party payer? A. commercial insurance B. covered entity C. patient D. health care provider

A. commercial insurance

Which of the following is the amount that the insured individual must pay to the healthcare provider before the health insurance company pays their portion? A. deductible B. coinsurance C. copayment D. allowed amount

A. deductible

Which of the following is not considered PHI? A. last year's number of patients with congestive heart failure B. last year's list of patients with congestive heart failure C. a patient's past medical condition D. a patient's current medical conditions

A. last year's number of patients with congestive heart failure

Which of the following best describes integrated care? A. systematic coordination of healthcare for patients B. ongoing follow up for patient care C. an organization that is created from merging two hospitals D. an organization that includes acute care and ambulatory care facilities

A. systematic coordination of healthcare for patients

What is the main difference between fraud and abuse?

Abuse is unintentional; fraud is intentional

A health record includes A. information about the patient's past medical conditions. B. information about the patient's present health information. C. treatments provided to the patient by healthcare providers. D. All the choices are correct.

All the choices are correct.

The HITECH Act of 2009 marked a significant achievement for health care because A. it allocated billions of dollars for health information technology. B. it established a National Health Information Technology Research Center. C. it provided incentives for physicians and hospitals to implement electronic health records. D. All the choices are correct.

All the choices are correct.

Which of the following are benefits of EHRs? A. improved access to patient information. B. faster communication among providers. C. improved documentation of care. D. All the choices are correct.

All the choices are correct.

What is the difference between an RHIT and an RHIA?

An RHIT works on the technical aspects of the system and an RHIA is a liaison and specialist in managing health information.

Which of the following is an advantage of automated data collection? A. Data is always accurate. B. Data is more consistently captured. C. Registration personnel is no longer needed. D. Quality check function is eliminated.

B. Data is more consistently captured

Federal and state laws do not always match when it comes to regulations pertaining to privacy, security, and overall record maintenance and retention. As the HIM director of a new healthcare facility, you are creating new privacy and security policies. Which of the following approaches will you follow? A. Use the state law as your only guide given your state requires that records are retained for a longer period of time. B. Look at both state and federal laws and use the more stringent one in terms of privacy protection. C. Use the federal law as your only guide because it always supersedes the state law for everything. D. Look at both state and federal laws but only use the state law as guidance.

B. Look at both state and federal laws and use the more stringent one in terms of privacy protection.

You are trying to identify the list of residents in a facility with certain cognitive patterns. Which of the following would be most efficient in finding that information? A. UHDDS B. MDS 3.0 C. OASIS D. DEEDS

B. MDS 3.0

Which of the following best describes Medigap? A. a health insurance that covers those who qualify for economic aid B. a health insurance that supplements Medicare coverage C. a health plan for eligible veterans D. a health plan that is only available for those on Medicaid

B. a health insurance that supplements Medicare coverage

Given the AHIMA Information Governance Principles for Healthcare, which of the following is an illustration of disposition? A. the data warehouse location B. a process that ensures data is disposed of properly C. a process that ensures data backup on a set schedule D. preparation for deposition in court

B. a process that ensures data is disposed of properly

A physical exam is a component of the patient's history and physical and includes all of the following except A. vital signs. B. allergies. C. review of body systems. D. objective information.

B. allergies.

Which of the following would not be categorized as an out-of-pocket amount? A. copay B. allowed amount C. coinsurance D. deductible

B. allowed amount

The billing aspect of a medical practice includes all of the following, except A. revenue management. B. hiring billing personnel. C. reporting. D. claims management.

B. hiring billing personnel.

In the wake of multiple Security Rule breaches, it would be advisable to do which of the following in order to reduce risk of breaches? A. continue to work with paper records; electronic ones are riskier B. implement an enterprise data storage to manage and protect data D. disable data transmission as it creates additional risk for the organization C. increase penalties

B. implement an enterprise data storage to manage and protect data

Which of the following scenarios is true about civil violations? A. The facility charged with a civil violation will not pay monetary penalties. B. The facility charged with a civil violation must terminate the employee who violated the law. C. A person charged with a civil violation does not usually face imprisonment. D. A person charged with a civil violation is entitled to passing the blame to the employer.

C. A person charged with a civil violation does not usually face imprisonment.

Which of the following is not true about the clinical trials registry? A. ClinicalTrials.gov provides access to funded clinical studies. B. ClinicalTrials.gov has information on both publicly and privately funded clinical studies. C. ClinicalTrial.gov collects and shares data about patient treatments. D. ClinicalTrials.gov contains only studies pertaining to human subjects.

C. ClinicalTrial.gov collects and shares data about patient treatments.

Which of the following is not true about a telehealth visit? A. It requires scheduling. B. It requires the patient to log in prior to the scheduled visit time. C. It is offered to patients' family members to join in instead of coming to the office. D. It requires sending a link for the virtual visit to the patient.

C. It is offered to patients' family members to join in instead of coming to the office.

Which of the following is true about the levels of interoperability? A. The higher the level, the bigger the communication infrastructure. B. The higher the level, the greater the amount of data transmitted. C. The higher the level, the greater the capability for interoperation. D. The level does not matter, as long as the data format is standard.

C. The higher the level, the greater the capability for interoperation.

Which of the following enables the analysis of data from multiple databases, including the EHR and other clinical information systems? A. a data index B. a data registry C. a data warehouse D. a database

C. a data warehouse

As Dr. Lee is visiting a patient, she notes: "Patient has ongoing diabetes. Vital signs are normal. Patient complains of abdominal pain. Plan to do an abdominal ultrasound." In what document will such information be found? A. an abdominal ultrasound B. diabetes evaluation C. history and physical D. chief complaint report

C. history and physical

All of the following except _____ are examples of unstructured data. A. patient's progress notes B. EKG test interpretation C. patient's gender D. operative report

C. patient's gender

All of the following documents except __________ need to be signed by the patient in order to be valid. A. general consent for care B. informed consent for an invasive procedure C. procedure report D. advance directive

C. procedure report

There are three stages of meaningful use. Stage 1 has already been implemented in many facilities and includes all except A. use of certified EHR for e-prescribing. B. use of certified EHR for electronic exchange of information. C. use of certified EHR for improving health outcomes. D. use of certified EHR to submit clinical quality measures.

C. use of certified EHR for improving health outcomes

Which of the following classification systems is used to code dental procedures?

CDT