final pt2QA Exercise #2 04/12/19, Practice Quiz 12.1 (RHIA & RHIT), Practice Quiz 12.2 (RHIA & RHIT), Practice Quiz 12.3 (RHIA & RHIT), Final Quiz 12.1 (RHIA & RHIT, Practice Quiz 11.1 (RHIA & RHIT), Practice Quiz 11.2 (RHIA), Final Quiz 11.1a (RHIT),
a physician directly enters an order for cipro from a patient with urinary tract infection into the computer system upon entering this order the system notifies the physician that the patient is allergic to chipper which of the following is used to notify the physician of the potential patient safety issue?
alert
The esophagus, stomach, small and large intestines are all parts of:
alimentary canal.
When analyzing discipline problems, which of the following should be considered?
all answers apply
According to the HIPAA Privacy Rule, the following persons must adhere to the minimum necessary standard when releasing patient-specific information.
all members of the organization: clinicians, staff, and volunteers
steps in data analysis include
all of the above
in order to assure and EHR dresses legal concerns it must
all of the above..
Who of the following who are permitted to have access to patient health records and information without the patient authorization as part of their training program?
all of these answers apply
Which of the following is considered confidential information if the patient is seeking treatment in a substance abuse facility?
all of these answers apply .
Which of the following measures should a health care facility incorporate into its institution-wide security plan to protect the confidentiality of the patient record?
all of these answers apply. .
What is the chief criterion for determining record inactivity?
amount of space available for storage of newer records
the filing supervisor has noticed a problem with the filing of loose reports in the file area. As supervisor, the must find out the root causes of the problem. The most beneficial QI tool to use would be the:
cause and effect diagram
Your release of information system has part of the computing on the workstation and part on the file server. What type of technology is being used?
client sever
you new release of information system has part of the computer on the workstation and part of the file server what type of technology is being used
client sever
The responsibility for performing quality monitoring and evaluation activities in a departmentalized hospital is delegated to the
clinical chairpersons of medical staff committees or ancillary department directors.
The function of a(an) _______ is limited to data retrieval.
clinical data repository
you are working with a database that is created form multiple databases being stored in a single database. This is an
clinical data repository
you are working with a database that is created from multiple database being stored in a single database. this is a
clinical data repository
The patient has been on medication X for several years. A physician ordered medication Y. The information system immediately sends the physician a message that says that medication Y is contraindicated due to medication X. What technology is being used?
clinical decision support systems
The hospital implemented an electronic query system to allow more effective communication with physicians and other health practitioners to improve clinical documentation in the patient record. This program is known as
clinical documentation improvement (CDI).
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using?
clinical information system
a list or collection of clinical words or phrases with their meaning is a
clinical vocabulary
a list or collection of clinical words or phrases with their meanings is
clinical vocabulary
This small physician practice does not have the technical staff to manage the EHR. The physicians are looking for someone who can manage the software and hardware for them at a set monthly cost. Their technology support staff is limited, so you want to use a technology where the software and database is stored and maintained remotely. This is called
cloud computing
The coder with the highest overall accuracy rating will get the day after Thanksgiving off. Which coder will get to spend the day after Thanksgiving off rather than coding?
coder c
A health care organization's compliance plans should not only focus on regulatory compliance, but also have a
coding compliance program that prevents fraudulent coding and billing.
According to the CDC, the most common sites for cancer of the digestive system are:
colon and rectum.
the concepts of system authentication access control data confidentiality data integrity and non-repudiatation are integral to
communications security
Which of the following examples would NOT be considered "reasonable accommodation" under the Americans with Disabilities Act?
completely renovating an entire department to accommodate a disabled employee
incident reports are analyzed:
concurrently
When a health information professional (record custodian) brings the medical record to court in response to a subpoena duces tecum, it is his or her responsibility to
confirm whether or not the record is complete, accurate, and made in the ordinary course of business.
A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as:
consultation
Willful disregard of a subpoena is considered
contempt of court.
You are a nurse who works on 3West during the day shift. One day, you had to work the night shift because they were shorthanded. However, you were unable to access the EHR. What type of access control(s) is being used?
context-based
The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?
continued stay review
The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?
continued stay review
I need a snapshot of the patient's condition so I would access the
continuity of care record
Which of the following systems would provide a snapshot of information about the patient's conditon?
continuity of care record
Adding the UCL (upper control limit) and LCL (lower control limit) to the chart above creates a
control chart
The board of directors of a 400-bed women's hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate. This reporting period, they see a rise in the rate and want to know if it is a significant increase. What is the best QI tool for this purpose?
control chart
What is the best tool for differentiating between common cause variation and special cause variation?
control chart
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
controlled vocabulary
Which of the following is a risky practice in the EHR?
copy and paste
Continuous quality improvement is best described by the following statements EXCEPT
corrective action targets clinicians more so than processes.
Yvonne is a recent graduate who has applied for a Trauma Registry position at a Chicago hospital while she prepares to apply to graduate school. In making the decision, she considers the offer of $15 per hour for a 40-hour week, benefits of 27.5% of her salary, and tuition waivers of six credits per year at $145. She calculated that her total compensation would be
$40,650.00
The HIM Supervisor conducted a timely performance evaluation for one of her employees and awarded the employee a 4% merit increase. If the employee's hourly salary is presently $7.10, what will the hourly salary be once this merit increase is applied?
$7.38
The average number of transcribed lines per month at Bent Tree Hospital is 142,500. The daily production standard is 950 lines per day. With 20 workdays in the month, calculate the minimum number of FTEs needed for this volume.
7.5
Alcoholic hepatitis with ascites:
70.11, F10.99
Which of the following best describes the function of kiosks?
A computer station that promotes the healthcare organization's services
Which of the following statements is true in regard to responding to requests from individuals for access to their PHI?
A cost-based fee may be charged for making a copy of the PHI.
Which of the following is an example of a security incident?
A hacker accessed PHI from off site.
You have been asked to provide an example of a trigger that might be used to reduce auditing. The example you should provide is:
A patient and user have the same last name.
Identify an appropriate use of the emergency access procedure.
A patient is crashing. The attending physician is not in the hospital, so a physician who is available helps the patient.
What conclusion can you make from the pie graph below?
A pie graph should not be used, because there are too many categories for effective display.
An EHR system can provide better security than a paper record for protected health information system due to:
Access controls, audit trails, and authentication systems
Within the context of data security, protecting data privacy means defending or safeguarding:
Access to information
What is the difference between data and information?
Data represent basic facts, while information represents meaning.
The protection measures and tools for safeguarding information and information systems is a definition of:
Data security
Electronic systems used by nurses and physicians to document assessments and findings are called:
Electronic point-of-care charting
The director of the Health Information Services Department is developing a plan to convert their existing filing system to an electronic document management system (EDMS). The tool that is most useful to the director in displaying the steps and completion schedule for each phase of the conversion is a
Gantt chart.
Mapping between ICD-9 and ICD-10 were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another)
General Equivalency Mappings
The following legislation requires that patient-identifiable health information remains confidential and protected against unauthorized disclosure, alteration, or destruction.
HIPAA Security Rule
Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?
HL7
The vendor that you work for has decided to get into the EHR market. What standard should you suggest using in developing the functions perfomed by the EHR?
HL7 EHR functional model
Since many private and public standard groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for:
Harmonization of standards from multiple sources
The creation of the National Practitioner Data Bank was mandated by the:
Health Care Quality Improvement Act
Which data bank is a result of HIPAA legislation?
Healthcare Integrity and Protection Data Bank
What federal legislation passed in 1986 gave immunity from legal action to practitioners regarding some peer-review process activities?
Healthcare Quality Improvement Act
One of the advantages of an EDMS is that it can:
Help manage work tasks
Programming language that allows for the display of information in a similar format on different operating systems and system hardware.
Hypertext markup language
The acronym HTML stands for:
Hypertext markup language
which type of patient incident would be of greatest interest to the hospital's liability insurance carrier?
Incidents resulting in patient harm
Which one of the following is not a description of a hybrid health record?
Includes an equal part of paper and electronically produced documents
what informal process is used in the system selection process to prescreen vendor?
RFI
Gatekeepers determine the appropriateness of all of the following components except:
Rate of capitation or reimbursement
How will hospitals benefit most from an EHR?
Reduction of errors
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation?
Refer this record to the risk manager for further review and removal of the incident report.
Which of the following stores data in predefined tables consisting of rows and columns?
Relational database
Which of the following would be an inappropriate procedure for the custodian of the medical record to perform prior to taking a medical record from a health care facility to court?
Remove any information that might prove detrimental to the hospital or physician.
The Joint Commission recently surveyed an acute care hospital. The hospital just received the survey report and the accreditation decision. Which of the following categories should the hospital leaders address first?
Requirements for Improvement
Which of the following vocabularies is likely to be used to describe drugs in clinically relevant form?
RxNorm
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
The Joint Commission
Which of the following organizations within the federal government is responsible for looking at the issues related to the efficiency and effectiveness of the healthcare delivery system, disease protocols, and guidelines for improved disease outcomes?
The correct answer is: Agency for Healthcare Research and Quality (AHRQ)
An organization identifies key people in various functional areas to be trained first, and then asks them to subsequently train other users in this same functional area. What is this approach to user training called?
Train-the-trainer
What type of information system would be used for processing patient admissions, employee time cards, and purchase orders?
Transaction processing system
What basic components make up every electronic network communications system?
Transmitters, receivers, media, and data
The information collected for your registry includes patient demographic information, diagnosis codes, functional status and histocompatibility information. This type of registry is a:
Transplant registry
ICD-10-CM has NO chapter-specific guidelines for coding and reporting digestive system diseases.
True
One of the differences between ICD-9-CM and ICD-10-CM pertains to codes for hemorrhoids. In ICD-9-CM, the codes for hemorrhoids were located in the circulatory system. In ICD-10-CM, they have been moved to the digestive system chapter.
True
Under the Immigration Reform and Control Act, all of the following apply EXCEPT
U.S. citizens must be given preference.
An audit trail may be used to detect which of the following:
Unauthorized access to a system
Which form of system testing ensures that each data element is captured correctly?
Unit testing
Healthcare fraud is all of the following except
Unnecessary costs to a program
Which of the following would be the best course of action to take to ensure continuous availability of electronic data?
Use mirrored processing on redundant servers
Which of the following is not true of good electronic forms design?
Use radio buttons to select multiple items from a set of options.
The director of health information services is allowed access to the medical record tracking system when providing the proper log-in and password. Under what access security mechanism is the director allowed access to the system?
User-based
Which of the following is not true about document imaging?
Uses microfilm to store images
Performs simple operations on files created by other programs.
Utility program
The policies and procedures section of a coding compliance plan should include all of the following except:
Utilization review
The acronym WAN stands for:
Wide area network
The physician who performed the highest number of services overall last Tuesday was Dr.
Wooley
What feature is a trademark of an effective PI program?
a continuous cycle of improvement projects over time
A histogram is a valuable tool for representing
a frequency distribution with continuous-interval data.
A histogram is a valuable tool for representing:
a frequency distribution with continuous-interval data.
Looking more closely at the LOS for these patients, when you calculate the standard deviation on the data, you would expect
a large standard deviation because the dispersion is large.
which of the following situations would be an example of risk control>
a paging system..
"Qualified employees should be given priority when vacancies within the organization occur" is an example of
a policy of the organization.
The process of reviewing and validating qualifications, granting professional or medical staff membership, and awarding delineated privileges is called the
credentialing
The Six Sigma methodology differs from other quality improvement models by defining improvement opportunities using
critical-to-quality tree.
In a recent review, it was determined that the EHR is essential to the operations of the home health agency. What type of review is this?
criticality analysis
A method that has been developed for representing a variety of data on a single display in an easy-to-read format is called a
dashboard
You have been asked to give an example of secure data. Which of the following will you give as your answer?
data that is encrypted that makes it unreadable
Identify the information system that collects data from multiple source systems but the data is not collected from these sources systems in real-time.
data warehouse
Organizations collect statistics to increase their knowledge of a specified population. The knowledge does not come automatically—it is developed in the following sequence:
data → information → facts → knowledge
Danelia combined her HIM and legal education and is now a Risk Manager. An employee has a complaint that may be considered a grievance. She should listen to the employee and then
deal with the issue as if it were a bona fide grievance.
You have been given the responsibility of destroying the PHI contained in the system's old server before it is trashed. What destruction method do you recommend?
degaussing
preventing the unauthorized or intentional changing of data assists in assuring data integrity changing of data can mean data has been modifies or:
deleted
An ophthalmologist has requested permission to perform specialized laser procedures within the hospital. His request is evaluated by the Credentials Committee through a process to determine the specific procedures and services this physician can perform. This is known as
delineation of privileges.
A patient is admitted in alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis?
delirium tremens
All of the following are elements of a contract EXCEPT
duty
The chief executive officer (CEO) at a health care facility begins a formal planning cycle at the beginning of each fiscal year. This annual planning process should begin with which of the following?
establishing the annual organizational objectives
Kimberly Wolf wants a Mercedes and the position of vice president of Information Services. She feels that achieving these goals will provide her with a sense of achievement, prestige, and reputation in the eyes of others. At what level of Maslow's hierarchy of needs is she operating?
esteem
Integration of decision support systems and best practices in medicine is known as the practice of
evidence-based medicine.
A physician excises a 3.1 cm malignant lesion of the scalp which requires full thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?
excision of lesion; Full-thickness skin graft to scalp
A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?
excision of lesion; full-thickness skin graft to scalp
The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?
executive information system
the beginning of the system processing cycle can be influenced by:
feedback
which type of media uses light source to transmit data
fiber optic
" A relatively large number of network processors are able to share the data contained in files of the sever and the actual processing of the data is distributed across the network" describes which network architecture?
file/server
Which of the following issues would be of LEAST concern when storing health records in off-site storage?
filing order of the records
You need a report that includes only Medicare patients. What operation enables you to generate this report?
filtering
The HIM department frequently experiences a backlog in loose report filing. A quality improvement team is assembled to identify the outcome variables and the major or root causes. What visual QI tool is helpful to report the findings?
fishbone (cause and effect) diagram
When you and your team have identified a problem and must determine the cause or causes of that situation, completing a(n) ________ can help.
fishbone diagram
the causes and effect diagram is also known as the:
fishbone diagram
As an HIM coding supervisor, you are asked to compare the current coding process with a proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure?
flowchart
Which of the following is incorrect about control charts?
focuses attention on process variation over a time period
Based on the graphic chart, which two areas should you recommend be acted upon first in order to address 80% of the patients' complaints?
food and cleanliness
Physicians at South Seas Clinic are expected to see six patients per hour on average. The physicians with the highest productivity each week are exempted from on-call responsibilities for the weekend. Which physician will get the weekend off this week?
hiltz
The display below is a
histogram, which is commonly used to display continuous data.
In assigning E/M codes, three key components are used. These are
history, examination, and medical decision making.
Juan Smith was pronounced dead on arrival (DOA). The hospital pathologist performed an autopsy on Mr. Smith's body. This statistical event would be counted in the:
hospital autopsy rate
William Rumple was pronounced dead on arrival (DOA). The hospital pathologist performed an autopsy on Mr. Rumple's body. This statistical event would be counted in the
hospital autopsy rate (adjusted).
A website, available to the general public, permits anyone to review specific measures of quality care for a particular hospital, is called ___________
hospital compare
the quality planning function involves which of the following activities
identification of improvement goals
Strong lateral relationships within a facility are most likely when
individual departments cooperate together to achieve organizational goals.
According to ICD-10-CM, which one of the following is not a mechanical complication of an internal implant?
inflammation of urethra due to indwelling catheter
facts and figures that have been processed and analyzed so that clinicians can used the results are known as
information
Case management coordinates an individual's care, especially in complex and high cost cases. Goals of case management include all of the following except:
information security
The company's policy states that audit logs, access reports, and security incident reports should be reviewed daily. This review is known as a(n)
information system activity review.
which of the following measures of central tendency is most impacted by extreme values?
mean
The Recovery Audit Contractor (RAC) program was developed to identify and reduce improper payments for
medicare claims
which is the most common type of patient incident that occurs in the 3 west nursing unit?
medication errors
Mary is designing a computer screen that will be used to collect patient demographic information. What input design should be utilized for the state field?
menu
You are asked by an HIM student to provide him or her an example of an administrative safeguard under the security rule. The appropriate response is
monitoring the computer access activity of the user.
Fetal monitoring strips are part of the _______ record and should be maintained_______.
mother's; according to the length of time required for a minor's records
The Unified Medical Language System (UMLS) is a project sponsored by the:
national library of medicine
Employee turnover is expensive and stressful on staff and reflects poorly on managers. The best defense against employee dissatisfaction is
open and honest communication.
the expense budget is also known as the
operating budget
The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information?
operation index
the best place to ascertain the size of an excised lesion for accurate CPT coding is the:
operative report
The best place to ascertain the size of an excised lesion for accurate CPT coding is the
operative report.
These data are best described as
ordinal
The director of a Health Information Department prepared a tool in which the following information could be obtained: job title, reporting line, span of control, and routes of promotion. The document she prepared is a(n)
organizational chart.
The HIM director is not satisfied with performance improvement results of the department. In order for the staff to truly accept the change that has been set into motion, the director must influence the core values and beliefs that are shared by the members of her staff. Which of the following terms is this scenario referring to?
organizational culture
Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient's health are examples of:
outcome measurement
Identify the requester that requires patient authorization before releasing PHI.
patient's attorney
The most widely-discussed and debated unique patient identifier is the:
patient's social security number
the four major categories of incident in a hospital setting are:
patient, visitor, employee, property
the number of years it takes to recoup expenditures is known as the
payback period
When the policy and procedures manual no longer reflect current practices, it creates a situation that becomes a risk management issue because:
policy and procedures should represent the normal course of business.
Gina is the HIPAA Privacy and Security officer and primary trainer for a regional health system. In determining how a certain department staff position uses health information, she must review the
position or job description.
Veronica is the HIPAA Privacy and Security Officer and primary trainer for a regional health system. In determining how a person in a position in a department uses health information, she must certainly review the
position or job description.
The data displayed in the histogram below could best be described as
positively skewed.
Dumping syndrome is also known as:
post-gastric surgery syndrome.
a rule is helpful to both managers and the employees in the decision making process. A rule:
pre-decides issues
HEDIS gathers specific data on women's health in which of the following areas?
prenatal care
Major responsibilities of the risk manager generally include
preventing and reducing loss.
Which of the following is NOT included as a part of the minimum data maintained in the MPI?
principal diagnosis
the right of an individual to determine the tome way and extent of information about him/her that is communicated to others is:
privacy
Under which category of law would Marleana Harrison bring a cause of action against Dr. Billy Ray for disclosing information regarding her previous physical examination to his wife, Jana Ray, who is Ms. Harrison's hairstylist?
private law
Carlos is a new scanning technician. To fulfill your responsibility as a supervisor and to help him learn and complete his work correctly, the best training resource to use would be a
procedure
The manager of the utilization review department wants to monitor and evaluate the prevention of inappropriate admissions. When would the manager need to collect data?
prospective review
As a general rule, a person making a report in good faith and under statutory command (e.g., on child abuse, communicable diseases, births, and deaths) is
protected
The administrator has asked us to develop a patient satisfaction database internally. This database will be used to collect data that can be used to improve our services. He does not want this to be a long, drawn-out process. Which of the following could speed up this process?
prototyping
The director of Health Information Services has recently received approval to purchase a new high-speed scanner. The director plans to redesign the department layout to accommodate the equipment and to ensure that the equipment is placed in the most appropriate area of the department. Which of the following tools will best assist the director with this new layout?
proximity chart
A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as Gram-negative pneumonia?
pseudomonas
What field monitors populations as a whole instead of patient specific data?
public health informatics
a hospitals utilization management plan should outline all of the following EXCEPT:
qualifications of the utilization management coordinator
The manager of the quality department is listing various sources of data. Which of the following data sources would be an example of an external source?
quality improvement organization (QIO) information
The credentialing process requires health care facilities to
query the NPDB to collect and report malpractice judgment and settlements.
an example of professional liability would be
radiologist..
Without even performing any complex calculations, you can get a quick, simple measure of dispersion in the LOS for yesterday's discharges by computing the
range of the data set
Without even performing any complex calculations, you can get a quick, simple measure of dispersion in the LOS for yesterday's discharges by computing the
range of the data set.
In your department, employee performance is rated using a continuous scale range of unsatisfactory through average to outstanding. Some other departments use a discrete system in which the supervisor assigns "fails to meet standards," "meets standards," and "exceeds standards." Both systems being used are
rating scales.
when a computer is first turned on the initial boot procedure is performed by a set predetermined operations using instructions stored in
read only memory
You are part of a data analysis team reviewing data generated from the EHR. Your team would like to further study the facility's cardiovascular disease population of patients. The committee wants to determine if there is a correlation between BMI (body mass index) and the age of the patients treated in the facility. Your expertise in data analytics calls you to recommend which of the following visualization tools to determine if a relationship exists?
scatter diagram
the QI tool which depicts the relationship between variables and can result in positive correlation, negative correlation or no correlation, is known as the:
scatter diagram
Jessica is the leader of a project team working on the definition of the women's health service line. Several departments are so enthusiastic about the progress that they ask for additions to the project. This is not uncommon, and is known as
scope creep.
the director of health information department has the department supervisors to review and revise all job descriptions.Daniella Segura the supervisor over coding analysis had determined that the job description for the senior code must be revised. Ms. Seguras decision to revise the job description is probably due to change in the:
scope of coding responsibilities
A patient is admitted with shortness of breath and hemoptysis. A chest X-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected and the patient was started on radiation to the brain. The principal diagnosis is the:
small cell lung carcinoma
The healthcare facility has implemented an application that allows patients to support each other. The information system is
social media
a self replicating or destructive code that can significantly harm the operations of an organization is:
software virus
Administrative, financial, and other information systems supply the EHR with much of its data. What are these various systems known as?
source system
The average percent of patients exceeding acceptable waiting time was 3.7%. The calculated UCL (upper control limit) is 9.4. When you plot the upper and lower limits, what would you suggest as the reason for the June variation?
special cause variation
Which of the following is an example of the breach of confidentiality?
staff members discussing patients' information in the elevator
When managers work to keep staff members feeling appreciated and valued for their contributions to the job and the organization, this is known as __________.
staff satisfaction
Which of the following is usually the largest expense for a health care facility?
staffing expenses
which of the following is not a component of a risk management plan?
standard of care
in order for the EHR and other systems to be interoperable the system much certain:
standards
A medical malpractice claim involving a wrong-site surgery was heard in a higher court, which resulted in the health care facility's requirement to pay the plaintiff $1 million in damages. A similar case with similar elements was also heard in a lower court, and thus the lower court followed the lead of the higher court in deciding the outcome of the case. The term that most appropriately describes the action of the lower court is
stare decisis.
Minors are basically deemed legally incompetent to access, use, or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?
state law because HIPAA defers to state laws on matters related to minors.
A patient was discharged from the acute care hospital with a final diagnosis of bronchial asthma. As the coder reviews the record, she notes that the patient was described as having prolonged and tractable wheezing, airway obstruction with was not relieved by bronchodilators and the lab values showed decreased respiratory function. The coder queried the physician to determine whether the code for________is appropriate to be added to the final diagnoses
status asthmaticus
Redness, ulcers, and/or bleeding of the mouth due to bacteria, fungi, or viruses, is known as:
stomatitis
a hospital CEO is assessing wheather the "cardiac center of excellence" designation would be of benefit to the organization if determined that this status would be of benefit the initiative will consume numerous human and financial resource. the longer term project should be outline in the organization
strategic plan
Written documents that assist an organization in achieving its objectives and carrying out its mission statement are known as
strategic plans.
the information system manager is testing what the system can handle with regards to passing large amounts of data. This is called:
stress testing
The type of indicator about the placement and number of fire extinguishers would be a(n):
structure
which of the following types of performance measures examine elements that facilitate care, such as resources, equipment, or qualifications of staff?
structure
Review the simplistic screen on the screen. This is an example of how__________data can be entered.
structured
Review the simplistic screen on the screen. This is an example of how ________ data can be entered.
structured data
a nurse use a personal digital assistant (PDA) to temporarily store data collected while treating the patient. The nurse uses a stylus to maneuver and entreat into the PDA the nurse is most likely creating what type of data
structured data
Drop boxes, radio buttons, and pick lists are used in
structured data entry.
HIM personnel charged with the responsibility of bringing a medical record to court would ordinarily do so in answer to a
subpoena duces tecum.
Which of the following is NOT an advantage of teams?
successful teams have dominating leader
The reference date for a cancer registry is
the date when data collection began.
The jejunum is part of:
the small intestine
The supervisor of release of information in a health information department is preparing a work distribution chart in the hopes of identifying some problem areas. Although the work distribution chart can provide the supervisor with a great deal of information concerning the work performed by her staff, it will not indicate
the solution to a specific problem area.
if the diagnosis, "first, second and third degree burns of the chest wall," a code is required for:
the third degree burn only
A major disadvantage of cross-sectional studies is that
the time sequence of exposure and disease is usually not known.
All of the following may present challenges to informed consent EXCEPT
the treating physician obtained the patient's signature.
What quality indicator would prove useful in tracking customer satisfaction in the correspondence/release of information function?
the turnaround time from the date a request is received to the date the information is provided to the requester
As a chief privacy officer, you have been asked why you are conducting a risk assessment. Which reason would you give?
to prevent breach of privacy
The HIPAA Privacy and Security Rule requires that privacy training be documented. What methods of documenting training efforts need to be used?
training content, training dates, and attendee names
The HIPAA Privacy and Security Rule requires that training be documented. What methods of documenting training efforts need to be used?
training content, training dates, and attendee names
To ensure consistency of coverage among trainers, you may want to develop
training manuals.
All of the following principles are illustrated in an organizational chart EXCEPT
unity of direction
The coder reviewed 10 patients' health records in order to assign diagnosis and procedure codes. Select the term used for this practice.
use
Southwest Health System has numerous semiretired staff. The Human Resources Department has provided training regarding the Age Discrimination in Employment Act (ADEA). They emphasized that it protects employees and applicants beginning at what age?
40
prolonged pregnancy is a pregnancy that had advance beyond___completed weeks of gestation
42
Marie, the coding supervisor, must determine the number of full-time employees (FTEs) needed to code 600 discharges per week. It takes an average of 20 minutes to code each record and each coder will work 40 hours per week. How many coders are needed?
5.0
What was the gross (hospital) death rate at Tampa Bay Health Center last year?
5.5%
Use the following statistics from Utah Home Health to calculate the absenteeism rate. January
5.68%
Historically, individually identifiable information for deceased individuals regardless of the time of death was covered under the HIPAA Privacy Rule. However, under the HITECH, individually identifiable information for deceased individuals is no longer covered after _____ years.
50
The number of deliveries in the facility in October is
55
How many deliveries occurred?
57
If the budgeted payroll expense was $24,300 and the actual payroll expense was $25,800, what is the percentage of cost variance?
6.17%
What was the average length of stay at Royal Palm Hospital in February?
7 days
A hospital reported the following statistics during a nonleap year. Calculate the percentage of occupancy for the entire year.
88%
two significant result of the social security act-medicare in 1965 were:
government..
Blindness due to an allergic reaction to ampicillin administered 6 years ago would be reported as a(n)
late effect of an adverse reaction.
The family of Mr. Kent filed a wrongful death lawsuit against Pier Memorial Hospital 10 years after the procedure was performed. In order to avoid the risk of Mr. Kent's electronic medical record being destroyed, a _______ was ordered by the court.
legal hold
As Director of Health information Services, you are negotiating a contract to purchase a new computerized dictation system that will be used across three satellite ambulatory clinics. What element is most critical in the contract negotiation to ensure use of the software in multiple environments?
license grant
credentials review is the process whereby the:
license..
Which of the following processes is mandatory for health care facilities?
licensure
Positions that have authority to direct the tasks of subordinates are called:
line authority.
what type of graphic display could be used to illustrate the month-to-month changes in incident rates in the labor and delivery nursing unit?
line chart
Which of the following relationships does the diagram above demonstrate?
one to one
You are conducting a study on the pain associated with a specific illness. For the purpose of your study, you classify pain level as follows:
ordinal
a traditional severe includes response statements that include strongly agree, agree, disagree and strongly disagree these response statements are
ordinal variables
the director of health information department prepared a document in which of the following information could be obtained: job title, reporting ling, span of control, and routes of promotion. the document she was preparing was a(n):
organization chart
OASIS data are used to assess the __________ of home health services.
outcome
Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient's health are examples of
outcome measures.
A patient satisfaction survey conducted after discharge is a method of quality measurement through
outcomes indicator.
Mission Health Systems has contracted with an agency to conduct recruitment and screening of potential candidates. This approach is called
outsourcing
a basic concept of office layout and workflow is that the
paper moves to the employee
Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components?
International Classification of Functioning, Disability and Health (ICF)
The acronym IP stands for:
Internet Protocol
The acronym ISP stands for:
Internet service provider
The ability to electronically send data from one electronic system to a different electronic system and still retain its meaning is called:
Interoperability
When some computers are used primarily to enter data and others to process data, the architecture is called:
Interoperability
the facility needs the hospital information system to share information with the electronic health record. the ability to exchange data between the two systems regardless of vendor is known as:
Interoperability
You are the quality coordinator for the medical staff. Analyze the chart above and determine the steps to be taken next.
Investigate the anomaly shown for December.
Community Hospital's hardware has been placed on back-order, the network team is having trouble getting the network to function properly. This is an example of:
Issues management
Which of the following statements is true about the Privacy Act of 1974?
It applies only to documents maintained by the federal government.
Which of the following statements best defines utilization management?
It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care.
Which of the following statements is FALSE in regard to departmental reengineering?
It is intended to make small or minor changes in order to improve a function or process.
Stenosis of salivary gland:
K11.8
Barrett's esophagus with high grade dysplasia:
K22.711
Gastroduodenitis with bleeding:
K29.91
Gastrocolic fistula:
K31.6
Acute appendicitis with perforation and peritoneal abscess:
K35.2
Appendiceal fecalith:
K38.1
Strangulated incisional hernia:
K43.0
Diaphragmatic hernia with obstruction:
K44.0
Crohn's disease of the small intestine, with SBO:
K50.012
Spastic colon with diarrhea:
K58.0
Chronic anal fissure:
K60.1
Incontinence due to (nontraumatic) anal tear of anal sphincter:
K62.81, R15.9
Hepatic fibrosis:
K74.0
Choledocholithiasis with acute and chronic cholecystitis:
K80.66
Strawberry gallbladder:
K82.4
The correct acronym for Metropolitan area network is:
MAN
In which phase of the system development life cycle is the primary focus on identifying and assigning priorities to the various upgrades and changes that might be made in an organization's information systems?
Planning
The first phase of the SDLC is the _____ phase.
Planning
The organizing process determines how the work in a particular department will be divided and accomplished. In order to be in the best position to organize the work effectively, the manager must first engage in which management function?
Planning
A special Web page that offers secure access to data is a(n):
Portal
Created language used to write application and utility programs.
Programming language
A surgeon requests the name of a patient he admitted on January 11, 2013. Which of the following would be used to retrieve this information?
R-ADT system
A SNF wanting to collect MDS assessments in a database and transmit them in a standard CMS format would use which of the following data entry software?
RAVEN
A system that enables processing of diagnostic studies results into tables, graphs, or other structures is:
Results retrieval and management technology
Information standards that provide clear descriptors of data elements to be included in computer-based patient record system are called _____ standards.
Structure and content
Incorporating a workflow function in an electronic information system would help support:
Tasks that need to be performed in a specific sequence
Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered
a series of core measures.
Which of the following employees is exempt under the Fair Labor Standards Act?
an RHIT who manages the Health Information Services department and is involved with planning and decision-making activities 90% of the time
What quality indicator would identify improvement needs in hospital electronic transmission of health care claims and remittances to allow interoperability with ICD-10 codes?
an increase in 5010 rejections
Per TMF, for a hospital admission to be medically necessary there must be:
an indication for hospitalization..
The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits?
an initial inpatient consult and a subsequent hospital visit
A physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign:
an unlisted procedure code located in the eye and ocular adnexa section
The three components of a data security program are confidentiality, integrity, and
availability.
You sit on the quality improvement team for the Nursing department that meets to generate ideas to address verbal order documentation problems about the "Read Back Verbal Order" policy. What QI tool would prove useful in sharing input and various recommendations for solving this problem?
brainstorming
Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)?
breast
occurrence screens are used to identify:
cases that will undergo peer review
Darling v. Charleston Community Memorial Hospital is considered one of the benchmark cases in health care because it was with this case that the doctrine of _______________ was eliminated for nonprofit hospitals.
charitable immunity
The primary advantage of concurrent quality data collection is that
chart completion issues can be remedied promptly.
Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team?
chief executive officer
you release of information system has part of the computing on the workstation and part on the file server. what type of technology is being used?
client server
In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to
confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.
You need to identify some patterns in our database. What technology should you use?
data mining
All of the following are among the Joint Commission's initial core measure sets for hospitals EXCEPT
diabetes
which of the following is not a synonym/acronym for "quality improvement- QI"?
PPS
which of the following is primary storage
RAM
which of the following is primary storage?
RAM
The organizing process determines how the work in a particular department will be divided and accomplished. In order to be in the best position to organize the work effectively, the manager must first engage in which management function?
planning
Traditional management functions, such as ________, must be applied to performance improvement initiatives.
planning
dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as
poisioning
Each procedure should indicate how it is related to a department's:
policies
Which of the following is a written description of an organization's formal position?
policy
When the policy and procedures manual no longer reflect current practices, it creates a situation that becomes a risk management issue because
policy and procedures should represent the legal course of business for the current time.
HIPAA allows health care providers to charge patients reasonable cost-based charges for copies of their health record. Which of the following is allowed when determining the charge?
preparing a summary
Installation of a new electronic document management system is scheduled for the HIM department. The department director calls a meeting of the HIM supervisors to coordinate plans for training the HIM staff. What key factors must be taken into consideration as part of the training preparation process?
presentation content and scheduling to accommodate all employee shifts
the best source for obtaining data for job analysis is the:
the person who performs the job
Get-Well Hospital reports an average LOS in February of 3.7 days with a standard deviation of 20. This tells us that:
there was a large variation in the LOS.
Pasadena Bay Hospital reports an average LOS in January of 3.7 days with a standard deviation of 20. This tells us that
there was a large variation in the LOS.
In CPT, Category III codes include codes
to describe emerging technologies.
Why would the database administrator add a foreign key to one of the tables?
to indicate that it is a primary key in another table
The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a
transplant registry.
How often are healthcare facilities required to practice their emergency preparedness plan annually?
twice
The name given to the error committed when the null hypothesis is rejected and it is actually true is
type I error.
The master patient index must, at a minimum, include sufficient information to
uniquely identify the patient.
the data on your hard drive was erased by a corrupted file that has been attached to an e-mail message. if you had_____software maybe not have happened
virus
The information systems manager is testing what the system can handle with regard to passing large amounts of data. This is called
volume testing
The main difference between concurrent and retrospective coding is
when the coding is done.
ICD-10-CM utilizes a placeholder character. This is used as a fifth character placeholder at certain six-character codes to allow for future expansion. The placeholder character is
"x"
ICD-10-CM utilizes a placeholder character. This is used as a fifth character placeholder at certain six-character codes to allow for future expansion. The placeholder character is
"x."
The transcription production for February was 225,333 lines. The total work hours for all transcriptionists for the same period were 2,000. The average hourly cost was $13.50. Determine the cost per line for operating this service for this month.
$0.12
You own a transcription company with 13 employees. Due to the decrease of your business, you need to dismiss 2 employees. To assure that you abide by federal regulations, you determine the 2 employees to be dismissed based upon their:
productivity
a detailed set of instructions that describe step-by-step the tasks that a computer should perform are called
program or software
Angel Home Care utilizes a discipline system that provides for stronger penalties for each successive repeat offense. They are most likely using
progressive discipline.
the movement from paper based medical records to electronic health records represents a significant challenge within a healthcare organization. which of the following processes is most important to managing the challenge?
project management
A union is engaged in an organizing campaign in a hospital facility. Which activity should management personnel avoid during this time?
promising employees a pay increase or promotion if they vote against the union
The HIM supervisor is evaluating software that would utilize electronic logging and monitoring of requests for copies of patient information and develop an accounting of disclosure. What department function is this most useful for?
release of information/disclosure management
In which of the following circumstances would release of information without the patient's authorization be permissible?
release to third-party payers
In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to
reliability
The ability to obtain the same results from different studies using different methodologies and different populations is
reliability
In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to
reliability.
Dr. Tovar is entering the care she is providing to a 40 year old female. The EHR suggested she order a mammogram. What is this example of ?
reminder
The HIM director has received a request to amend a patient's health record. The appropriate action for him to take is to
route the request to the physician who wrote the note in question to determine appropriateness of the amendment.
At an integrated delivery system, the hospital and clinic have separate networks. There are times when they need to share information across the network. This can be accomplished with a
router
at our integrated delivery system the hospital and clinic have separate networks. there are times when they need to share information across the network. this can be accomplished with a
router
The director of health information department has discovered that the department's policy regarding the usage of the copy machine has been consistently abused by the majority of the staff. to put an end to this inappropriate use of the copy machine the director should institute a department.
rule
if you want to show how a process changes and fluctuates over a certain time period, the QI tool of choice would be a:
run chart
Patty supervises the electronic document management (EDM) section. She is preparing a report that includes a graphic that displays data over time and provides an excellent visualization of quality and quantity trends. This style of a report is called a(n)
run or line chart
Gary's primary concern is job continuity and adequate health insurance for his large family. What level of Maslow's hierarchy of needs does Gary operate from?
safety
You job is to determine the documents subject to the HIPAA Security Rule. The document that you identify is
scanned operative report stored on CD.
Which of the following is NOT an advantage of an electronic document management system?
scanned record data can be manipulated
Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements?
scanning all 250,000 records for a cost of $195,000
The abstract completed on the patients in your hospital contains the following items: patient demographics, prehospital interventions, vital signs on admission, procedures and treatment prior to hospitalization, transport modality, and injury severity score. The hospital uses these data for its
trauma registry.
Reporting the monthly average turnaround time for the release of information (ROI) over a 6-month period using a run or line chart will reflect
trends and detect if improvements were made.
a computer application/system is purchased from a vendor and installed within the organization no modification of the system is required before it is used within the organization.this describes a
turkey system
Using Donabedian's framework for quality assessment (structure, process, and outcome), which of the following is an appropriate human resource outcome?
turnover rate is reduced
A patient has a total of abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes: 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s) with or without removal of ovary(s) and 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure)
unbundling
Cheryl is the director of the Health Information Services Department, and Suzanne is the assistant director. Cheryl notices one of Suzanne's subordinates leaving the department for an unscheduled break. When the employee returns, Cheryl immediately asks the employee to step into her office and begins discussing the unauthorized break. Which organizational principle is this director violating?
unity of command
Holly is the day supervisor who works from 7:00 AM to 4:00 PM. Kim is the evening supervisor who works from 2:00 PM to 11:00 PM. Sarah is a transcriptionist who works from 10:00 AM to 7:00 PM, which overlaps the day and evening shifts. Sarah asked Holly, the day supervisor, if she could leave early for personal reasons. Holly said Sarah could leave early if Kim, the evening supervisor, agrees. Which theory of management does this situation violate?
unity of command
a patient is undergoing hemodialysis for end stage renal disease in the outpatient department of an acute care hospital. the patient develops what is believed to be severe heartburn. however she is sent to observation for several hours at which time the patient was admitted to inpatient care for future work-up. the cardiologist diagnosed the patient problem as unstable angina. What is the principal diagnosis for the acute hospital stay?
unstable angina
The names of the hospital services are hard to read. The best way to deal with this problem would be to
use a column chart instead of a bar chart.
You have been asked to develop scenarios that will be used to design and program a new relase of information system. These scenarios will include the processes to be used in detail. What are you designing?
use cases
In relation to birth defects registries, active surveillance systems
use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs.
To accomplish the Joint Commission's safety goal to eliminate wrong-site, wrong-patient procedures, the organization can use all of these EXCEPT
using imaging guidance on all procedures.
With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory?
utilization review
Anna Kathryn is attending budget training for new supervisors. The representative from Finance explains that _____ costs will vary in direct proportion to changes in the volume of care provided.
variable
The most realistic approach that could encourage increased productivity in the tedious prepping area is to
vary and rotate the work assigned to each prepper.
in the PFP i have asked information regard tin the amount of time that a vendor has been in business and the number of installation of the production under consideration. If I want to review this information you go the _____section
vendor information
The vendor has provided an update to their software. With this update, the system has new functions. This is known as a
version
Which of the following health care systems have to comply with the requirements of the Freedom of Information Act?
veterans' hospitals
the data on your hard drive was erased by a corrupted file that had been attached to an email message. if you had_____software maybe this would not have happened
virus
Southside Community Hospital utilizes a wide area network to transport data across the Internet. This is done by using a private tunnel. This is a(n)
vpn
An organization chart identifies all of the following except:
wages and benefits
Resources that produce little-to-no value to the organization, such as non-utilized talent, inventory miscalculations, and staff members waiting for information so they can do their jobs, is known as _______, which must be reduced, if not eliminated, in a lean managed organization.
waste
Dr. Smith goes to Hollywood Hospital's Web site and logs in. He sees a list of patients currently in the hospital, test results, and more. Ms. Brown, a patient of Dr. Smith who is having surgery next week, logs onto the same Web site and only sees the date and time of her preoperative visit. This is an example of
web portal
Dr. Smith goes to Hollywood Hospital's Web site and logs in. He sees a list of patients currently in the hospital, test results, and more. Ms. Brown, a patient of Dr. Smith who is having surgery next week, logs onto the same Web site and only sees the date and time of her preoperative visit. This is an example of
web portal.
Looking at the graph above, you can assume that more people
were admitted to the facility with infections than acquired infections in the hospital.
In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded in which of the following cases?
when a new patient is seen in the office
CPT provides Level I modifiers to explain all of the following situations EXCEPT
when a patient sees a surgeon for follow-up care after surgery.
the main difference between concurrent and retrospective coding is:
when the coding is done
Which of the following is required by HIPAA standards?
A written contingency plan
Jason collected data on the length of stay (LOS) for 10 patients and then determined the median LOS as follows:
Jason forgot to put the numbers in sequential order before determining the median.
What is wrong with Jason's determination of the median?
Jason forgot to put the numbers in sequential order before determining the median.
The anesthesia department is adding a new indicator to its plan. The chief anesthesiologist has come to you, the director of quality management, to help her design a data collection methodology. The two of you are now considering who will be doing the data collection. All of the following are factors in your deliberations EXCEPT
Joint Commission standards and required characteristics.
Dental caries, pit and fissure surfaces, with penetration to dentin:
K02.52
Blind loop syndrome due to surgical procedure:
K91.2
Malfunction of colostomy:
K94.03
Infected gastrostomy due to abdominal wall cellulitis:
K94.22, L03.311
a rare malignant tumor often associated with AIDS is
Kaposi's sarcoma
In order to improve efficiency and productivity, which of the following sequence of steps is the most effective?
Know the objective; break down the work into component activities, and the group activities into proper organizational units.
Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. The successful transmission is dependent on which of the following standards?
LOINC
Which of the following disorders is not classified in Chapter 11-Diseases of the Digestive System?
Lactose intolerance
Computer that can be conveniently balanced on a person's knees
Laptop computer
Which of the following is NOT part of the digestive system?
Larynx
The chief information officer is a senior-level executive who is responsible for:
Leading the organizations strategic IS planning process
Medical school graduates must pass a test before they can obtain a __________ to practice medicine.
License
An amendment to the Civil Rights Act of 1964, that extends the 180-day statute of limitations previously applied to the filing of an equal-pay lawsuit refers to the
Lilly Ledbetter Fair Pay Act.
The acronym LAN stands for:
Local area network
Which classification system was developed to standardize terminology and codes for use in clinical laboratories?
Logical Observation Identifiers Names and Codes (LOINC)
Which classification system was developed to standardize terminology and codes for use in clinical laboratories?
Logical Observation Identifiers, Names and Codes (LOINC)
The PQRS is a reporting system established by the federal government for physician practices who participate in Medicare for quality measure reporting. Beginning in 2017, this program transitioned into
MIPS
CMS has increased the weight for MS-DRG A by 14%, increased the weight for MS-DRG B by 20%, and decreased the weight for MS-DRG D by 10%. Given these new weights, which MS-DRG generated the most revenue for Venice Bay Health Center?
MS-DRG C
The MS-DRG that generated the most revenue for Venice Bay Health Center is
MS-DRG C.
The patient was admitted and discharged before a notice of privacy practices could be provided to him. The proper action to take is
Mail the notice of privacy practices to the patient.
Computer containing a powerful central processing unit that controls the activity of the dummy monitor.
Mainframe
Which of the following computer architectures uses a single large computer to process data received from terminals into which data are entered?
Mainframe
Which of the following systems would the HIM department director use to receive daily reports on the number of new admissions to, and discharges from, the hospital?
Management information system
Which of the following uniquely identifies each record in a database table?
Primary key
In attempting to control the patient safety issues associated with hybrid medical records, which of the following would be the best practice for a healthcare facility to do?
Print out all documents and maintain these as a general practice
To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place?
Prior to any user authorization for access to data
Patient care can be improved through the use of technology. Which of the following is an example of how this happens?
elimination of illegible orders
The director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the director's response?
elimination of the need for expensive desktop computers
Human Resources provide training for new supervisors. It includes discussion of the Equal Pay Act, which was passed to eliminate discrimination based on which of the following?
employee gender
The high cost of staff turnover is eating away at the department's budget, so Thomas is creating a(n) __________ program to increase staff satisfaction.
employee retention
You have been asked to provide examples of technical security measures. Identify what you would include in your list of examples.
encryption
A major consideration in a hospital or facility closure is to
ensure that authorized parties have access to the information as provided by law.
Keith is director at a medical center that includes a daycare center and has several employees who have young children. He knows that it is important to be familiar with the provisions of the Family Medical Leave Act (FMLA), which includes all the following provisions EXCEPT
ensuring any job the employee is qualified for upon return.
a hospital information security program places emphasis on data back-ups in order to be ready to restore data if needed in any emergency situation. this demonstrates which of the following basic goals of a security program
ensuring integrity of data
One-to-one, one-to-many, and many-to-many are terms used to describe
entity relationships
The hospital is undergoing the development of an information system strategic plan. The part of the process where changes in the community, legislation, and other factors are monitored is called
environmental scanning
the information security officer is responsible for
documenting the information security related policies and procedures of the organization
When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding?
donor site
Robert Burchfield was recently caught accessing his wife's health record. The system automatically notified the staff of a potential breach due to the same last name for the user and the patient. This was an example of
a trigger.
The proper method for correcting a documentation error in a paper medical record is for the author to
draw a single line through the incorrect information, date, and initial the change.
an organization spends appropriate time and resources investigation an EHR. they do this in order to make a good decision and to assure appropriate use of resource the organization is aware that there are legal ethical and financial consequences associate with how they choose the system to be used the evaluation process they use in making their decision is known as:
due diligence
When a decision is made to restrict or deny clinical privileges during the recredentialing or reappointment process to a medical staff member, _______________ must be offered.
due process
A PEG procedure would most likely be done to facilitate:
eating
a coder incorrectly enters a patients sex as a male on an abstract. after doing so the system alerts the coder to this error because the procedure code for a hysterectomy was also assigned to this patients record this an example of a
edit check
Your department must send information electronically to the state health department every day. Currently this is taking a significant amount of time. What technology can be used to automatically send this information without human intervention?
electronic data interchange
All of these are quality improvement strategies EXCEPT
error-based penalties
A population-based cancer registry that is designed to determine rates and trends in a defined population is a(n)
incidence-only population-based registry.
Needlesticks, patient or employee falls, medication errors, or any event not consistent with routine patient care activities would require risk reporting documentation in the form of an
incident report
the primary tool for identifying risk is the:
incident report
You recently installed a new computer system and you just learned that the vendor does not have the right to use one portion of the system. Another company owns the rights to the information contained in this portion of the system. What clause in your contract would you review to see if you are protected from being sued by the other company?
indemnification
Niagara Falls Health Center needs occasional help in coding to remain current. Rena, the coding manager, is seeking an individual who is available evenings and weekends and will be responsible for his or her own actions. At a regional HIM meeting, Rena announces that she is looking for a(n)
independent contractor.
data enter is done throughout the day by users in various departments to change medical record numbers. once entered the change is processed immediately and available throughout the system. this is known as
real time processing
Consider the following situation: The department's working hours are 8:00 AM to 6:00 PM. After 6:00 PM, if a record is needed in the emergency room for a possible readmission, the ER clerk has access to the facility's electronic health record (EHR) in order to retrieve the record. On the occasions when the ER clerk has retrieved a record it appears as if the clerk was viewing records unnecessarily within the EHR. What would be the best training or development method for the ER clerk in order to rectify this situation?
receive training by the Release of Information (ROI) supervisor
The method of calculating errors in a coding audit that allows for benchmarking with other hospitals and permits the reviewer to track errors by case type is the:
record method
As a prerequisite in the implementation of an electronic health record, what process would facilitate automatic indexing?
redesigning forms to include bar codes
The major purpose of random assignment in a clinical trial is to
reduce selection bias in allocation of treatment.
Barbara is being seen at a physician's office that she has never been to before. This physician practice is independently owned and is not associated with a hospital or other physician practice. She did not have to request copies of her medical records, but the physician has everything that she needs. The physician must be part of a(n)
regional health information organization.
Which of these functions is found in an ambulatory EHR but no in an acute care EHR?
registration
In the Act phase of the PDSA method, what step can assist in implementing change in a department?
distributing new policies and procedures to people affected by the changes and explaining the rationale for the changes
which of the following is a concept is used to classify networks?
distribution of processing function
A patient who is taking the drug Antivert may be diagnosed with:
dizziness
Mandatory reporting requirements for vital statistics generally
do not require authorization by the patient.
In order to use the inpatient CPT consultation codes, the consulting physician must
document his findings in the patient's medical record.
The coding supervisor at Bayside Hospital regularly has the coders recode records from the previous week in an effort to improve and monitor coding consistency. The supervisor has collected the data displayed below on four coders.
interrater reliability.
The data in the column on the far right were collected when the coders traded records for recoding. This is a common practice used to check
interrater reliability.
The Joint Commission's emphasis on improving quality of patient care for a participating facility is exemplary through the required self-assessment process tool known as
intracycle monitoring.
The facility has used Internet technology in order to establish an area restricted to employees where policies and procedures, forms, and more can be stored. This is a(n)
intranet
a private internet system that secures data from external discovery via the use of firewall is known as a
intranet
computer and other devices connected to one another for the purpose of sharing program devices and data are said to be
networked
A small portion of the form you are using for a research study is reproduced below.
nominal data.
As director of the HIM department, you are asked to chair a committee that will review, select, and implement a CPOE system. The information has been collected, and you bring your committee together to prioritize their suggestions. This method of working with information is known as
nominal group technique.
The data display below is a
normal distribution of curve
As supervisor of the record completion function of the HIM department, you are asked for record completion statistics for specific physicians who are being evaluated for reappointment to the medical staff. Which of the following information elements would you report for each physician?
number of delinquent records
The span of control in an organization refers to the
number of people who report to one supervisor.
The database being implemented must be able to store video, images, and audio. Which of the following database models should be considered?
object oriented
You are preparing a training program for specific functional areas of the HIM department (e.g., coding, release of information). Which of the following is the primary factor to consider in developing an effective training program?
objectives of each functional area
You are preparing a training program for specific functional areas of the department (e.g. coding, transcription, etc). Which of the following is the primary factor to consider in developing an effective training program?
objectives of each functional area
Blockage of an organ caused by calculi, organic matter, or tumors is known as:
obstruction
One of the major functions of the cancer registry is to assure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
of the life of the patient
Joint Commission requires that medical record review be performed to evaluate adequacy, accuracy, completeness, and quality of documentation:
on an ongoing basis.
You use an information system to create a letter notifying a requester that your facility does not have any records on file for the individual's records requested. What system are you using?
release of information
one of the problems facing national health information network is
intraoperability
An improper disclosure of patient information to unauthorized individuals, agencies, or news media may be considered a(n)
invasion of privacy.
The primary difference between an experimental (randomized) clinical trial and other observational study designs in epidemiology is that in an experimental trial, the
investigator determines who is and who is not exposed.
Under the Patient Self-Determination Act of 1990, evidence of advance directives
is required to be documented in the health record.
The total number of infections at South Beach Hospital during the first quarter (January-March) was
38
When interviewing a prospective employee, which question would be inappropriate to ask?
"Do you own a home?"
You have been given the responsibility of determining when there is an inappropriate use of PHI. These situations have been reported as potential violations. Determine which one is an inappropriate use of PHI.
"Mary, at work yesterday I saw that Susan had a hysterectomy."
The supervisor over release of information has requested a meeting with her superior, the director of Health Information Services. She begins the meeting by describing how overwhelmed she is feeling. She is extremely behind in her work and she does not know what she can do to change the situation. In advising the supervisor, the director suggests that perhaps she should begin addressing her problem by attending a management workshop. Which of the following workshop topics is more likely to help the supervisor with her problem?
"The Nature of Delegation"
when interviewing a prospective employee which of the following questions is inappropriate to ask?
"do you own a home?"
Which of the following is a technique for graphically depicting the structure of a computer database?
Data model
As the supervisor of the birth certificate process, you conduct a monthly review of the birth certificates procesed versus the certificates returned from the Bureau of Vital Statistics. Based on your review, a total of 468 birth certificates were filed and 12 were returned. What is the accuracy of processing birth certificates?
97.4%
There is an Excludes 2 note at the beginning of the Diseases of the Digestive System chapter. Which is NOT one of the conditions noted in the Excludes note?
Circulatory disorders
Mr. Beasley determined that the rate of absenteeism with three of his employees was 15%. He felt that this was unacceptable and decided that there were two different ways he could handle this situation. He evaluated these alternatives and thought the best thing to do would be to suspend all three for 2 days. Once he implemented this idea, he analyzed the consequences. How would you label this process?
Decision making
What is it called when accrediting bodies such as The Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government?
Deemed status
Which of the following is a disadvantage of retrospective data collection?
Deficiencies in documentation can effect reimbursement.
Software that controls how the computer works
Operating system
A distribution is said to be positively skewed when the mean is
shifted to the right.
Which of the following is NOT a main objective of reengineering?
to increase cost
The Level II (national) codes of the HCPCS coding system are maintained by the:
Centers for Medicare and Medicaid Services
forms cost $150 per thousand (K) for the first 5000 and $100/(K) thereafter. if you need to order 8000 what will your cost be?
$1050
one of the HIM clerk's hours wage if $7.10. During one week the employee worked the regular 40 hours work week plus an additional 4 hours of overtime. the salary for the particular week would be
$326.60
you currently lease the microfilm equipment and are making quarterly payments of $1200. you also lease two word processors at $90 each per month. you lease will continue four more years on all of the above equipment. What will your semi-annual budget amount be for leased equipment
$3480
During the month of September, Superior Health Care Center had 1,382 inpatient discharges, including 48 deaths. There were 38 deaths over 48 hours. Statistics also show 4 fetal deaths, 3 DOAs, and 4 inpatient coroner's cases. Which of the following calculations is correct to figure the net death rate?
(48-10 x 100) / (1,382 - 10)
A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.
-53
A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.
-57
Mrs. Jones had an appendectomy on November 1. she was taken back to survey on November 2 for evacuation of hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit
-78
The permanent RAC program was completely implemented in the United States by:
January 2010
You are the coding supervisor and wish to know the amount of time spent on coding by eight employees this month. You have the following productivity log. What percentage of time was spent on coding?
11.3%
You have been conducting productivity studies on your coders and find that 20% of their time is devoted to querying physicians about missing or unclear diagnoses. Assuming your coders work a 7-hour day, how many minutes do they spend per day querying physicians?
84
Which of the following is a legal concern regarding the EHR?
Ability to subpoena audit trails
The vision of the EHR is that discrete data would be entered by providers into an EHR via:
Templates
if 3000 lose sheets are filed in a one week period by two workers filing for eight hours per day. what is the average production rate per minute?
0.625
one significant change for hospitals as a result of PPS reimbursement is:
a shift to the outpatient setting of services
A plaintiff must establish which burden of proof to recover damages for medical negligence or malpractice? 1. a breach of the duty to care by the defendant 2. damages or injury resulted from the defendant's negligence 3. a duty of care relationship between the defendant and patient 4. causation existed for harm to the plaintiff from the defendant's conduct
1, 2, 3, and 4
A patient admitted to the hospital on January 24 and discharged on February 9 has a length of stay of
16 days.
The statistics reported for a 300-bed hospital for 1 year were 20,932 discharges with 136,651 discharge days and 3,699 consultations performed. What was the consultation rate for the year?
17.7%
Mr. McDonaldson was admitted to your hospital at 10:45 PM on January 1. He died at 4:22 AM on January 3. How many inpatient service days did Mr. McDonaldson receive?
2
Your just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?
Abstracting
How should these deaths be counted in the hospital death rates?
None of these deaths will be included in the gross death rate.
As the director of the Health Information Department, you are preparing a request for approval to purchase an encoding system. Because this is considered a capital request, you are required to submit the cost-benefit ratio. The software and license cost is $6,000, hardware maintenance is $1,500, and the training of two employees will cost $500. It is expected that the encoding system will increase reimbursement by $10,000. The cost-benefit ratio is
1.25
Sandy Beach Hospital reports 1,652 discharges for September. The infection control report documents 21 hospital-acquired infections and 27 community-acquired infections for the same month. What is the community-acquired infection rate?
1.6
Get-Well Hospital reports 1,662 discharges for September. The infection control report documents 21 nosocomial infections and 29 community-acquired infections for the same month. What is the community-acquired infection rate?
1.7
What was the net death rate at Happy Valley Health Center last year?
1.7%
A study found that liver cancer rates per 100,000 males among cigarette smokers and nonsmokers in a major U.S. city were 48.0 and 25.4, respectively. The relative risk of developing liver cancer for male smokers compared to nonsmokers is
1.89.
Chapter 11 of ICD-10-CM, Diseases of the Digestive System, contains:
10 blocks/subchapters.
Chapter 11 of ICD-10-CM-Diseases of the Digestive System-contains:
10 subchapters divided by anatomic site.
The OB/GYN Department reported the information in the table shown above to the Quality Management/Statistics Committee. When the committee considers these adverse outcomes from the OB/GYN Department, which of the cases will be included in the numerator of the facility's fetal death rate?
101-43-26
Which of the cases listed in the table above will have an impact on the facility's gross death rate?
101-44-23
Eighty requests for records to be pulled for the emergency room were processed in January. From the histogram provided above, what was the most frequent amount of time taken to process a request?
11-20 minutes
the next available number to assigned a Oceanside Hospital is 41369 D
10361
The special web page that offers secure access to data is a(n):
Portal
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased?
14
A patient admitted to the hospital on January 24 and discharged on February 9 has a length of stay of
16 days
Clinical privileges are granted to the physician for an interval specified in the medical staff by laws, but not longer than
2 years
Use the statistics provided in the table to compute the fetal death rate at All Women's Hospital for March.
2.2%
If there are 150,000 medical records and the Health Information Department receives 3,545 requests for records in a week, what percentage of the records are requested weekly?
2.4%
Bayside Hospital has 275 adult beds, 30 pediatric beds, and 40 bassinets. In a nonleap year, inpatient service days were 75,860 for adults, 7,100 for pediatrics, and 11,800 for newborns. What was the average daily census for the year?
227
Get-Well Hospital has 275 adult beds, 30 pediatric beds, and 40 bassinets. In a nonleap year, inpatient service days were 75,860 for adults, 7,100 for pediatrics, and 11,800 for newborns. What was the average daily census for the year?
227
After a work sampling study was completed, it was found that 20 percent of a coder's time was devoted to creating electronic queries to be sent to the physicians' electronic inboxes. How many minutes of a 7-hour day are taken up with this activity?
84
Which of the following is recommended for design of forms for an EDMS?
24 lb. paper for double-sided forms
Refer to the Summary of Selected Blood Product Review table shown above. What percent of the fresh frozen plasma units met indications?
24%
27645 Radical resection of tumor; tibia 27646 Fibula 27647 Talus or calcaneus
27646 radical resection of tumor; fibula.
After reviewing the following excerpt from CPT, code 27646 would be interpreted as
27646 radical resection of tumor; fibula.
an example of a valid code in the ICD-10-PCS system is
2W3FX1Z
A hospital averages 72 discharges per day. Coders must average 27 records per day. How many full-time coders does the department need?
3
After a work sampling study was completed, it was found that 20% of a coder's time was devoted to pulling records for physicians with missing diagnoses. How many minutes of a 7-hour day are taken up with this activity?
84
Use the information shown in the table above. Calculate the average percentage of patients for the entire year who waited longer than an acceptable amount of waiting time. (The sample size for each month's data is 100.)
3.7%
If population size (N) = 1,200 and the proportion of subjects needed (p) = 0.5 and the acceptable amount of error (B) = 0.05, then sample size (n) =
300
The HIM department of a local hospital will experience a 20% increase in the number of discharges processed per day as the result of a merger with a smaller facility. This 20% increase is projected as 120 additional records per day. The standard time for coding a record is 15 minutes. Compute the number of FTEs required to process this increased volume in coding based on an 8-hour day.
4
In deciding to purchase or lease a new dictation system, the director of Health Information Services calculated the payback period and rate of return on the investment. The hospital's required payback period is 3 years with a required rate of return of 20%. If the equipment costs $32,000 and generates $8,000 per year in savings, what would the payback period for this equipment be?
4 years
At Get-Well Hospital, record processing takes approximately 18 minutes. If there are 15,620 discharges for the month, how many personnel hours are needed for this volume of work?
4,686
At Great Plains Regional Hospital, record processing takes approximately 18 minutes. If there are 15,620 discharges for the month, how many staff hours are needed for this volume of work?
4,686
You are responsible for calculating and reporting average length of stay (ALOS) for your hospital each month. This month, there were 92 discharges, and the total discharge days equal 875. One of the patients discharged this month had a total of 428 discharge days, so the ALOS is distorted by this unusually long stay. In this situation, you should report an ALOS of
4.91 days and make a note that the data on one patient with an unusually long LOS was subtracted prior to making the calculation.
Selena works 40 hours per week at Rio Grande Radiology, which pays time-and-a-half for overtime and double-time for holidays. During the past week, Selena took 6 hours of unpaid personal leave and worked an 8-hour holiday. How many hours will Selena be paid?
42
The number of births in the facility in October is
56
What was the fetal death rate at New Beginnings Maternity Center in December?
6.8%
A covered entity must act on a request for accounting disclosures no later than _____ days after its receipt and within ______ days of extension, as long as it notifies the individual in writing of the reasons for the delay and when the accounting will be made available.
60, 30
The chart above shows a normal distribution. What percentage of the cases falls within the two lines showing the standard distribution between -1 and +1 on either side of the mean?
68%
The inpatient census at midnight is 67. Two patients were admitted in the morning; one died 2 hours later; the second patient was transferred to another facility that same afternoon. The inpatient service days for that day will be
69
the average number of transcribes lines per month at Bent Tree Hospital is 142,500. The daily production standards is 950 lines per day. with 20 work days in month calculate the minimum number of FTE's needed for this volume
7.5
Get-Well Hospital has 200 beds and 20 bassinets. There was a sudden spurt in the birth rate in the town in November. The hospital set up five additional bassinets for the entire month. Total bed count days for Get-Well Hospital in a nonleap year would be:
73,000.
Sea Crest Hospital has 200 beds and 20 bassinets. There was a sudden spurt in the birth rate in the town in November. The hospital set up five additional bassinets for the entire month. Total bed count days for Sea Crest Hospital in a nonleap year would be
73,000.
The mean number of minutes with the physician (considering all physicians) is
8 minutes
The median number of minutes with the physician (considering all physicians) is
8 minutes
The mean number of minutes with the physician (considering all physicians) is
8 minutes.
Styles Hospital has 200 beds and 20 bassinets. In a nonleap year, Styles Hospital admitted 16,437 adults and children; 16,570 adults and children were discharged. There were 1,764 live births and 1,798 newborns discharged. The bed turnover rate for the year was
82.9.
Which of the following is FALSE in regard to budget variances?
Temporary budget variances are expected to continue in subsequent months.
your department has a productivity standard of 7.63 min/unit for abstracting and data entry. employee a completed 271 records in a 37.5 hour work week. eighteen of those records did not meet the acceptable quality standard. what is the productivity rate for this employee?
85.8
What was the percentage of occupancy for adults and pediatrics in February?
88.2%
in a filing system containing a total of 1,255 records, 48 records are identified as misfiles. what is the percentage of filing accuracy for the area
96%
Identify an exception to the definition of a breach.
A coder accidently sends PHI to a billing clerk in the same facility.
All of the following are steps in medical necessity and utilization review, except:
Access consideration
The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:
Accreditation
Systems testing of a new information system should be conducted using:
Actual patient data
Which of the following is coded as an adverse effect in ICD-10-CM?
Tinnitus due to allergic reaction after administration of ear drops
When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n) __________ indicating that Medicare might not pay and that the patient might be responsible for the entire charge.
ABN
you need a system that will provide information on your census, update your master patient index, and distribute demographic data. what type of system would you purchase?
ADT
Coding policies should include which of the following elements?
AHIMA Standards of Ethical Coding
The correct acronym for Application service providers is:
ASPs
Which of the following digestive system conditions is NOT classified to Chapter 11 in ICD-10-CM?
Adenomatous polyp of colon
Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?
Administrative safeguards
An applicant with 25 years of job-related experience submitted an application for the job opening advertised within the local newspaper. The supervisor of the vacant position reviewed all of the applications and accesses publicly available social media sites specifically to determine the age of the applicants. The application of the 67-year-old was quickly eliminated from consideration. Which federal regulatory requirement was violated?
Age Discrimination in Employment Act (ADEA)
Category K20 has an instructional note to code which of the following?
Alcohol abuse and dependence
Instructional notes may appear:
All of these.
A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options here, what is the best course of action?
Allow her to review her record after obtaining authorization from her.
St. Joseph's Hospital has a psychiatric service on the six floor of the hospital. A 31-year-old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action?
Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patient.
Federal legislation has a significant impact on the workplace. Which of the following requires employers to make reasonable accommodations for individuals to perform essential job functions?
Americans with Disabilities Act
Which of the following describes the act that requires employers to make reasonable accommodations in the workplace for individuals to perform essential job functions?
Americans with Disabilities Act
The HIM supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has not specific data to support this suspicion. In this case, what should the supervisor do?
As the security officer for audit trail data to confirm or disprove the suspicion.
Which of the following security controls are built into a computer software program?
Application controls
Performs tasks on behalf of the end user.
Application program
Which of the following tasks is not performed in a electronic health record system?
Assembly
Which of the following is a software program that tracks every access to data in the computer system?
Audit trail
Which of the following is an example of data security?
Automatic logoff after inactivity
It would be most profitable for Sea Side Clinic to increase episode of care service with
Be Healthy.
As part of an EHR system selection, due diligence should be done:
Before contracting for an EHR product
As part of an EHR system selection, due diligence should be done?
Before contracting for an EHR product
The RFP generally includes a detailed description of the system's requirements and provides guidelines for vendors to follow in:
Bidding for the contract
Which form of wireless technology uses infrared light waves to beam data between devices in close proximity to one another?
Bluetooth
terminating access.
Bob submitted his resignation from Coastal Hospital. His last day is today. He should no longer have access to the EHR and other information systems as of 5:00 PM today. The removal of his information system privileges is known as
You want to stay within the reimbursement rate allowed by your Component State Association, so it is important to you that you have at least a 95% chance of eating a lunch that costs no more than $10.00. Therefore, when lunchtime comes, you head to
Bon Appetite or Mario's.
Which one of the following would NOT be a strategy when purchasing an electronic health record system?
Broaden the vendor field and select several vendors of choice.
there was unexpected hardware failure for out EHR. It is expected to be up and operational in three hours.Until then which of the following plans would you need to initiate?
Business continuity plan
an uninterruptible power supply (UPS) is MOST important when considering backup systems for which of the following types(s) of workstations
desktop
Historic accomplishments impacting quality in medical care include all EXCEPT
implementation of NDC.
An object equipped with a special card that enables it to broadcast and receive radio or cellular signals that reach a network via access points
Wireless
Which statement is true concerning CDR and EHR?
CDR supports management of data for an EHR.
To run an analysis on a large set of data from many patients, the best tool is a(n):
CDW
Which of the following is a snapshot in time and consolidates data from multiple sources to enhance decision making?
CDW
Electronic prescribing is a special case of:
CPOE
Which of the following is an application that uses standard order sets and other clinical decision support that supports physician order entry into the computer?
CPOE
enhanced legibility is the key benefit associated with
CPOE
To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?
CPT codes
to gather statistics for surgical services provided on an outpatient basis which of the following codes are needed
CPT codes
Case finding methods for patients with diabetes include a review of all but which one of the following?
CPT diagnostic codes
Juan has been asked to investigate e-health companies. Which of the following would NOT be included in his investigation?
Cafe Services: a company that provides cafeteria services to the hospital.
AR days have not decreased as expected. The coding supervisor knows that he must initiate change within the coding process to ensure achievement of the goal. Which of the following actions should the coding supervisor take first?
Call a meeting with the coders to discuss the issue.
Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:
Can deny access to psychotherapy notes
Which employee needs to be counseled concerning her productivity?
Casandra
In your new position as director of Health Information Services, you have noticed that department supervisors arbitrarily allow employees to make up missed time due to absences. You decide that you need a policy to reinforce the attendance policy and cut down on tardiness and absences. Which policy statement would support your overall departmental goals?
Changes in work schedules must be approved in advance and depend on departmental operations.
Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise?
City Hospital should obtain a business associate agreement with Community Hospital.
Sexual harassment in the workplace is prohibited by which law?
Civil Rights Act of 1964
Which of the following is not one of the basic functions of the utilization review process?
Claims management
When some computers are used primarily to enter data and others to process data the architecture is called:
Client/server
Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy, and radiology information systems?
Clinical data repository
Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy,and radiology information system?
Clinical data repository
What committee usually oversees the development and approval of new forms for the health record?
Clinical forms committee
Who are the primary users of the health record for delivery of healthcare services?
Clinical professionals who provide direct patient care
In CPT, Category III codes include:
Codes to describe emerging technologies
The concept of systems integration refers to the healthcare organization's ability to:
Combine information from any system within the organization
This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.
Commission on Accreditation of Rehabilitation Facilities
A cancer program is surveyed for approval by the:
Commission on Cancer of the American College of Surgeons
A cancer program is surveyed for approval by the
Commission on Cancer of the American College of Surgeons.
The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with:
Completeness
According to current theory in the quality management field, should concurrent data collection or retrospective data collection be utilized?
Concurrent and retrospective data collection methods are both necessary in order to effect meaningful interventions and contain costs.
What is the general name for Medicare rules affecting healthcare organizations?
Conditions of Participation
Most healthcare informatics standards have been developed by:
Consensus
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
Controlled vocabulary
The one aspect of managed care that has had the greatest impact on healthcare organizations is:
Cost control
which of the following groups provides managed care organizations with information about physician's qualifications?
Credentials verification organization
A nomenclature of codes and medical terms which provides standard terminology for reporting physicians' services for third party reimbursement is:
Current Procedural Terminology (CPT)
a nomenclature of codes and medical terms which provides standard terminology for reporting physicians service for third party reimbursement is:
Current Procedural Terminology (CPT)
A nomenclature of codes and medical terms that provides standard terminology for reporting physicians' services for third-party reimbursement is
Current Procedural Terminology (CPT).
Which code represents an HCPCS Level II National Code?
D0417
In selecting a messaging standard for use in a picture archival communication system the BEST choice would be
DICOM
In selecting a messaging standard for use in a picture archival communication system, the BEST choice would be
DICOM
The exchange of digitized images such as x-rays, CT scans, and MRIs is supported by:
DICOM
Standards from which organization would be used for enabling exchange of clinical images?
DICOM.
The Medical Record Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rats. The HIM director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude?
Data are insufficient to determine whether the hospital is in compliance.
Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:
Elements of performance
Which quality management theorist focused on the use of the PDCA cycle in continuous clinical quality management improvement efforts?
Deming
In which type of facility does the Privacy Act of 1974 permit patients to request amendments to their medical record?
Department of Defense health care facility
What advice should be given to a physician who has informed you that she recently discovered that a significant portion of a discharge summary she dictated last month was left out?
Dictate the portion omitted with the heading "Discharge Summary—Addendum" and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., "9/1/17-See Addendum to Discharge Summary"—Signature).
The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the _____ approach.
Direct cutover
Which of the following statements is FALSE when addressing characteristics of the legal health record in an electronic document management system?
Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems.
You have been asked how to handle versioning of documents in the EMDS. Which of the following should be your response?
Display the second version but identify that a previous version.
Conflict is inevitable. What is the LEAST effective way to manage conflict?
Do not intervene: creative solutions often come from conflict.
Which quality management theorist believed in the contrasting views of Theory X (presumed that workers disliked work) and Theory Y (assumed that under the right conditions, people would seek responsibility and be creative)?
Douglas McGregor
When a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications, this is commonly referred to as a _____ strategy.
Dual core
Which of the following are used to associate relationships between entities (tables) in a relational database?
Foreign keys
Which one of the following is NOT an advantage of a computerized master patient index?
Duplication of patient registration can never occur.
The local safety council requests statistics on the number of head injuries occurring as a result of bicycle accidents during the last year. To retrieve this data, you will need to have the correct:
E codes and ICD-9-CM codes for this diagnosis
Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations?
Each physician practice should obtain a business associate agreement with the hospital.
A transition technology used by many hospitals to increase access to medical content is:
Electronic document management system
Which of the following is a transition strategy to achieve an EHR?
Electronic document management system
Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
Electronic document management system
Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
Electronic documentation management system
Which system is used primarily to report services and supplies for reimbursement purposes?
HCPCS
What is the biggest threat to the security of healthcare data?
Employees
Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:
Encoders
Why does an ideal EHR system include point-of-care template charting?
Ensures duplicate data entry burden
Why does an ideal EHR system require point-of-care charting?
Ensures that appropriate data are collected
A male worker meets and regularly exceeds the work standards in the coding unit while the female workers in the unit usually, but not always, meet basic work standards. Based upon this information, the supervisor did not recommend a merit increase for the male worker since this increase would result in him receiving a higher wage than the female workers in the same unit. Given the scenario, determine which (if any) federal regulatory requirement has been violated?
Equal Pay provisions of the Fair Labor Standards Act
What is the term for an explicit statement that directs clinical decision making?
Evidence-based practice guideline
the eco needs to make a decision about the future of health care facility. to make this decision, he utilizes an information system that queries a database containing data from a number of different infomartion system. What type of system is being used
Executive information system
Which of the following uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base?
Experts system
Works with raw data
Extensible markup language
A highly productive male coder has been struggling at home. His wife sustained a serious work-related injury at her place of employment. The coder calls a meeting with his supervisor to inform her that he needs to care for his wife and requests 8 weeks of unpaid time off of work. The DNFB (Discharged Not Final Billed) is unacceptable at $20 million due to the recent implementation of an EHR. The financial stability of the hospital is at stake so the supervisor terminates the coder for making such a request. Which federal regulation, if any, has been violated in this scenario?
Family and Medical Leave Act (FMLA)
Corporate compliance programs became common after adoption of which of the following:
Federal Sentencing Guidelines
Which of the following issues compliance program guidance?
HHS Office of Inspector General (OIG)
If an HIM department acts in deliberate ignorance or in disregard of official coding guideline, it may be committing:
Fraud
a project timeline was created using computerized project management software the timeline shows the tasks of database conversion and parallel testing as milestones to be reached before moving onto the next phase on the project the time is a
GANTT chart
Of the following, which digestive system cancer is relatively rare?
Gallbladder
the HIM department director in a large outpatient clinic is implementing a new computerized charting system. what tool can the director use to communicate the activities that need to get done at specific times in order to have the system up and running in six months?
Gantt chart
the director of the health information services department is developing a plan to convert their existing filing system to a terminal digit filing system. the tool that is most useful to the director in displaying the steps and completion schedule for each phase of the conversion is a :
Gantt chart
The bacteria that cause stomach ulcers is:
H. pylori.
Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?
ICD-10-CM
The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve the data, you will need to have the correct
ICD-10-CM codes.
an example of intensity of service criteria would be:
IV or IM medications every 12 hours
A risk analysis is useful to:
Identify security threats
What does the term access control mean?
Identifying which data employees should have a right to use
The key for linking data about an individual who is seen in a variety of care settings is:
Identity matching algorithm
Referring to the case study below, what would you do as director of the quality department?
Immediately dismiss Mary G upon her arrival back in the department.
Administration has asked the clinical provider order-entry task force to select the method of implementation that will reduce risk to the hospital. What method should they choose?
Implement one module in one unit while running the current system in parallel.
Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations?
Implement session terminations.
In which phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users performed?
Implementation
A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:
Implementation plan
In Medicare, the most common forms of fraud and abuse include all of the following except:
Implementing a clinical documentation improvement program
Which classification system is used to classify neoplasms according to site, morphology and behavior?
International Classification of Diseases for Oncology (ICD-0)
Which classification system is used to classify neoplasms according to site, morphology, and behavior?
International Classification of Diseases for Oncology (ICD-O)
which of the following organization was formed as an outgrowth of the American College of Surgeons?
JCAHO
_______ are symptoms and signs that occur as the result of an underlying condition.
Manifestations
Mary processed a request for information and mailed it out last week. Today, the requestor, an attorney, called and said that all of the requested information was not provided. Mary pulls the documentation, including the authorization and what was sent. She believes that she sent everything that was required based on what was requested. She confirms this with her supervisor. The requestor still believes that some extra documentation is required. Given the above information, which of the following statements is true?
Mary is not required to release the extra documentation because the facility has the right to interpret a request and apply the minimum standard rule.
Data definition refers to:
Meaning of data
Which of the following dictates how the medical staff operates?
Medical staff bylaws
Which of the following would be considered discrete data?
Medication dosage
Audit logs and alert pop-ups are examples of:
Metadata
Developing, implementing, and revising the organization's policies is the role of:
Middle managers
An object that can be carried or wheeled from place to place
Mobile
According to the Joint Commission's hospital standards, the review of quality of patient record documentation must be:
Multidisciplinary
Which of the following statements describes a method of following a procedure?
Multiple-page discharge summaries are stapled together in the left-hand corner.
An accreditation agency counterpart to the Joint Commission for managed care organizations is the
NCQA
What feature distinguishes the nominal group technique (NGT) from brainstorming?
NGT determines the importance of responses through a rating system.
The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the:
National Center for Health Statistics
The Unified Medical Language System (UMLS) is a project sponsored by the
National Library of Medicine.
The Institute of Medicine (IOM) published report titled "To Err Is Human: Building a Safer Health System," heightened concern by the U.S. government and accrediting agencies. This led the Joint Commission to place emphasis on improving patient safety and sentinel event occurrences through its safety program, known as
National Patient Safety Goals (NPSG).
Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital?
National Practitioner Data Bank
Which of the following connects computers together in a way that allows for the sharing of information and resources?
Network
Referring to the case study below, are the meeting minutes about the decisions regarding Dr. Z of the Department of Surgery and of the Executive Committee admissible in court?
No, under state laws, records of medical review committees are not subject to introduction into evidence.
You have been given a list of data elements that need to be added to the database that you are creating. You notice, that on of the data elements is the patient's full name. Determine how to modify the data element in order to improve search capabilities.
Normalize the data element
Mountain Hospital has discovered a security breach. Someone hacked into the system and viewed 50 medical records. According to ARRA, what is the responsibility of the covered entity in a reasonable time not to exceed 60 days?
Notify the patient.
In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
Nursing staff
If administrators of a home health agency wanted to measure the outcomes of adult patients receiving their agency's services, which tool would they use?
OASIS
you just used a scheduling system to schedule an appendectomy for DR. Smith they system automatically looked up how long it takes Dr. Smith to perform the surgery. it contacted the patients insurance company to confirm that the procedure is covered by the patients policy and notified materials management of the supplies that would be needed that day. this is an example how ____could work
OLAP
As a health information professional, you've become involved in developing an HIE in your region. The agency that would provide the best resources for HIE development is:
ONC
Justin, an HIM educator, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. Which of the following legal issues will he describe?
OSHA
Jennifer, an HIM educator, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. Which of the following legal issue will she describe?
OSHA Act
As head of the performance improvement department, you are asked to evaluate patient satisfaction and offer recommendations for action. The performance tool shown above is used to graphically display the results. What is the name of this chart?
Pareto chart
The health information reception desk is experiencing a huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next 4 weeks. They want to focus on solving the response-time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal?
Pareto chart
CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10-PCS. The use of these two code sets will be effective on
October 1, 2015
To ensure relevancy, an organization's security policies and procedures be reviewed at least:
Once a year
The correct acronym for Personal digital assistant is:
PDA
Which of the following encourages patients to take an active role in collecting and storing their health information?
PHR
Which of the following is considered a consumer-centric informatics application?
PHR
Which of the following is considered a two-factor authentication system?
Password and swipe card
The legislation that required all federally funded facilities to inform patients of their rights under state law to accept or refuse medical treatment is known as
Patient Self-Determination Act.
Which of the following is the unique identifier in the relational database patient table?
Patient number
In the relational database show here, the patient table and the visit table are related by::::
Patient number:::
The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities?
Payment determinations and audit of cost reports
which of the following groups contract with the Health Care Financing Administration (CMS) to monitor the quality of care provided to Medicare Beneficiaries?
Peer Review Organization
Which of the following is not a type of utilization review?
Peer review
which of the following measures can be used to evaluate the outcome of care for adult patient with asthma?
Percent of patient that can demonstrate how to use an inhaler
A form of computer hardware that is added to a host computer to expand its capabilities
Peripheral
Computer that can be conveniently held in a person's hand.
Personal digital assistant
A culture and sensitivity report was returned to the inpatient unit of Brian Hospital. The sensitivity showed bacterial resistance to the current antibiotic the patient was receiving. The patient continued on the same antibiotic without improvement. A generic quality screen identified this case for review. At a minimum, which committee should review this case?
Pharmacy and Therapeutics Committee
A surgeon left a clamp in a patient, resulting in a return to the operating room. In an integrated organizational quality management model, all of the following entities would receive data about the investigation EXCEPT the
Pharmacy and Therapeutics Committee.
A surgeon left a clamp in a patient, resulting in a return to the operating room. In an integrated organizational quality management model, all of the following entities would receive data about the investigation EXCEPT the:
Pharmacy and Therapeutics Committee.
Which of the following interactions fits the definition of a patient encounter?
Phyllis and Howard
Which of the following are security safeguards that protect equipment, media, and facilities?
Physical access controls
Placing locks on computer room doors is considered what type of security control?
Physical control
The FOCUS PDCA model used in performance improvement is best known for its change strategy technique of
Plan, Do, Study, Act.
the organizing process determines how the work in a particular department will be divided and accomplished. in order to be in the best position to organize the work effectively the manager must first engage in which management function ?
Planning
A statement or guideline that directs decision making or behavior is called a:
Policy
which of the following would most likely be found in an intranet?
Policy and Procedure manual
which of the following would most likely be found in an intranet?
Policy and procedure manual
An organization that reviews the facility's provision of health care services, respond to Medicare beneficiary complaints that have been filed, and take action by implementing quality of care improvements is known as a(n) ______________
Quality Improvement Organization (QIO)
Which of the following technologies would reduce the risk that information is not accessible during a server crash?
Server redundancy
Which of the following best describes the national health information infrastructure proposed by the National Committee on Vital and Health Statistics?
Set of technologies, standards, applications, systems, values and laws
A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed?
Retrospective utilization review
Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except:
Returned overpayments
The director of the Health Information Services Department has asked that the supervisor of coding institute a method to monitor the accuracy of coding. What method would be the most effective approach?
Review a random sample of each employee's work monthly.
A new health information management clerk has been on staff for 2 days. She has thus far analyzed charts incorrectly, sent out confidential information improperly, and used the copy machine inappropriately. Evaluate this situation and determine the best resolution.
Review the job procedure with the clerk and have the analysis supervisor monitor her progress.
which of the following tasks is the most appropriate for the health information service director to delegate to the supervisor of record processing statistics?
Reviewing monthly statistical reports to verify accuracy
An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?
Role-based
Most health care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay.
Severity of illness/intensity of service criteria (SI/IS)
Which of the following classification systems was designed with computer systems in mind and is currently being used for medical research studies, clinical trials, disease surveillance, and consumer health information services?
SNOMED CT
A common language used in data definition, and data manipulation is
SQL
Lewis-Beck Medical Center has been collecting data on patient satisfaction for 6 months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used?
SQL
The HIM director needs to retrieve data from a database. What might she use?
SQL
Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are:
Safe harbors
A Gantt chart is useful in which of the following management activities?
Scheduling
Which of the following is NOT a function of the GI system?
Secrete hormones.
Which of the following is not an automatic control that helps preserve data confidentiality and integrity in an electronic system?
Security awareness program
Which employee has shown the most improvement?
Shirlyn
During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all of the system modules. For example, they have to use one log-on for CPOE and another log-on to view laboratory results. One physician suggests having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide?
Single sign-on is less frustrating for the end user and can provide better security
The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the:
Social security number
Position descriptions, policies and procedures, training checklists, and performance standards are all examples of:
Staffing tools
The acronym SGML stands for:
Standard generalized markup language
XML is based on this separate language
Standard generalized markup language
Which of the following services is most likely to be considered medically necessary?
Standard of care for health condition
Technical specifications or other precise criteria to be used consistently as rules, guidelines, or other definitions of characteristics.
Standards
What is the purpose of computer databases?
Store and retrieve data
Dr. Smith has a practice in Macon, Georgia. He is treating a patient who is physically located in Soperton, Georgia, which is about 70 miles away. What technology is required for Dr. Smith to treat the patient?
Telehealth
This organization has been responsible for accrediting healthcare organizations since the mid 1950s and determines whether the organization is continually monitoring and improving the quality of care they provide.
The Joint Commission
Which of the following is the largest healthcare standards-setting body in the world?
The Joint Commission
Which of the following can be used to discover current hot areas of compliance?
The OIG workplan
A group practice has hired an HIT as its chief compliance officer. The current compliance program includes written standards of conduct and policies and procedures that address specific areas of potential fraud. It also has audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?
The correct answer is: A hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation
Review the above organizational chart and determine which of the following statements is FALSE about the relationships of the employees displayed on the chart:
The director has subordinates.
The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric; field length: 50; required field: yes; default value: input mask: none. Which of the following is true about the definition of this data element?
The field type should be changed to Character.
Identify the situation that violates a patient's privacy.
The hospital provides patient names and addresses to a pharmaceutical company to be used in a mass mailing of free drug samples.
What criterion is critical in selecting performance indicators for a health information management department?
The indicators must include the most important aspects of performance.
Differentiate between the physical and logical data models.
The logical data model shows what the system should do, and the physical data model shows how the logical data model will be created.
One of the coders is out on medical leave unexpectedly. At this facility, electronic workflow is used to distribute work. The supervisor needs the work normally sent to her to be distributed among the other coders. Which of the following statements is true?
The supervisor can change the established criteria.
Which theory suggests that in the right conditions people will seek responsibility and be creative?
Theory Y
The physician office you go to has a data integrity issue. What does this mean?
There has been unauthorized alteration of patient information.
Which of the following statements best describes the scalar or chain of command principle?
There is a clear flow of authority from superior to subordinate throughout the organization.
What is the biggest problem with the pie graph displayed above?
There is more than one variable displayed on the chart.
A transcription supervisor collected the data displayed above. What kind of data display is it? And how many errors are attributed to skipped words?
This is a histogram chart; 12 errors were due to skipped words.
Alisa has trouble remembering her password. She taped the password to the bottom of her keyboard. As the chief privacy officer, your appropriate response is:
This is inappropriate and must be removed.
The EHR utilizes existing source systems to supply data.
This is true because the EHR uses many source systems to populate the data.
According to CPT, in which of the following cases would an established E/M code be used?
Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?
Tracer methodology
HIM professionals have been working with a multidisciplinary committee to identify the best solution that will allow hospital physicians coordinated access to all forms of incoming and outgoing messages including voice, fax, e-mail, and video mail. Currently, physicians have to log in to various systems, using different IDs and passwords to retrieve all their messages, reducing effectiveness and efficiency. Which of the following would provide the best solution to the current problem?
Unified messaging
A key element in effective systems implementation is:
User training
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria is:
Utilization review
Which of the following is a valid ICD-9-CM diagnosis code?
V30.00 Single live born, born in hospital
The correct acronym for Virtual private network is:
VPN
Which of the following is not a true statement about a hybrid health record system?
Version control is easy to implement.
Which of the following is not a true statement about a hybrid health record system?
Version control is unnecessary.
In general, which of the following statements is correct?
When federal and state laws conflict, valid federal laws supersede state laws.
Which quality management theorist believed that merit raises, formal evaluations, and quotas established through benchmarking hinder worker productivity and growth?
W. Edwards Deming
The correct acronym for World Wide Web is:
WWW
The National Labor Relations Act (NLRA), which serves as the foundation for U.S. labor laws and collective bargaining, is also known as the
Wagner Act
All of the following are key criteria for abstracting digestive system conditions EXCEPT:
What is the underlying disease?
Summer is the document imaging manager. She has had a meeting with the scanning clerks. They are complaining that the pay rate for their position is too low in their facility. What would be the best way to deal with this complaint?
Work with HR on a job evaluation and current wage and salary survey.
Your department was unable to provide a patient with a copy of his health record within HIPAA's 30-day limitation. What should you do?
Write the patient and tell him that you will need a 30-day extension.
In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards?
X12N
To effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standard?
X12N
The correct acronym for Extensible markup language is:
XML
The QI plan for your hospital requires each coder maintain a minimum of 94.5% accuracy in coding. You manage the coding department, and the past year's average accuracy rating was 95.3%. The QI plan allows a standard deviation (SD) of ±2 against the minimum of 94.5% accuracy. Did your coding staff's overall average meet within standard deviation range?
Yes, within ±2 above SD
This is not de-identified information, because it is possible to identify the patient.
You have been given some data. The patient's name, address, social security number have all been removed. It does include the patient's account number. Identify the true statement.
Dr. smith needs something small and lightweight to use for dictating reports and entering data on the go. You suggest he use
a PDA
Neddy Garza, supervisor of coding and abstracting would like to determine the coders accuracy. Which type of management tool would provide her with the information she needs?
a coding audit
The supervisor of coding and abstracting would like to determine the coders' accuracy. Which type of management tool would provide her with the information she needs?
a coding audit
What feature is a trademark of an effective PI program?
a continuous cycle of improvement projects over time.
In the ICD-10-CM classification system, severe shock due to third degree burns sustained in an industrial accident would be coded as:
a current injury
What quality improvement (QI) tool uses criteria to weigh different alternatives? This display would assist in viewing all relevant information at the same time.
a decision matrix
There is an opening for a coder in a 150-bed acute care hospital. The position requires someone who can code from a wide variety of medical records using both ICD and CPT. Of the following candidates interviewing for this position, which would be the most appropriae to hire?
a graduate of a 2-year community college HIT program, RHIT eligible, with 1 year of outpatient coding experience
a direction to "code first underlying disease should be considered:
a mandatory insruction
A direction to "Code first underlying disease" should be considered:
a mandatory instruction
the general all three key components (history, physical examination, and the medical decision making) for the E/M codes in CPT should be met or exceeded when:
a new patient is seen in the office
In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when
a new patient is seen in the office.
Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered:
a series of core measures.
The performance tool shown above is used to provide structure by classifying information into smaller groups. What is the name of this chart/diagram?
affinity diagram
A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is:
acute pancreatitis
In order to derive the total inpatient service days for any given day, you would need to
add same-day admits and discharges to the inpatient census.
Harry H. Potts was admitted to your hospital to receive a second round of chemotherapy for an invasive tumor. Four days after admission, Harry complained of a sore throat and developed a fever. Harry's throat culture was positive for strep. His strep throat will be
added to the numerator of the hospital's hospital-acquired infection rate.
Maria has received a request to update a patient's insurance number. She accesses the __________ and updates the system. What system is she using?
admission-discharge-transfer system
Monic has received a request to update a patients insurance number. she accesses the________and updated the system. What system is she using?
admission-discharge-transfer system
tachycardia after taking a correct dosage of prescribed Lortab would be reported as a(n):
adverse reaction to a drug
You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?
abstracting
When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?
access control
the cancer committee at your hospital request a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the:
accession register
in a new system implementation process the patient financial services department has determined that the new system must contain for the last 5 year of patient bad debt accounts. this information is sent electronically from the existing system and loaded in the new system as baseline of information from which to build upon. the process demonstrates which concept?
acquisition
As the new coding manager, you met with the coding staff to encourage feedback on ways to increase coding accuracy to meet established benchmarks. The coders provided feedback through brainstorming that you compiled on flipcharts and organized into categories. This is known as a(n)
affinity diagram...
You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing?
aggregate data
Jessica has noted increased complaints by employees of headaches and fatigue. Which of the following factors should he consider?
air quality
A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n):
alert
Dr Smith is entering a medication order in a CPOE. A window pops up with the following message: Patient is on beta-blocker, which is a contraindication for this medication.Do you want to order this medication? Yes or No. This is an example of a(n)
alert
Dr. Smith is entering a medication order in a CPOE. A window pops up with the following message: Patient is on beta-blocker, which is a contraindication for this medication. Do you want to order this medication? Yes or No.
alert
Major responsibilities of the Risk Manager generally include:
all of the above
a data dictionary
all of the above are correct responses
the anticipated end result of an EHR system would include:
all of the above*
security threats can be:
all of the above.
which of the following may contribute to allowing authorized users to gain access to programs or files they are no authorized to access?
all of the above.
The Blood Usage Review Committee has a quality monitor established to review all blood transfusion reaction cases. The HIM director will be working with the committee to identify and abstract patient outcome information for committee evaluation. What data should be collected?
all relevant data
A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign
an unlisted procedure code located in the eye and ocular adnexa section.
the written plans of QI, RM, and UM in a hospital must be evaluated at least:
annually
which of the following data sources i source is used by a hospital medical staff coordinator to gather information about a physician malpractice claims history ?
application for appointment/reappointment completed by physician
University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs?
application service provider model
the project manager is responsible for all of the following functions EXCEPT:
approval of the budget for the project
The project manager is responsible for all of the following functions EXCEPT
approval of the budget for the project.
The current hospital policy time frame for authenticating verbal orders adheres to the CMS COP that requires the ordering physician, or another health care practitioner responsible for the care of the patient, to write orders according to hospital policy and authenticate
as per governmental and facility policies.
Josh is a new supervisor at a mental health facility. He discovers that Charlotte, one of his employees, has shared her password with a coworker. This action violates policies and procedures and is the first occasion of difficulty with this employee. Disciplinary action should be taken by
asking for guidance from Human Resources and then acting.
Mary is a new supervisor at a mental health facility. She discovers that one of her employees has shared her password with a coworker. This action violates policies and procedures and is the first occasion of difficulty with this employee. Disciplinary action should be taken by
asking for guidance from Human Resources and then acting.
Which of the following tasks is not performed in an electronic health record system?
assembly
Which one of the following is NOT a step in developing a health record retention schedule?
assigning all records the same retention period
Which one of the following is NOT a technical security control employed by electronic health record systems?
audit trails
The nurse needs to look up new physician orders. First, the nurse should confirm that she has access to this information. This process is known as
authentication
Choose the appropriate data field types that is best for the data element "health record number".
auto-numbering
Which one of the following is NOT a technical security control employed by electronic health record systems?
automatic log off
The hospital quality department adopted the Lean Management quality model using JIT, which ensures required process items and resources are
available at the right place and the right time.
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?
department staffing
Recognizing diversity in the workplace
brings awareness to the individual qualities that an employee brings to the organization.
a patient is admitted in alcohol withdrawal suffering from derlirium tremens the patient is chronic alcoholic principle diagnosis?
derlirium tremens
The HIPAA security rule term for instructions on how to comply with security standards is known as
implementation specification.
the origin of clinical pathways is the___industry
business
The primary goal of a hospital-based cancer registry is to
improve patient care.
There was an unexpected hardware failure for our EHR. It is expected to be up and operational in 3 hours. Until then, which of the following plans would you need to initiate?
business continuity plan
QUALITY INDICATOR: Number of insurance claims requiring resubmission due to errors (not related to coding) will not exceed 3%.
business office
The medical staff wants a speech recognition system where the staff dictates and then the editing of the dictation is done by editors. What type of speech recognition is this?
back-end speech recognition
Which of the following technologies works best with automated record-tracking systems to speed the data entry process?
bar codes
DSM-5 is used most frequently in what type of health care setting?
behavioral health centers
DSM-IV-TR is used most frequently in what type of healthcare setting?
behavioral health centers
The comparing of one facility's outcomes to another, similar facility, or to national standards is known as ______________
benchmarking
The improvement process of comparing the collection and coding of POA indicators at your facility with those of comparable other health care facilities is referred to as
benchmarking
THe healthcare facility has decided to purchase all of their information systems from Vendor A so that the information systems will be integrated. This system selection strategy is known as
best of fit
Which of the following would be a foreign key in the patient table?
billing number
The chief security officer has recommended a security measure that utilizes fingerprints or retina scans. He recommended
biometrics
the smallest digit on the computer indicated using the presence or absence of an electrical signal by which each number and character is represented using the binary system is the
bit
Refer to the Summary of Selected Blood Product Review table shown above. Which quality improvement function would prompt the production of the table?
blood usage review
The person or group who is overall responsible and accountable for maintaining the quality and safety of patient care is the
board of directors (BOD) or governing body.
The Joint Commission has a standard stating that a hospital must plan and design information management processes to meet _____________ information needs.
both internal and external
The Joint Commission on-site survey process incorporates tracer methodology, which emphasizes surveyor review by means of
both system tracers and patient tracers.
The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed:
brachytherapy
You sit on the quality improvement team for the nursing department that meets to generate ideas to address verbal order documentation problems about the "Read Back Verbal Order" policy. What QI tool would prove useful in sharing input and various recommendations for solving this problem?
brainstorming
given the following diagnosis, "carcinoma of ancillary lymph nodes and lungs, metastatic from breast what is the primary cancer site?
breast
Jane believes new equipment will make her staff more efficient. The board has asked for an analysis of the cost of the equipment to be compared with the benefit to the facility. This mathematical process is known as a ________
cost-benefit analysis
Select the information system where you would find TNM stage.
cancer registry
The most common type of registry located in hospitals of all sizes and in every region of the country is the:
cancer registry
the most common type of registry located in hospitals of all sizes and in every region of the country is the:
cancer registry
The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of this data is:
cancer registry abstracts
The most common type of registry located in hospitals of all sizes and in every region of the country is the
cancer registry.
When developing the security plan, the plan must address the records subject to the security rule. This would include
cancer registry.
What two types of budgets are often prepared by managers of Health Information Management department?
capital budget and operating budget
Surgical case review includes all the following EXCEPT
cases with elements missing in the preoperative anesthesia consultation.
When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?
certificate of authentication
The combining form for gall or bile is:
chole/o.
Ryan Garnder was seen in the outpatient department with chronic cough and the record states "rule out lunch cancer" what should be coded as the patients diagnosis?
chronic cough
Puget Sound Health System has set hiring goals and taken steps to guarantee equal employment opportunities for members of protected groups (e.g., American Indians, veterans). It is complying with
civil right act
what is the advantage of using claims data as a source of information for evaluating the quality of patient care?
claims data are readily available
A transcriptionist's productivity level, as determined by line count per day, has dropped significantly over the past 2 weeks. As a result, there is a backlog in transcription of history and physical reports and surgical reports. Several doctors and the operating room supervisor have complained. An appropriate initial course of action for the supervisor of transcription is to
counsel the transcriptionist privately and develop an action plan for improved performance.
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT
covered entities provide every patient with its annual business report.
There are times when good staff members can burn out. As a manager, a _________ program can help the organization retain these quality workers while providing the staff member with something new to do.
cross-training
After receiving completed requisitions to fill positions within the HIM Department, Human Resources can be most effective in recruiting qualified applicants with the assistance of a
current job description
After receiving a completed requisition to fill positions within the HIM department, Human Resources can be most effective in recruiting qualified applicants with the assistance of a(n)
current job description.
flow charting of process in order to convert the process from a manual process to an electronic process would occur in which of the following phases of the system development life cycle
design
The physician will be called automatically when a lab result is at the panic level. This is an example of a
data -driven rule
As HIM Department Director, you are on the implementation team for the new MPI. You have been assigned the responsibility of looking at every data element stored in the system and establishing criteria for the use of each. An example of what you are doing is shown below. Name: Last name Description: This field is for the paient's last name Number of characters: 30 Alphanumeric Alpha: Acceptable characters a-z Responsible person:HIM Director Used in reports: Admissions list, discharge list, transfer list, health record number list, UB-92, CMS-1500 You are responsible for the
data dictionary
field formate-30 characters data format- alphanumeric default value- within normal limits Generating system LIS
data dictionary
You are interested in some data analysis on patients with cardiac problems. You have downloaded the data that you need on the cardiology patients from the data warehouse into a smaller database that you can work with. You are using a(n)
data mart
the technique used to identify patterns in data using fuzzy logic or neural networks is called
data mining
There is a problem with the data dictionary. The drop-down fields do not have all of the options that are needed. This is a problem with
data quality
Which of the following can be released without consent or authorization?
de-identified health information
In performing a "what if" query to determine if the facility should expand the emergency department, which of the following systems would be used?
decision support system
A supervisor determined that the rate of absenteeism with three of his employees was 15%. This was unacceptable and he researched two possible solutions to the problem. He evaluated these alternatives and thought the best thing to do was to suspend all three employees for 2 days. Once he implemented this solution, he analyzed the consequences. How would you label this process?
decision-making
Which of the following is NOT a benefit of the electronic document management system in the HIM Department?
decreased use of computer technology
After the researchers see the number of subjects they will have to interview, they reexamine their criteria. The researchers could decrease the number of subjects while having the least impact on the reliability of the study by
decreasing p or increasing B.
The U.S. federal government's CMS substitutes compliance of its Conditions of Participation requirements to hospitals that already have accreditation awarded by various other agencies that include the Joint Commission, CARF, AOA, or AAAHC. This is known as
deemed status
The supervisor of a Health Information Management department has aspirations of becoming the HIM director. She works very long hours so that she can address all department issues herself rather than relying on her staff to assist her. Which type of management skills is she in need of improving in order to attain her goal of department director?
delegating skills
the supervisor of a health information department has aspiration of becoming the HID director. She works very long hours so that she can dress all department issues herself rather than relying on her staff to assist her. with type of management skills is she in need of improving in order to attain her goal of department director
delegating skills
The medical professionals who specialize in the study, diagnosis, and treatment of disorders of the oral cavity are known as:
dentists
Chris and Amy, two coders on your team, have come to you complaining that Jane, the discharge clerk, is deliberately holding back charts, causing a coding backlog. You are not sure Jane is really the cause of this problem because Chris and Amy have a history of blaming others for their work-related delays. To determine if Jane is truly a "problem employee," it would be best to first
determine the source of the conflict.
In ensuring security compliance, the Department of Health and Human Services has a seven-step guide to implementing a security management process. All of the following are steps within this processes EXCEPT
develop a contingency plan.
The director of Health Information Services has asked the supervisor over imaging to determine productivity standards for the imaging clerks. In initiating this process, the supervisor has determined that the best way to institute work standards is to
develop standards based on professional standards and industry benchmarks.
As a chief privacy officer for Premier Medical Center, you are responsible for which of the following?
developing a plan for reporting privacy complaints
All of the following are among the Joint Commission's initial core measure sets for hospitals EXCEPT:
diabetes.
which of the following symbols would you use to depict a decision point on a flow chart
diamond
The method of verifying who a public key belongs to is called a(n)
digital certificate.
The most secure model of signatures used in information systems is
digital signature
In electronic health records, authentication may be achieved by
digital signature.
The patient is diagnosed with congestive heart failure. A drug of choice is
digoxin
What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft?
disaster
You have been assigned the responsibility of reviewing and revising the contingency plan. Identify what needs to be included.
disaster planning
a hospital who has lost is ability to use the EHR because of fire in the data processing center would use what process to restore their processing ability
disaster recovery
minimizing patient readmission by arranging for the proper level of care is a goal of:
discharge planning
A retrospective review as part of quality improvement activities is conducted after the patient has been
discharged
As the director of Health Information Services, you manage the department with the assistance of four supervisors. One day you observe a coder coding charts from the face sheet without reviewing the record for additional documentation. The most appropriate course of action would be to
discuss your concerns with the Supervisor of Coding and direct her to address this issue immediately.
Which of the following actions illustrates the use of employee empowerment by upper management?
discussing suggested approaches of improving productivity and performance with employees
A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2018. Which of the following indices would be the best source in locating the needed records?
disease index
The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?
disease index
A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a(n)
disease registry.
pareto charts:
display categories of data in descending order
You are writing the policy that will be used to determine a valid authorization. You are basing the policy in the HIPAA Privacy Rule. The policy will require the authorizations to have a(n)
expiration date.
Diseases and conditions of the digestive system can be caused by all of the following EXCEPT:
external injuries.
Sally wants to motivate her staff members to earn and submit their required continuing education credits by the deadline, so she is offering a $25 gift card to the first one to complete their requirements. Sally is using _____ motivation techniques.
extrinsic
A type of job evaluation that requires the identification of essential factors or elements common to all jobs and the comparison of jobs on the basis of rating those elements (not the job as a whole) refers to
factor comparison.
The use of metrics to conduct root cause analysis that will facilitate changes throughout the organization can best be presented using a
fishbone diagram.
Two transcriptionists are able to set their own work hours provided the department is covered by one of them during regular office hours. This kind of work arrangement is referred to as
flex time.
Blanca arrives for work Monday through Friday any time between 7:00 and 9:00 AM, is on the job until at least 3:00 PM, and then may leave any time between 3:00 and 6:00 PM. Blanca's schedule is an example of
flextime
Hannah arrives for work Monday through Friday any time between 7:00 AM and 9:00 AM, is on the job until at least 3:00 PM, and then may leave any time between 3:00 PM and 6:00 PM. Hannah's schedule is an example of
flextime
One of the major functions of the cancer registry is to assure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
for the life of the patient
One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
for the life of the patient
As director of the HIM department, it is your responsibility to reduce the turnaround time for your organization's accounts receivable balance. The performance improvement tool shown above was used to add weights in order to prioritize ideas. What is it called?
force field analysis
Which appraisal method places the employees into a set of ordered groups (e.g., top 10%, above average 20%, middle 40%) on the basis of a global measure?
forced ranking
Patients in the pediatrics ward were studied to determine their favorite color. The survey results are listed below. The results of the favorite color study are reported in a
frequency distribution.
You want to construct a data display for a frequency distribution. You will use a:
frequency polygon or histogram.
Refer to the Summary of Selected Blood Product Review table shown above. Based on the results reported in the table, which blood component or derivative should first be the topic of an in-depth study?
fresh frozen plasma
Physicians who specialize in the study, diagnosis, and treatment of digestive system diseases are known as:
gastroenterologists
Which one of the following is necessary during the stategic planning process for the EHR?
gauging the user's readiness for the EHR
The CIO has given you a list of critical success factors developed for the EHR that your facility is developing. Which of the following would you expect to see on this list?
get buy-in from the key players
A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of
glaucoma
A coder notes that patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of
glaucoma
A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of
glaucoma.
according to the standards of the national committee for quality assurance which of the following groups in a managed care organization is responsible for overseeing quality management activities?
governing board
the ultimate responsibility for quality improvement in the hospital rests with the:
governing body
As based in case law decisions and the Joint Commission standards, who is ultimately responsible to ensure quality and appropriateness of patient care in a health care facility?
governing body or board of trustees
What types of software provide a front-end structure/interface that presents information in a familiar format leading to a natural style of interaction through the use of icons and a mouse?
graphical user interface
Dashboards are a method used in health care that
graphically display a performance improvement project conducted.
Twelve new cases of a certain disease occurred during the month of August. If 4,000 persons were at risk during August, then the
incidence was 3 per 1,000 persons.
Report generation has four operations: filtering, sorting, calculations, and
grouping
One of the ways that an EHR is distinguished from a clinical data repository is that the EHR
has clinical decision support capabilities.
The number of DRG validation changes made by the QIO will not exceed 2%.
health information
the number of DRG validation changes made by the QIO will not exceed 2%.
health information departmen
Information found in which of the following would not be considered secondary data?
health record
A 75-year-old female was admitted for repair of a hiatal hernia which was performed on the first day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur which was surgically reduced. Further complications included severe angina for which a cardiac catheterization and PTCA were performed. The principal procedure is:
herniorrhaphy
In quality review activities, departments are directed to focus on clinical processes that are
high risk.
If you want to allow the reader to compare the results of Group A with those of Group B on one graphic display, your best choice would be to construct a
histogram
the landmark opinion delivered in the 1965 court case of darling vs. charleston was the:
hospital was liable for it's actions based on corporate liability
The facility Hospital Information System team has been researching network topologies and has decided on one that combines the attributes of bus, ring, and star topologies. What topology has the team chosen?
hybrid network
A patient is seen in the emergency room of an acute care hospital with tachycardia and hypotension. The patient had received and injection of tetanus toxoid (correct dosage) earlier at his primary care physician's office. Which for the following is appropriate sequencing for this encounter?
hypotension;tachycardia; therapeutic use E code (tetanus toxoid)
An employee in the admission department stole the patient's name, Social Security number, and other information and used it to get a charge card in the patient's name. This is an example of
identity theft.
Part of the employment application process is completing documentation required by the IRC. This compliance requirement is related to
immigration
All children will be entered into which of the following registries at birth and thus will continue to be monitored by the registry in their geographic area?
immunization registry
This registry collects data on recipients of heart valves and pacemakers:
implant registry.
The director of the Health Information Services Department has determined that an in-service for department supervisors on developing productivity standards within their respective areas is needed. As an outcome of this in-service, the director would like the supervisors to understand that when setting productivity levels, a supervisor must
implement productivity standards that align with the mission and goals of the organization.
The ideal consent for medical treatment obtained by the physician is
informed
Which of the following is needed when a physician conducts an invasive procedure?
informed consent
A work environment that is not ergonomically sound could lead to
injuries
All of the following items mean the same thing, EXCEPT
inpatient census
All of the following items mean the same thing, EXCEPT
inpatient census.
Dr. Jeremy is establishing a clinical trial research study for his patients with lung cancer wishing to participate in a chemotherapy clinical trial. As assistant director, you are responsible for clinical abstract of data and advise him to first seek approval of research involving human subjects through the
institutional review board (IRB).
you have just inserted data contained in a spreadsheet into your word process document this is and example of____system
integrated
you have just inserted data contained in a spreadsheet into your word processed document. this is an example of a(n)_____systems
integrated
Which of the following tests determines how well new systems being implemented work with existing systems?
integration test
which of the following test show how well new systems being implemented works with existing system
integration test
the current status of EHR development in the most organization is such that there are multiple "feeder" system that send data from ultimate storage (and future retrieval) to a centralized EHR system. Varying technology is used by system developers and this sometimes creates problems when trying to achieve total system integration. which concept is important to assuring interoperability between system
interface standards
A fetal death occurring during the 21st week of pregnancy, weighing 1,000 g is considered to be a(n)
intermediate fetal death.
The hospital utilizes the best of breed model for its information systems. The hospital is able to exchange data between the information systems from the various vendors seamlessly. This concept is
interoperability
With data exchange standards, the ability to transfer data from one system to another system is called
interoperability
the concept of various system working together to achieve the common goal of a national EHR system is
interoperability
what data exchange standard the ability to transfer data from one system to another system is called
interoperability
What type of testimony is inappropriate for a health information manager serving as custodian of the record when he or she is called to be a witness in court?
interpretation of documentation in the record
QUALITY INDICATOR: Ninety-five percent of physician appointments/reappointments will be completed within 90 days of receipt of all required materials.
medical staff office
During orientation, a new employee receives the employee handbook. All of the following information about the employee handbook is true, EXCEPT that
it provides a contractual obligation to continued employment.
You are excited about the functionality of your firm's new EHR. Which of the following is an example of that functionality?
its electronic communications
Human Resources use a systematic procedure to determine the relative worth of a position to the organization. When this approach is used, compensation for the position is most likely based on
job evaluation
Trevor is a new document scanning technician. To fulfill your responsibility as a supervisor and to help him learn and complete his work correctly, the best training resource to use would be a(n)
job procedure.
An area identified for needed improvement through benchmarking and continuous quality improvement is known as a
key performance indicator.
You have been asked to give an example of a clinical information system. Which one of the following would you cite?
laboratory information system
To enter the results of a CBC into the computer system, you would use a(n)
laboratory system
Blindness due to an allergic reaction to ampicillin administered six years ago would be reported as a(n)
late effect of an adverse reaction
The best form/graph for demonstrating trends over time would be a(n)
line graph
You want to graph the number of patients admitted to three different medical staff services on each day of the last month. Because you have a large number of observations (one for each day of the month) and you want to be able to compare the observations for each of the three services on one data display, your best choice is a
line graph
The clinic has decided to use mobile technology. Identify the best practice for this technology.
logic bomb
An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n)
logic-based encoder.
risk management programs were introduced to reduce:
malpractice suits
a system's ability to assist in estimating the consequences of propose decisions would be a category related to what kind of system
managerial decision support
Which index is used by the HIM Department to link the patient's name and number in relation to access and retention of the patient record?
master patient index
Englewood Health Center collected the following data on patients discharged on January 1, 2017. Which measure of central tendency would be most affected by Mallory's extremely long LOS?
mean
An interning medical student at the Goodwill Community Hospital accessed several patients' files to obtain their names, DOB, and Social Security numbers, which were used to impersonate patients and file claims with multiple insurance companies in hopes of receiving payment to cover the remaining tuition fees for medical school. This act can be best categorized as
medical identity theft.
A system of preferred terminology for naming disease processes is known as a
medical nomenclature.
according to the joint commission standards, which of the following hospital committees would be responsible for overseeing the proecess of monitoring the quality of care provided by physicians that practice in the hospital
medical staff executive committe
Ninety-five percent (95%) of physician appointments/reappointments will be completed within 90 days of receipt of all required materials.
medical staff office
Your facility has implemented the clinical systems needed to support the EHR. The knowledgebased and decision support systems will be installed next. Your team has a firm plan to indicate the direction you should take and the expected timeframe. This called a
migration path
Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n)
minor seeking treatment for breast reduction.
All of the following are examples of intentional torts EXCEPT
misfeasance
Dr. Sam Vineyard improperly performed a knee replacement surgery, which caused the patient to develop an infection that lead to the amputation of the leg and thigh. The best term to describe the action performed is
misfeasance.
The measure of central tendency you are describing is the
mode
the single most frequently occurring in set of observation is
mode
According to CPT, antepartum care includes all of the following except:
monthly visits up to 36 weeks
According to Frederick Herzberg, challenging work, recognition of workers and their accomplishments, and employee self-improvement are examples of
motivators
In statistics, the notation "ΣXY" means
multiplied each pair of the X and Y scores and then summed their values.
I have been asked if I want to be in the directory. The admission clerk explains that if I am in the directory,
my friends and family can find out my room number.
When engaging the services of a paper record storage vendor, all but which one of the following factors should be included in the contract?
name and cell phone number of vendor delivery drivers
the "cooperation party"responsible for maintaining the ICD-10-CM disease classification is the:
national center for health statistics
Which application design is used in a computer-assisted coding (CAC)
natural language processing
you have been hired to work with a computer-assisted coding initiative. the technology that you will be working with is
natural language processing
Intrusion detection systems analyze
network traffic.
the flowchart symbol which denotes starting and stopping is the:
oval
A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?
overwriting the backup tapes
Refer to the Summary of Selected Blood Product Review table shown above. Which blood component or derivative had the most units reviewed?
packed red blood cells
A basic concept of office layout and workflow is that the
paper moves to the employee.
"Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"?
pathology report
in compiling statistics to report the specific cause of death for all open-heart surgery cases the quality coordinator assists in documenting
patient care outcome
The primary advantage of concurrent quality data collection is that:
patient care problems can be remedied immediately.
You have been asked to create a presentation on intentional and unintentional threats. Which of the following should be included in the list of threats you cite?
patient's Social Security number used for credit card applications
The most widely discussed and debated unique patient identifier is the
patient's Social Security number.
Dr. Jones, an OB-GYN physician is reviewing a medical record of Dr. Smith's in the OB committee meeting. Dr smith performed a cesarean section and the indications for doing so are not clearly documented. this chart was selected for a process known as:
peer review
Physicians who are members of the Surgery Committee meet to review surgical cases referred for quality issues and deviations from standard care norms. This type of review in which a physician's record is reviewed by his or her professional colleagues is known as
peer review
What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?
performance improvement
One of your new employees has just completed orientation, receiving basic HIPAA training. You are now providing more specific training related to her job. She asks whether the information she provided during the hiring process, as well as benefits claims, are also protected under HIPAA. Which of the following can you assure her that the Human Resources Department protects?
personal health information
The following "sentinel events" must be available for Joint Commission review EXCEPT
petechiae due to adverse drug reaction.
The following "sentinel events" must be available for Joint Commission review EXCEPT:
petechiae due to adverse drug reaction.
a culture and sensitivity report was returned to the inpatient unit of Brain Hospital. The sensitivity showed bacterial resistance to the current antibiotic the patient was receiving. the patient continued on the same antibiotic without improvement a generic quality screen identified this case for review. at a minimum which committee should review this case
pharmacy and therapeutics committee
a project that has been confirmed and will be carried out in small segments is a:
phased in program
The HIM director received an e-mail from the technology support services department about her e-mail being full and asking for her password. The director contacted tech support, and it was confirmed that their department did not send this e-mail. This is an example of what type of malware?
phishing
Under the Americans with Disabilities Act (ADA), prior to employment, it is illegal to require a
physical exam.
HIPAA Security Component concerned with having a building alarm system installed would be a(n)
physical safeguard
The physician office has set the information systems so that they will log out after 5 minutes of inactivity. This is an example of which of the following?
physical safeguard
The results of a quality improvement study indicated that an informed consent was not obtained for 25% of the surgical procedures performed. The director of the Health Information Department was kept well informed regarding the issue and decided to begin corrective action by providing an in-service. The most important participants who should attend this in-service are
physicians and residents.
In conducting an environmental risk assessment, which of the following would be considered in the assessment?
placement of water pipes in the facility
The HITECH breach notification requirement is significant and different from any other requirements in the past because it
places organizations on the radar of regulatory agencies and in the media spotlight.
Who decides whether all or portions of the medical record will be received in evidence in a court of law?
presiding judge/court
During a risk management strategy session, the HIM director states that policies and procedures must be created to prevent specific opportunities for an adverse outcome, as well as those that will function to diminish any that might not be preventable. This type of strategy is known as a _____________
proactive strategy
You have had a problem with duplicate medical record numbers in your facility's MPI. Now you are joining a health information exchange, so you will need to clean up your database and prevent the duplicates from happening again. If you want to find near matches as well as identical matches in your MPI, you should implement a ___________algorithm.
probabilistic
Which two theories of negligence are used to hold health care facilities accountable for the actions of its employees?
respondent superior and corporate negligence
Joseph Woodley has been on a third-floor nursing unit since October 2016 and was finally discharged to a nursing home in December 2017. When the average length of stay is calculated for the year 2017, this very long length of stay will
result in a special cause variation in the average length of stay.
Rita Mizner, MBA, RHIA, is director of Information Services for Mt. Sinai Medical Center. She is well respected for a management style that empowers her staff. All of the following are characteristics of effective delegation, EXCEPT
retaining authority to make key decisions.
You are helping the nursing department to write indicators to determine appropriate formulas for ratios and to determine data collection time frames. One important aspect of care is the documentation of education of patients. More specifically, the nursing department would like to assess its documentation of education on colostomy care for patients with new colostomies.
retrospective
What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms?
review of systems
Which of the following tasks is the most appropriate for the Health Information Services director to delegate to the supervisor of Record Processing and Statistics?
reviewing monthly statistical reports to verify accuracy
One of your first tasks as the new Manager of Health Information Services is to review the department policy and procedure manual. You have determined that several policy statements are incongruent with appropriate current employee practices. Proper management conventions require:
revising the policy appropriately and documenting the date of the change.
One of your first tasks as the new manager of Health Information Services is to review the department's policy and procedure manual. You have determined that several policy statements do not align with appropriate existing employee practices. Best practice of management processes would require
revising the policy appropriately and documenting the date of the change.
You are reviewing your privacy and security policies, procedures, training program, and so on and comparing them to the HIPAA and ARRA regulations. You are conducting a
risk assessment.
The medical malpractice crisis of the 1970s prompted the development of _____________________ in health care facilities.
risk management
collection an analysis of data about patient incidents that occur in a hospital is a job responsibility of the:
risk manager
The best protection against injuries and ensuing financial liability is:
risk prevention.
During the Utilization Review Committee meeting, a case presented for discussion involved a surgical case resulting in unexpected loss of lower extremity below the knee due to complications requiring extended length of stay. Being a sentinel event, the committee requested that an investigation and reporting was required to identify the cause and prevention of future occurrences. This investigation and required reporting to the Joint Commission is known as a
root cause analysis
During the Utilization Review Committee meeting, a case presented for discussion involved a surgical case resulting in unexpected loss of lower extremity below the knee due to complications requiring extended length of stay. Being a sentinel event, the committee requested that an investigation and reporting was required to identify the cause and prevention of future occurrences. This investigation and required reporting to the Joint Commission is known as:
root cause analysis.
The outpatient coding staff has been working to improve coding accuracy. The standard for the number of cases that must be coded has been raised four times in the past year. The staff said, "The more cases that must be coded, the greater the error rate will be for the corresponding time period." The department keeps statistics on both the numbers of cases coded and the corresponding error rate. What is the best QI tool for testing the coding staff's theory?
scatter diagram
the director of a health information department has asked the department supervisor to review and revise all job descriptions. Missy Harris, the supervisor over coding analysis, has determined that the job description for the senior coders must be revised. Ms. Harris' decision to revise the job description is probably due to change in the:
scope of coding responsibilities
The director of a Health Information Department has asked the department supervisors to review and revise all job descriptions. The supervisor over coding and analysis has determined that the job description for the senior coders must be revised. The decision to revise the job description is probably due to a change in the
scope of coding responsibilities.
if an EHR is used to display radiological images (as in a PACS systems) which of the following data retrieval considerations would be most important in assuring quality of the data display
screen density
An urban university based hospital has found the EHR to be invaluable in the process of teaching interns how to better treat patients. this example demonstrates with type of use of the EHR
secondary use
During the month of May, there were 800 discharge abstracts processed at a cost of $0.90 per abstract for a total of $720.00. In June, 732 discharge abstracts were processed for a total cost of $658.80. This type of cost is known as
semifixed.
Computers that provide shared services to other computers on a network
server
The most profitable insurance company for the units of services Sea Side Clinic performs is
service B with Be Healthy.
wound disruption (after major surgical procedure) requiring Reclosure is an example of:
severity of illness criteria
Most acute care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay.
severity of illness/intensity of service (SI/IS) criteria
To properly implement performance improvement (PI), organizations should ensure that all employees participate in an integrated, continuous PI program. This is known as
shared leadership.
Charles Jones is employed as a regional coding consultant by a corporate hospital chain. In the organization chart, this position would be
shown as a staff position.
According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a
significant procedure.
When coding neoplasms, topography means
site
You are determining the sample size for a quality study. Which of the following factors should you consider first?
size of the target population
You are determining the sample size for a quality study. Which of the following factors should you consider first?
size of the target populations
Great Plains Transcription Services has a job opening for a home-based transcriptionist who can transcribe medical and surgical reports. Which of the following types of tests should be administered?
skill
data variable chosen for inclusion in a data analysis project should:
support the reason for study a specific problem
The quality review process of invasive and noninvasive procedures to ensure performance of appropriate procedure, preparation of patient, monitoring and postoperative care, and education of patient describes
surgical review
CASE tools are used in which step of the system life cycle
system development
a medication is ordered for a patient the system ends a reaction alert back to the system user indicating a potential drug interaction with another medication begin take by the patient. the alert is a form of:
system feedback
A study compared the effects of retesting on the scores of students who failed a writing test. Students who did not pass on their first attempt were allowed to retest. Results showed that students had higher mean scores at retest whether they attended additional training before retesting or not.
t-test
The patient's heart is being monitored while he is at home. This is known as
telaheath
The EHR system implementation team is using simulated patients and simulated patient information to add progress notes, nurses' notes, and so on, to the EHR prior to implementation. Which phase is the team involved in?
testing
The employee selection process increasingly involves a background check. All of the following are true EXCEPT
that the extent depends on the level of the employee's authority.
The director of Health information department has received the quarterly variance budget report the report indicated the "overtime" category is unfavorable. the director is required to justify this overtime expense. which of the following would be considered and acceptable explanation for this expenditure? Overtime is unfavorable this quarter due to:
the annual purging of inactive files
The director of a Health Information Department has received the quarterly variance budget report. The report indicates the "overtime" category is unfavorable. The director is required to justify this overtime expense. Which of the following would be considered an acceptable explanation for this expenditure? Overtime is unfavorable this quarter due to
the annual purging of inactive files.
Mary is designing a computer screen that will be used to collect patient demographic information. What input design should be utilized for the state field?
the drop-down menu
The mechanism that provides a communication and problem-solving tool for employees to express a complaint that management has violated one of its own policies, and caused adverse consequences to the employee, refers to
the grievance process.
Dr. Smith accesses the EHR in his office to see what patients are ready to be seen and what calls he needs to make. This functionality is called
the in-basket function
Elements of a breach notification should include all of the following EXCEPT
the name of the individual within the entity responsible for the breach so that a civil claim can be filed against the individual.
In preparing a capital budget request, the first priority will be to document
the need for the new equipment and the return on investment.
According to the American Reinvestment Recovery Act, all of the following are elements of a compliance report relating to privacy and security of health information with the exception of
the number of audits that are anticipated to be performed.
Research has shown that productivity increases with all of the following actions EXCEPT when
the office environment is reengineered.
A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status?
the patient's employer
As manager of release of information, you supervise an employee who has been a correspondence clerk for many years. Her performance has gradually diminished and has become substandard. What method would most likely prove to be ineffective in assisting this employee in improving her performance?
threatening to fire the employee
a surgeon wants to access PHI from the hospital when his patients arrive in the office for their post surgical visits the hospital has agreed to allow the physician to use a hospital approval PDA for this purpose. this scenario demonstrates the benefits of
wireless communication
utilization review/management (UR/UM) first became mandatory:
with the passage of Medicare legislation
Which physician spent the longest average time with patients on that day?
wolf
The supervisor of retention and retrieval was receiving frequent complaints from the file clerks regarding the discharge clerk's job performance. The file clerks stated that it was becoming difficult to maintain their productivity levels because the discharge clerk was not processing the requisition slips in a timely manner. In order to get a clearer understanding of the situation, the supervisor asked the file clerks and the discharge clerk to complete a task list for a 2-week period. The supervisor is constructing a:
work distribution chart.
The supervisor over imaging has received frequent complaints from the scanning clerks regarding a prepping clerk's job performance. The scanning clerk's productivity levels have been impacted by the prepping clerk's inability to process the discharge charts in a timely manner. In order to get a clearer understanding of the situation, the supervisor asked the scanning clerks and the prepping clerk to complete a task list for a 2-week period. The supervisor is asking her employees to complete a
work distribution chart.
In explaining the benefits of a document management system, you include:
workflow
The most important consideration in planning the office layout for a Health Information Services department is the
workflow
Which of the following HIPAA components would the general New Employee Orientation training most likely cover?
workstation security
