HIT 101 Mid Term
During the discovery phase of a legal proceeding, each party seeks to discover important information about the case through a pretrial investigation. What do you call discovery and production of electronically stored information?
e-discovery
The Secure Socket Layer (SSL) protocol was developed to meet the need to provide ______ for connections to the Internet.
encryption
Why is the master patient index maintained permanently?
It is the key to identifying all patients who have been treated by the facility.
Which of the following is true about Medicare Part A insurance?
It provides hospitalization insurance for those 65 years old or older and for other groups, including people with end stage renal disease and those receiving disability benefits for a minimum of 24 months.
Where would you find the results of blood tests?
Laboratory results
This entity/group collects data about facilities that supply health care and the services rendered in the United States.
National Health Care Survey
Discharge summary documentation must include ________________________.
Significant findings during hospitalization
Quality indicators of health care documentation include
A,B and C
Why would it be important to keep a detailed database of the inventory and configurations of existing hardware in a system?
"A", "B" and "C"
Technologies involved in the capture of medical records include
"A", "B", and "C"
How many primary sections are used in a terminal digit filing system?
100
In acute care, The Joint Commission (TJC) requires a report of a comprehensive H&P be completed and available within _____, or sooner if surgery is to be performed.
24 hours
The postanesthesia note should be completed within ________ after surgery.
24 hours
The NwHIN is the following:
A set of standards, services and policies that enable the secure exchange of health information online
A provisional autopsy diagnosis should be recorded in the patient's record within ______ and signed by the pathologist.
3 days
A review of the hospice care plan is required every ___ days.
30 days
The Joint Commission (TJC) permits an interval history and physical examination when a patient is admitted within _____ for the same condition. In this circumstance, the H&P is updated as necessary.
30 days
The initial assessment must be completed within ___ hours if an individual is admitted to a psychiatric hospital or detoxification facility.
72 hours
The Joint Commission requires specific items be included in a Medical History and Review of Systems when the patient is a child or adolescent. What are these specific items?
A developmental age evaluation and educational needs assessment
Some examples of reports that would be contained in a Business Intelligence System (BIS) are:
A, B, and C
To be Medicare certified, a home health care agency must provide skilled nursing care and at least one of the following therapeutic services:
A, C and D
____________ is the process by which a private nongovernmental organization or agency performs and external review and grants recognition to a a program or institution that meets certain standards.
Accreditation
With regard to hospice patients, physical and psychosocial assessments are required. The physical assessment describes functional capacity, physical symptoms and their management, and _________. The psychosocial assessment of the patient and family includes spiritual needs.
Acute and chronic pain
When faced with standards or regulations which are different, which of the following would determine the healthcare organization's policy?
Adhere to whichever standard or regulation is more stringent
HIM professionals can contribute to improving prevention of injuries by
Advocating for the required use of external use of injury coding in all hospitals and emergency departments.
In the Emergency Department (ED) record, the following data items are required by the CMS Conditions of Participation: Identification, History and Physical, Diagnosis, Treatment, and Disposition. The Joint Commission adds which of the following items:
All of the above
The Joint Commission only accredits acute care hospitals.
false
What legislation amended the Health Information Privacy and Accountability Act of 1996 (HIPAA) and has the key goal of creating a national standard for the configuration and content of health records so that information can be easily shared between providers in different organizations? Prior to this legislation, healthcare organizations could choose from among a few standard formats, therefore standardization was impossible.
American Recovery and Reinvestment Act of 2009 (ARRA)
As part of a quality study, you have been asked to provide information on the menstrual history, number of pregnancies and number of living children on each OB patient from a stack of OB records. The best place in the record to locate this information is ___________.
Antepartum record
Choose the best answer: If a patient is readmitted to the same hospital for treatment of the same condition within 30 days after the previous admission, an interval note can be used in place of a complete history and physical if the interval note also includes:
Any relevant changes in condition and physical findings since the last admission
According to the Abdelhak textbook, which one of the following is not a public health obligation?
Assure everyone has access to Obamacare.
Several benefits of an electronic health record were discussed. Which of the following is not a benefit?
Availability of technology- completely avoids user error when entering data
Which entity or organization details what is required to be in the content of the facility based long-term care medical record?
Both "A" and "B"
Educational programs that offer two year and four year HIT and HIM programs are accredited by _________, an independent accrediting organization that serves the public interest by establishing and enforcing quality accreditation standards for the educational programs.
CAHIM
If an Outpatient Rehabilitation Center (ORC) seeks accreditation, the accreditation is bestowed by _________.
CARF
Public health goals for the year 2020 are expressed in terms of the entire population of the US. The publication, Healthy People 2020, is sponsored by
CDC
AHIMA offers several credentials, not just the RHIT and RHIA credentials. Which credential is offered to individuals who can acquire, manage, analyze, interpret and transform data into quality information?
CHDA (Certified Health Data Analyst)
what government agency within the department of health and human services administers the medicare and medicaid programs
CMS (centers for medicare/medicaid services)
Which program focuses on accelerating the transition of laboratory discoveries into actual patented treatments?
CTSA
The concept of prepaying a fixed amount per person for health care services is known as _______.
Capitation
Which AHIMA credential followed the 1996 HIPAA regulations which asked that Privacy Officers be responsible for the development and implementation of privacy-related policies?
Certified in Healthcare Privacy and Security (CHPS)
Which leadership position within a typical hospital organization is responsible for planning, management, design, integration and implementation of health information systems?
Chief Information Officer
In a medical history, which of the following documents the nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words?
Chief complaint
Which one of the following departments is considered to be an ancillary department in the hospital organization?
Clinical laboratory services
The name of the accreditation entity for rehabilitation facilities is ______________.
Commission on Accreditation of Rehabilitation Facilities (CARF)
Which accrediting body has developed standards requiring that a single record be maintained for any patient in a rehabilitation facility and have also dictated what that medical record should contain?
Commission on Accreditation of Rehabilitation Facilities (CARF)
Research has shown that HIT applications help improve care and lower overall costs. CPOE has been singled out as being extremely beneficial but what is it?
Computerized Physician Order Entry
The application which is designed for providers to enter orders online with capability to link to advice that can be used in the care process is the _________.
Computerized physician order entry (CPOE)
Complete the following sentence: Medicare Part B __________.
Is referred to as Medicare medical insurance and helps pay for physician fees for services and other outpatient services
Which term refers to a health care organization's ability to provide a full range of health care services from the least acute to the most acute?
Continuum of care
Health records created and maintained by hospitals contain clinical documentation stored as data and information. What is the difference?
Data are collected in the form of dates, numbers, symbols, images, illustrations, texts, lists, charts and equations. Information represents the analysis of data for a specific purpose.
Which government agencies first announced uniform standards for the exchange of electronic clinical health information?
DHHS & Dept. Veterans Affairs
The Master Patient Index (MPI) should contain enough demographic data to readily identify the patient and his or her record. There are usually two levels to the MPI, the ______ level that contains information about the patient that usually remains consistent from visit to visit and does not contain episode specific data, and the _____ level that has account information that varies by the date of service.
Demographic, Visit (Episode of Care)
A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken?
Destroy records that have been inactive for a period exceeding the statute of limitations.
Health Level 7 (HL7):
Develops message standards for health care
Which one of the following is not a core public health function?
EHR development
SNOMED-CT; LOINC; HL7 are all:
Electronic Record standards adopted by the DHHS OD and Dept of Veterans Affairs
In accordance with the ____________, emergency departments must complete a medical screening examination prior to collecting any information regarding a patient's ability to pay for the services.
Emergency Medical Treatment and Active Labor Act (EMTALA)
The Consolidated Omnibus Budget Reconciliation Act (COBRA) was written out of concern for the management of indigent patients. What law was established by COBRA and is also known as the "Patient Antidumping Law"?
Emergency Medical Treatment and Labor Act (EMTALA)
Which of the following statements is NOT true with regard to clinical applications?
Examples of Clinical Applications include Payor codes used for Reimbursement.
What does it mean for a facility to have deemed status under the Medicare Conditions of Participation
Facility is already accredited under the Joint Commission or the Agency on Aging
The Personal Health Record (PHR) can replace the legal health record.
False
In the context of sharing of information among health care providers, HIE stands for
Health Information Exchange
Laws that give patients the right to access their own health information include all except
Freedom of Information Act.
Which of the following is a prepaid health plan (capitation) that provides healthcare services in return for the payment of a monthly membership premium?
Health Maintenance Organization
The top leading current cause of death in the United States as of 2010 is
Heart Disease
In behavioral health, an interdisciplinary care plan is a core expectation. The plan may be _________ or _______ oriented.
Goal or Recovery
Who has the ultimate authority and responsibility for the hospital's operation and is responsible for the quality of care administered to the patients?
Governing Board
As part of the ____________, covered entities are required to provide patients with a Notice of Privacy Practices and update this notice as needed.
HIPPA privacy rule
The Office of the National Coordinator for Health IT (ONCHIT) was created as part of the HITECH Act of 2009. Which committee makes recommendations to the Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange of health information?
HIT Standards Committee
In an all-electronic health record environment, which one of the following would not be used as a method of information entry?
Handwritten entries on paper forms; forms placed in paper charts
The American Society of Testing and Materials (ASTM), National Library of Medicine (NLM), and Health Level 7 (HL7) are examples of
Health Care Standards Organizations (SDO)
In Pharmaceutical services, the ________ contains information on drugs including, but not limited to, names, dosages and strengths, packaging, characteristics, and clinical usage.
Hospital formulary
Wit regard to the Uniform Hospital Discharge Data Set, the UPIN is used for
Identification
Which of the following statements is not true with regard to Behavioral Health?
If an order is written for restraint or seclusion as a treatment procedure, the order can last no longer than 48 hours
What should be included in the significance section of a research proposal?
Importance of the research project
AHRQ identifed five goals for the adoption of HIT which one is NOT one of the goals?
Improve medication safety by rewriting the names and spelling of drugs
Which of the following is NOT a potential challenge organizations face while implementing electronic health record systems?
Increase communication between providers
Data that have been processed into a meaningful form, either manually or by computer, to make them valuable to the user, are collectively referred to as ___________ .
Information
Primary Care services include all but which of the following?
Inpatient care for burn patients
IHTSDO stands for____ and is responsible for _____.
International Health Terminology Standards Development Organization; Own, maintain, and distribute SNOMED-CT
What is defined as "core data elements... (that) promote comparability and compatibility of data by using standard data items with uniform definitions"? These apply to all residents of nursing homes certified to participate in Medicare and Medicaid?"
MDS (Minimum Data Set)
In the context of data management, the principle of capture once and use many applies to
Mapping how individual data is collected for multiple purposes across the business enterprise.
Software that appears to be a part of the existing software but produces unwanted behavior is known as ____________. Examples would be Trojan horses.
Masqueraders
The ______ is the key to locating the patient record in any filing system. It identifies all patients who have been treated by the facility and lists the (record) number associated with the name.
Master Patient Index (MPI)
The American Recovery and Reinvestment Act of 2009 (ARRA) established financial incentives for healthcare providers to adopt electronic health records (EHR) systems and required that providers select certified products and that ________________ be made of them.
Meaningful Use
In 1965, the Social Security Act of 1935 was amended, establishing Title XVIII Health Insurance for the Aged. At this time, with the creation of _______ and _______ , the federal government became a significant player in the health care delivery system in the US.
Medicare/Medicaid
What CDC publication can you access to find out public health information from individual states?
Morbidity and Mortality Weekly Report
The postpartum record includes information about the:
Mother after delivery
The MDS, the data set used in facility based long term care, is under the direction of the ________ and shares the purpose of increasing uniformity and comparability of data.
National Committee on Vital and Health Statistics (NCVHS)
The regulatory data set for home health care reporting is _______.
OASIS
Which of the following organizations is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced HIT and the electronic exchange of health information?
ONCHIT
What is the name of The Joint Commission's performance measurement and improvement initiative called? This initiative moved the accreditation process from a "once every 3 year" process to a "continuous quality improvement" process.
ORYX
Which federal regulation mandated that employers provide a safe and healthy work environment?
Occupational Safety and Health Administration Act (OSHA)
The responsibility of conducting and monitoring audits, inspections, and investigations regarding programs or projects sponsored by the DHHS is delegated to the ___________.
Office of Inspector General (OIG)
In addition to HIPAA Privacy regulations, healthcare providers who treat Medicaid or Medicare patients must adhere to OIG compliance regulations. OIG stands for ____________.
Office of the Inspector General
Complete the following sentence: ________ consists of health care services that relieve or alleviate patient symptoms such as pain and nausea; it is not curative.
Palliative care
Which of the following statements about paper-based records is NOT true?
Paper-based records can be viewed by numerous users at once.
When patients see multiple healthcare providers in different settings, none of whom have access to the patient's complete information, such information can be provided (by the patient) by means of a(n)
Personal Health Record (PHR)
In moving toward an information system solution, which one of the following considerations is of LEAST value in considering alternative electronic health record (EHR) systems?
Personal development of clinical staff
Because most elderly people take multiple medications, a __________ is required in facility-based long term care to review for potential drug interactions, discrepancies in medications ordered versus those given, and recommended changes.
Pharmacy consultation
In describing the progress of a disease in a given population, which study concurrently describes characteristics and health outcomes at one specific point or period in time?
Prevalence or cross-sectional study
Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay?
Progress notes
The technology which enables a health system, for example, to have a feed to the Center for Disease Control (CDC) Web site so that any updates to clinical outbreaks will automatically appear on a physician portal without having to check the CDC Web page manually is called ___________.
Really Simple Syndication (RSS)
Complete the following sentence: _________ is a type of short term care in which the focus of care is on giving caregivers time off and yet continue the care of the patient.
Respite Care
POSITIONCreateModifyViewAuthorizePharmacistYYYNNurseNNYNAttending MDNNYY The table above offers examples of __________.
Role-Based Access Controls
HIPAA requires that all Internet submissions containing patient data to be sent using, at a minimum, _____ to protect confidentiality. This works by using a private key to encrypt data that are being transferred.
SSL
In behavioral healthcare, in most states only licensed physicians are allowed to issue orders for ______ and _____ for patients requiring this intervention.
Seclusion and Restraint
In a case-control study, why are the cases and controls often matched on variables such as age and sex?
So that cases and controls are similar except for the disease under study only
Duplicate patient numbers management uses a deterministic method when it includes
Specified data elements that are either an exact match or a partial match.
The legal document which directs a hospital's representative to submit a specific health record or other business record to the court that holds jurisdiction over the pending proceedings is called a ____________.
Subpoena duces tecum
One component of a comprehensive Health Information System (HIS) involves surveillance and the related population health system to detect and monitor disease at an early stage for public health surveillance. This type of system is generally referred to as a
Syndromic Surveillance System
Access control, Audit controls, Integrity, Person authentication and Transmission security all fall under ________ safeguards in the HIPAA Security Rule.
Technical
A ______ is a set of terms representing the system of concepts of a particular subject or field. Examples are the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) and the International Classification of Diseases, Tenth Edition (ICD-10-CM).
Terminology
Who owns the medical record? Choose the answer that is the most accurate.
The medical record is the property of the healthcare organization who created the documentation; however the information in the medical record belongs to the individual patient. In general, patients have a right to review and obtain copies of their health information.
Which of the following statements about a CPOE system is true?
There is no paper generated during the CPOE process.
What is the function of a consultation report?
To document opinions about the patient's condition from a provider other than the attending physician
What is the intention of managed care?
To minimize use of services and contain costs while ensuring the quality of care
Which of the following statements is not true with regard to the Legal Health Record (LHR)?
To retain its legal status, the LHR must be contained on electronic media.
Public health officials need excellent health information systems to be able to
Track policy outcome measures.
CMS (Centers for Medicare/Medicaid Services) is under the Department of DHHS, Department of Health & Human Services.
True
Data from the patient record that are stored in government and private databases are often termed secondary patient data and are used in the aggregate for these purposes.
True
Which data set was developed for capturing primary data on outpatients and clinic patients?
Uniform Ambulatory Care Data Set
What is the name of the data set instituted in 1974 by the Department of Health, Education, and Welfare that defines a common core of data on individual hospital discharges in the Medicare and Medicaid programs?
Uniform Hospital Discharge Data Set (UHDDS)
Password security is a big part of computer system security. The textbook mentioned several steps that could be taken by an organization to decrease sharing of passwords between individuals. Which of the following would not decrease sharing?
Users can be sent a password through electronic mail or postal service.
Qualitative analysis is quite different from quantitative analysis. Which of the following statements does not belong in a description of what a qualitative analysis might check?
Verify that preoperative, operative, and postoperative anesthesia reports are present and authenticated.
Select the best example of the electronic health record (EHR) documentation principle of integrity in action.
When a transcribed report moves from the vendor's dictation/transcription system to the facility's EHR system, the document's content remains the same as when it was transcribed.
Which of the following insurances specifically addresses coverage of the healthcare costs and lost income associated with work-related injuries and illnesses?
Worker's Compensation
Which of the following scenarios are appropriate uses of bar code technology? Choose the best answer.
a, b, and c
When specific data items are selected from medical records for clinical and administrative decision making, this is known as statistical analysis or ________.
abstracting
which of the following services are not covered by medicare part B insurance
admissions to acute care hospital
The Agency for Healthcare Quality and Research (AHRQ) Research Portfolio does the following:
all above the above
A HIM professional in a hospital would be supporting implementation of a syndromic surveillance system when he/she
all of the above
Agencies fo the Department of Health and Human Services (DHHS) award contracts and grants to conduct research to meet which of the following goals?
all of the above
In a paper and hybrid health record environment, preparation for disaster recovery includes
all of the above
Tertiary Care is a term used for the care provided at facilities with advanced technologies and specialized care units. Which of the following provide tertiary care?
all of the above
Which benefit(s) can be realized from computerized health information systems?
all of the above
Choose the best answer which describes the purpose of medical record documentation.
all of the above are legitimate purposes for medical record documentation
What is another term for outpatient care?
ambulatory care
JAVA allows programs, called _______, to live on top of HTML pages and runs on the client side.
applets
Complete the following sentence: The Privacy Rule
applies to protected health information in any format created or used by health care providers, plans and clearinghouses.
Most laboratory tests are stored with a(n) _____ _______ which is a unique identifier that identifies the specimen
ascension number
The process of identifying the author of a particular record or computer entry into a health information system is called
authentication
The process of verifying or confirming the identity of a user that is requesting access to information is known as __________.
authentication
The measure of how much information can be transmitted simultaneously through a communication channel is known as _______.
bandwidth
A healthcare department seeks a software application solution. They select a software package that offers the most benefits in their area and that relies on interface engines to make captured data compatible with that of the rest of the organization. The department has adopted the _________ approach to their selection process.
best of breed
Which is a primary function of American Health Information Management Association?
both a and c
Medical record data contained on electronic media should be destroyed by any of the following methods except ...
burning
Because the health record is considered a ______ _______, its contents are admissible as evidence in legal proceedings. The HIM professional must testify that the records were maintained in the normal course of business.
business record
An HIM professional identifies cases of those patients who have contracted the disease under study and compares them to similar cases who do not have the disease.. The odds ratio is an estimate of the relative risk an individual has if he or she is exposed to a certain characteristic/risk factor. It is determined as part of which study design?
case-control study
Community Health Centers were designed to provide comprehensive care in an area that has limited or nonexistent health care services for a certain population or special health needs. What is the term used to describe a defined geographical area serving a Community Health Center?
catchment area
Each multimedia file transmitted in a telecommunication application requires a utility that both compresses and decompresses the file. This is accomplished by using a mutually agreed upon __________.
coder/decoder (CODEC)
The American National Standards Institute (ANSI):
coordinates the development of voluntary consensus standards in the United States
Uninterpreted raw facts, values or symbols are generated by patients or biologic processes. These may include age, pulse rate, test results, diagnostic code, height, and weight. Collectively, these values are known as _____.
data
___________ ____________ is a mathematical technique that applies formulas to a file to produce a smaller file.
data compression
An integrated primary patient record is organized by
date
The term Clinical Data Repository is not synonymous with Data Warehouse. The former serves the needs of day-to-day operations, whereas a data warehouse, usually designed for read-only access, serves longer-term business and clinical needs of the organization. Data warehouses provide functionality for ___________, whereby management personnel query the system for information on which to assess alternative courses of action.
decision support
What type of EHR application or function would help clinicians manage care through evidence-based guidelines?
decision-support
When an incomplete record has not been finished within the time specified, it is termed a __________ record. Most hospitals have some type of physician sanction when these records exist.
delinquent
the principal agency ofbthebfederal government that is primarily responsible for the numerous regulatory programs that affect the health industry is the
department of health and human services
EHR systems are a series of linked applications or functions. The "Results management" application is data taken from ____________.
diagnostic tests
If several diagnoses potentially fit the patient's clinical presentation, the list of alternatives is called a(n) ____________.
differential diagnosis
In general terms, _______ is the formal pretrial legal process the parties in a lawsuit use to obtain information, often as testimony from involved individuals.
discovery
A hypothesis or research question identifies the goal of a research study. The concepts in the hypothesis are the variables. The independent variable is the disease under study, and the dependent variable is the risk factor or characteristic under study. True or False.
false
Acute care facilities serve clients with chronic diseases or clients who have disabilities and need care for 30 or more days
false
Epidemiology is the study of disease and the determinants of disease in individual cases.
false
For records previously involved in an investigation or in litigation, once the statute of limitations has expired on an episode of care, the documentation can be destroyed (assuming the records are due for destruction per the retention schedule).
false
In the field of epidemiology, outcomes research focuses solely on measures of mortality.
false
Joint Commission accreditation preempts the need for state licensing of a health care organization in all 50 states.
false
Regarding the quality of data collected by a HIM professional in studying a specific disease, validity and reliability are really measuring the same thing.
false
Stage One of Meaningful Use for Public Health requires that an eligible professional successfully submit one test submission for each of these three types of data: lab data, syndromic surveillance data, and immunization data.
false
Stage Two of Meaningful Use for Public Health requires public health agencies to be able to receive patient-identified data based on syndromic surveillance rules and send alerts to health care providers about public health events.
false
State and federal record retention requirements no longer apply to health records maintained by facilities that have been sold or closed permanently.
false
The Joint Commission only accredits acute care facilities.
false
The designated record set is the business record generated at or for a health care organization. It is the record that would be released upon receipt of a (authorized) request.
false
With all of the advances in medicine, the primary data source used to justify each claim submitted for payment is now the physician's testimony in court.
false
Most of the technology used to control access to the Health Information System (HIS) is controlled via a ___________ which is a system to prevent access to a private network from the outside or limit access to the outside from within the network.
firewall
Complete the following sentence: Third party payers require progress notes for home health care visits _________.
for each visit billed
Another name for the primary care physician who participates in a comprehensive managed care plan and who is responsible for coordinating all care provided to the managed care enrollee (patient) is a __________.
gatekeeper
________ is a data processing term referring to the level of detail contained in a given data set.
granularity
Results reporting usually includes a(n) ____________ so the user can view displays of results, such as flow sheets.
graphical user interface (GUI)
A health care organization is processing large amounts of data, requiring a large amount of computing power. To accomplish this, the organization uses a combination of computer resources from multiple administrative sites. This scenario illustrates the use of
grid computing
This type of care provides a multidiscipinary health care program that is responsible for the palliative and supportive care of terminally ill patients and their families, with consideration for the physical, spiritual, social, and economic needs.
hospice
The following scenario is an example of a ____ record: Dictation, lab, and X-ray results are available electronically, whereas progress notes, provider information, graphs and doctor orders are on (scanned) paper
hybrid
What is a tentative assertion called that is assumed by the researcher but not positively known until it is tested?
hypothesis
Implied consent is assumed when a patient voluntarily submits to medical treatment. Expressed consent is permission that is either spoken or written. In the healthcare setting, most expressed consent is given in the form of _______ to treatment.
informed consent
Data that have been processed into a meaningful form, either manually or by computer, to make them valuable to the user, are collectively referred to as ___________ .
infromation
The characteristic of data quality where the data are "true to the source and have not been altered or destroyed" is known as data _________.
integrity
What is the primary advantage of using biometric devices for granting access to a computer system?
it is not possible to forge identity
Which one of the following organizations is currently responsible for the accreditation of health care organizations?
joint commission
_________ is (are) derived from information once information is organized, analyzed, and synthesized by the user. New data or information can be derived from the data and information already present.
knowledge
If data compression is able to reproduce the original file exactly, the compression ratio is said to be ________.
lossless
Conditions of Participation specify for healthcare providers the regulations that they must follow to be reimbursed for the health care given to patients who use ____________ as their payment source.
medicare and medicaid
In facility-based long term care, a pharmacy consultation should be documented __________.
monthly
How many organizations does Centers for Medicaid and Medicare (CMS) contract with in each state to serve as that state's quality improvement organization (QIO)?
one
What is the term given to the process through which users must change their password at a specific frequency (e.g. 30 days, 90 days)?
password aging
A health record abstractor who needed to locate the microscopic description of tissue excised during surgery would most likely find this information within the _______.
pathology report
Where images are digitized, they are typically stored in a specialized computerized system called a __________________.
picture archiving and communication system (PACS)
in the continuum of healthcare services,______, is directed at preventing injury or a condition usually provided in ap haycians office or public helsth department or clinic. examples include immunizations or genetic testing.
preventative care
A ____ captures relevant past and current (social, financial, demographic, and medical) problems of each patient.
problems list
Choosing the correct ICD code is most directly tied to ___________.
proper reimbursement
When the amount of payment is determined before the service is delivered, what type of payment system is in place?
prospective
A _____ key is a key that the user gives to anyone he or she wants to receive the encrypted message.
public
Analysis of a record for the presence of required reports and authentications is known as _________.
quantitative analysis
The type of data included in health information which refers to literature, research outcomes, formulary, clinical alerts, etc. which enhance clinical knowledge or operational decision making is called ___________.
reference data
What does the HIMSR textbook state as the primary reason that shorter lengths of stay in acute care facilities has resulted in discharge of patients with more complex problems to long term care facilities?
reimbursement incentives that reward hospitals for shorter lengths of stay
In determining which population has the greatest likelihood of developing the disease under study, the incidence rate of the exposed group divided by the incidence rate of the unexposed group is the formula to determine the
relative risk
Patients admitted to Long Term Care facilities are usually called __________ because the patient resides in the facility.
residents
In terminology common to Health Insurance policies, a ________ is a policy amendment that may increase or decrease benefits.
rider
Data from the medical record that are stored in government and private databases are often termed ____________.
secondary patient data
HIPAA regulations address protection from malicious software (or malware) as one of the components of the __________ Rule.
security
It is helpful for the information system to generate reports of user activity and role-based access lists for the various applications on a periodic basis. The textbook listed several examples of security reports. Which of the following would not be considered a security report?
show all users who report to the CFO
In the field of epidemiology, prospective studies are most useful for investigating diseases of high incidence.
true
An enterprise EHR system may comprise cohesive linked applications that include such things as medicine dispensing devices, robotics and monitoring equipment, which are also known as ______________.
smart peripherals
Software that is installed on the user's computer without his or her knowledge, which is used to collect personal information from the computer, then sends it to an unauthorized database is known as _________.
spyware
Institute of Electrical and Electronics Engineers (IEEE) 1073:
standard for transmission of data from medical devices
The process of authentication for access to information is usually based upon various criteria. Which of the following would not be considered an authentication tool?
state licensure
What is the law called that dictates the maximum period of time that may elapse between a compensable event and a subsequent legal action?
statute of limitations
For hospital settings, the American Hospital Association recommends retaining health records for a minimum of _______.
ten years
A ______ is a set of terms representing the system of concepts of a particular subject or field. Examples are the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) and the International Classification of Diseases, Tenth Edition (ICD-10-CM).
terminology
The goal of computer security is to guard against inappropriate use of health information without compromising the caregiver's "need to know." A process which allows a user who is not typically authorized to access a certain individual record is known as _________________.
the "break-glass" option
Which of the following phrases does NOT describe a critical access hospital (CAH)?
the CAH does not need to be certified by the state as being necessary to the residents in the community
Beginnning in the 1980s, hospitals were required to start using a prospective payment system, A reimbursement method in which the amount is determined in advance of services rendered. Reimbursement for hospital inpatient care is determined by a classification scheme called ________. This payment system allowed Medicare to group patients based on their diagnoses.
the DRG (Diagnosis-related groups) prospective payment system
The term quality has several meanings according to the dictionary. According to the HIMSR textbook, the expression data quality suggests ___________.
the correctness of data
Data elements required by the Joint Commission Record of Care (RC) hospice standards include the following EXCEPT ________________:
the patient's medication list
Home health care describes services provided to the patient in _________.
the patient's place of residence
One of the problems discussed in the textbook for the implementation of telehealth and specifically, teleradiology is _____________.
the size of the image files that need to be transmitted
Psychologists, therapists, and mental health counselors are licensed by __________.
the state in which they practice
In a cohort study, two groups free of disease are followed forward in time to determine whether the disease develops.
true
As the HIMSR text explains, during their lifetime, a patient's health records are created and maintained in many different settings, by multiple providers, at various points of time. The purpose of the Health Information Exchange (HIE) is to provide the means for the care provider to access and share patient information from any point of care. _____ is the term used to describe a service location that "follows" the patient through the healthcare continuum.
the virtual department
ambulatory surgery patients undergo certain procedures that can be performed on an outpatient basis, which means the patient
travels to and from the treatment facility on the same day and is not hospitalized, institutionalized, or is admitted as an inpatient
A Prospective Study determines whether a characteristic or suspected risk factor truly preceded the disease or health condition under study. For this reason, prospective studies are most useful for investigating diseases of high incidence. True or False.
true
A hybrid record contains documentation of both manual and electronic processes.
true
A private key is one that the user maintains and never gives out.
true
According to the textbook, the American Indians have their own government-funded and operated health care facilities.
true
Accreditation is a systematic quality review process that evaluates the healthcare facility's performance against preestablished standards.
true
All hospitals, nursing homes and pharmacies must be licensed by the state Department of Health, but regulations may differ from state to state.
true
As eligible health professionals and hospitals adopt, implement, and upgrade their EHR systems through the CMS EHR Incentive programs (Meaningful Use programs), there is an opportunity for public health agencies (PHAs) to receive health data routinely from settings other than emergency departments and urgent care centers.
true
Assuring and supporting healthy pregnancies is considered a core public health activity.
true
By definition, a legal health record (LHR) is the record that would be released upon request with an appropriate authorization.
true
Care at Community Health Centers may be provided at no charge or the cost may be based on the patient's ability to pay, which is referred to as a sliding scale fee.
true
Critical Access Hospitals (CAH) arose to meet the needs of populations that do not have adequate acute care facilities. A hospital classified as a CAH receives reimbursement enhancements for meeting the needs of an underserved area.
true
Each state sets its own terms for Medicaid reimbursement to hospitals and health care providers.
true
Electronic fetal heart rate monitoring records are considered to be part of the mother's record but may be filed elsewhere.
true
Federal facilities, such the Department of Veterans Affairs (VA) do not require state licensure.
true
Fifty component state associations plus associations in the District of Columbia and Puerto Rico comprise the organizational structure of American Health Information Management Association.
true
For observation patients (Medicare), CMS suggests that physicians use 24 hours as a benchmark. If a patient is expected to require hospital care for 24 or more hours and meets the inpatient criteria for admission, the physician should admit the patient.
true
If HIM professionals understood more about the causes of injuries, more could be done to prevent them.
true
Issued by CMS, Meaningful Use (MU) rules define the minimum requirements that healthcare providers must meet through their use of certified electronic health record technology (CEHRT) to qualify for the payments of various (incremental) stages of MU.
true
Nuclear medicine is distinguished from Radiology because the procedures involve the use of radioisotopes (radionuclides) for diagnosing and treating the patient.
true
Public health provides both direct clinical services and community services.
true
Respite care is short term care in which care is provided to a patient for the purpose of giving the caregiver time off from the daily burden of providing care to the ill patient.
true
Secondary care is a term implying care by a specialist, usually through referral from the primary care physician.
true
Telemedicine involves the delivery of medical care from one site to another via electronic communications. Even though there is no physical contact between patient and provider, reimbursement and regulatory requirements still apply and issues of physician licensure and medical liability must be considered.
true
The Designated Record Set is defined as a group of records maintained by or for acovered entity that is the medical and billing record about individuals; enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; information used in whole or in part by or for the HIPAA-covered entity to make decisions about individuals.
true
The designated record set is generally broader than the legal health record because it addresses all protected health information.
true
The three major types of epidemiologic research study designs are (1) descriptive studies, (2) analytical studies, and (3) experimental studies.
true
The use of contract services, also called outsourcing, by Health Care Organizations is increasing. The HIM Department may use contract services for Transcription or Coding.
true
To treat diseases, healthcare providers must identify factors by which patients become infected. In a causal relationship such as this, the cause is the independent variable, and the effect is the dependent variable.
true
Unless required by (state) laws and regulations, under the Health Insurance Portability and Accountability Act (HIPAA) Privacy standard, the patient's formal consent is not required to use health information for treatment, reimbursement, operational, and reporting purposes.
true
When a public health issue makes the news, such as an E.coli outbreak from contaminated food, the Centers for Disease Control and Prevention is responsible for investigating and minimizing threats to society.
true
When conducting a case-control or retrospective study, a researcher should match cases on variables known to be associated with the disease or the exposure under study. True or False.
true
Without appropriate documentation to support the care given, the health care setting or the provider will not be reimbursed for services rendered. In other words, "if it isn't documented, it wasn't done," is a phrase commonly heard in health care.
true
the Centers for Medicare and Medicaid Services (CMS) contracts with quality improvement organizations (QOI) to ensure that patients get the right care at the right time.
true
To maintain certification, a prescribed number of CEUs must be obtained with a reporting cycle. What is the length of the reporting cycle for AHIMA credentials?
two years
The use of a token plus a password as an authentication tool is called _____________.
two-factor authentication
Utilization of partitioning software to create separate and distinct application environments on a single server describes the use of ________ as applied to computing. A server running the Microsoft Windows operating system is an example.
virtualization