Intro To Health Information Technology Exam
A secure gateway and is a part of a computer system or network that is designed to block unauthorized access while permitting authorized communications. 1.Firewall 2.Physical safeguard 3.Intrusion detection 4.Access controls 5.Authorization
1.Firewall
Create social and physical environments that promote good health for all. 1.Healthy People 2020 2.National Institutes of Health 3.Centers for Disease Control and Prevention 4.National Academy of Medicine Reports
1.Healthy People 2020
The type of permission that is inferred when a patient voluntarily submits to treatment. 1.Implied consent 2.Informed consent 3.Patient rights 4.Authorization
1.Implied consent
Vital signs = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
1.LOINC
Laboratory tests = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
1.LOINC
The ___________ established the Common Clinical Data Set. A.CMS B.ONC C.HHS D.NCQA
A.CMS
The right of an individual to keep personal health information from being disclosed to anyone is a definition of ______ A.Confidentiality B.Integrity C.Privacy D.Security
A.Confidentiality
A family physician requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physicians specialist would record findings, impressions, and recommendations in what type of report? A.Consultation B.Medical history C.Physical exam D.Progress note
A.Consultation
Data field, definition, data type, and format are all common data elements found in the _____. A.Data dictionary B.Data map C.Database D.Data set
A.Data dictionary
Reviewing patient's list of medication at each visit. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
5.Currency
A patient's gender, phone number, address, next of kin, and insurance policyholder information would be considered what kind of data? A.Administrative data B.Clinical data C.Authorization data D.Content data
A.Administrative data
The incidence of cancer is identified through the _____. A.Facility registry B.Population registry C.Combination of both the facility registry and the population registry D.Healthcare organization cancer program
D.Healthcare organization cancer program
Stricter state statutes take precedence over the HIPAA Privacy Rule _____. A.In all situations B.Never C.If the state law has been in existence longer than HIPAA D.I they provide greater confidentiality of healthcare information
D.I they provide greater confidentiality of healthcare information
Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: A.By the hospital B.By the patient C.By the attending and consulting physician D.Jointly by the hospital, physician, and patient
D.Jointly by the hospital, physician, and patient
The nationwide health information network is now called which of the following? A.Connectathon B.eHealth Exchange C.Health information exchange organization D.National health information exchange
D.National health information exchange
What is a system of terms that follows pre-established naming conventions? A.Classification B.Code system C.Clinical terminology D.Nomenclature
D.Nomenclature
Infusion pumps and robotics are examples of which of the following? A.EHR systems B.Medical devices C.Smart peripherals D.Specialty clinical applications
D.Specialty clinical applications
Skilled nursing care is defined as skilled nursing observations and _____. A.18 hours of certified nursing assistant care B.32 hours of rehabilitation care C.Social interaction D.Technical procedures
D.Technical procedures
A kiosk is a _____. A.Data repository B.Form of personal health record C.Human-computer interface D.Type of portal
D.Type of portal
The HITECH act was created by what law? A.ARRA B.HIPAA C.ACA D.Utilization Review Act
D.Utilization Review Act
A system characterized by "a set of concepts and relationships that provide a common reference point for comparisons and aggregation of data about the entire health care process, recorded by multiple different individual, systems or institutions." Terminology system or Classification system
Terminology system
Intentional software intrusions are also known as _____. A.Hackers B.Criminals C.Internal threats D.Malware
A.Hackers
Patient account information includes _____. A.Insurance B.Patient gender C.Next of kin D.Race
A.Insurance
Which of the following is a characteristic of the legal health record? A.It is the record disclosed upon request B.It must be electronic C.It includes the designated record set D.It includes a patient's personal health record
A.It is the record disclosed upon request
_____ are the biggest threat to the security of healthcare data. A.Natural disasters B.Employees C.Fires D.Equipment malfunctions
B.Employees
As the meaningful use (MU) incentive program for using EHR is phased out, what is taking its place? A.Alternative payment models B.Health information exchange C.Promoting Interoperability D.Value-based care
B.Health information exchange
The three elements of a security program are ensuring data availability, protection and: A.Suitability B.Integrity C.Flexibility D.Robustness
B.Integrity
Which of the following is the standard for clinical lab test observations under the promoting interoperability program? A.CPT B.LOINC C.ICD-10-PCS D.HCPCS Level II
B.LOINC
If a patient is not asked to sign a general consent form when entering the hospital and later sues the hospital for contact that was offensive, harmful, or not otherwise agreed to, what cause of action has the plaintiff most likely included in his lawsuit? A.Battery B.Lack of informed consent C.Negligence D.Breach of contract
B.Lack of informed consent
A data dictionary for an EHR or other health information system _____. A.Depicts relationships between all terms used in the system B.Lists and defines all data elements used in the system C.Supplies codes for all data in the system D.Uses modeling to organize data from their source
B.Lists and defines all data elements used in the system
An RAI/MDS and care plan are found in records of __________ patients. A.Home healthcare B.Long-term care C.Behavioral healthcare D.Rehabilitative care
B.Long-term care
Secondary data sources consist of _____. A.Individual health record. B.Registries C.Healthcare claim D.Care plan
B.Registries
What vocabulary is used to encode laboratory orders and results? A.CPT B.ICD-10-CM C.LOINC D.SNOMED
C.LOINC
Generally, term used to describe court in the highest tier of state court systems. 1.District court 2.State supreme court 3.State appellate court 4.Trial court 5.US Supreme Court 6.US Court of Appeals
2.State supreme court
Treats patients who have acute and chronic lung disorders. 1.physical therapist 2.respiratory therapist 3.occupational therapist 4.surgical technologist
2.respiratory therapist
Proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trail system. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
5.Arbitration
A right or permission given to an individual to use a computer resource, such as a computer, or to use specific applications and access specific data. 1.Firewall 2.Physical safeguard 3.Intrusion detection 4.Access controls 5.Authorization
5.Authorization
The patient's test results and diagnosis are the same throughout the chart. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
5.Currency
Data should be complete, accurate, and consistent. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
5.Data integrity
Central collection of data used to improve the quality of care and measure the effectiveness of an aspect of healthcare delivery. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
5.Disease registry
PA and Lateral Chest: 12/8/XX Findings: The lungs are clear. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
5.Imaging report
Create a process for proper preservation of information based on requirements from regulations, accrediting organizations, and company policy. 1.Compliance 2.Disposition 3.Accountability 4.Transparency 5.Retention
5.Retention
Written document directing an individual to furnish documents and other records to a court= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
5.Subpoena duces tecum
Court with the power to overturn the final judgments of federal and state courts of appeal. 1.District court 2.State supreme court 3.State appellate court 4.Trial court 5.US Supreme Court 6.US Court of Appeals
5.US Supreme Court
Policies and procedures that address the management of computer resources and security. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
6.Administrative controls
Individual or party who is the object of a lawsuit= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
6.Defendant
The patient states that he has experienced difficulty swallowing for the last two weeks. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
6.Medical history
Professional liability of healthcare providers in the delivery of care to patients. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
6.Medical malpractice
Height: 5'2", Weight 150.4 lbs. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
6.Precision
List of patients with severe injuries. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
6.Trauma registry
Spoken or written agreement; may be given by a patient to a healthcare provider to permit treatment. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
7.Express contract
The identification, evaluation, and control of risks that are inherent in unexpected and inappropriate events. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
7.Risk management
Create a process for ensuring that all the information meets the requirements of appropriate laws, regulations, standards, and organizational policies. 1.Compliance 2.Disposition 3.Accountability 4.Transparency 5.Retention
1.Compliance
Which system includes ICD-10-CM codes to assist with meeting administrative requirements? 1.DSM-5 2.ICD-O-3 3.ICF 4.ICD-10-PCS
1.DSM-5
Final Diagnosis: Coronary Artery Disease. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
1.Discharge summary
List of diseases and conditions of patients treated in a facility sequenced according to classification code numbers. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
1.Disease index
Court in the lowest tier of the federal court system. 1.District court 2.State supreme court 3.State appellate court 4.Trial court 5.US Supreme Court 6.US Court of Appeals
1.District court
Information about the patient that is documented by the clinicians who provide services to the patient. 1.Primary data 2.Aggregate data 3.Patient-identifiable data 4.Secondary data
1.Primary data
Safeguarding system access= 1.Privacy 2.Integrity 3.Availability
1.Privacy
A type of data server that collects and processes specific types of data for follow up, research, and other uses. 1.Registry 2.Artificial intelligence 3.CRM 4.Analytics
1.Registry
Surgical notes must be documented within 24 hours of the procedure. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
1.Timeliness
Civil wrongdoing= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
1.Tort
Evaluate and treat patients to improve functional mobility, reduce pain, and limit disability. 1.physical therapist 2.respiratory therapist 3.occupational therapist 4.surgical technologist
1.physical therapist
Which of the following is an electronic record technological capability that allows a paper-based x-ray report to be accessed? A.Database management B.Documents imaging C.Text processing D.Vocabulary standards
B.Documents imaging
Identify the type of negligence that applies when a physician does not order the necessary test. A.Nonfeasance B.Malfeasance C.Misfeasance D.Intentional tort
B.Malfeasance
Home health agency process and improvement outcome measures are based on data from the _____. A.Home Health Compare Data Set B.Outcomes and Assessment Information Set C.Uniform Hospital Discharge Data Set D.Common Clinical Data Set
B.Outcomes and Assessment Information Set
_____ is the most common type of social engineering technique. It is accomplished through the use of email. A.Baiting B.Phishing C.Spearphishing D.Tailgaiting
B.Phishing
Which of the following is a patient's right under HIPAA? A.Right to obtain an advanced directive B.Right to request an amendment of the health record C.Right to control the minimum necessary PHI allowed D.Right to identify the designated record set
B.Right to request an amendment of the health record
What makes SNOMED CT different from CPT? Choose all that apply. A.Unlike CPT, there is no book of SNOMED CT codes. B.SNOMED CT content is broader than CPT in both scope and use. C.CPT is the only clinical terminology. D.SNOMED CT and CPT are standards selected by the ONC.
B.SNOMED CT content is broader than CPT in both scope and use.
Identify the screen design concept that assists with data validation. A.Checking to ensure that the data is in an appropriate range B.Selecting from a predefined list such as in check boxes and radio buttons C.There is an undo feature D.Navigation is clear
B.Selecting from a predefined list such as in check boxes and radio buttons
The unique identifier that identifies a specific patient visit is known as _____. A.Health record number B.Serial-unit numbering C.Patient account number D.it numbering
B.Serial-unit numbering
Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public's health? A.Chief Executive Officer of the Centers for Disease Control and Prevention B.Surgeon General of the United States C.Secretary of Health and Human Services D.President of the National Institutes of Health
B.Surgeon General of the United States
Identify an example of information. A.The number of patients discharged has increased 175% over the past year. B.The RBC test result is 12.6 with the WBC test result is 11.6. C.The HIM employees worked 320 hours. D.The HIM committee will meet to discuss the problem with the delinquent chart count.
B.The RBC test result is 12.6 with the WBC test result is 11.6.
A child's health record should be retained for _____. A.The statute of limitations plus five years B.The age of majority plus the statute of limitation C.The age of majority D.The age of majority plus three years
B.The age of majority plus the statute of limitation
Which of the following persons were intended to be supported by Medicaid in Public Law 89-97 of 1965? A.Single-parent families B.The elderly C.Veterans D.Pregnant women
B.The elderly
Identify the true statement about immunization registries. A.The purpose of immunization registries is to eliminate communicable diseases. B.The immunization registry compiles immunizations from a variety of healthcare providers C.The immunization registry reminds parents to track their children's immunizations D.Immunizations are not addressed in Health People 2020.
B.The immunization registry compiles immunizations from a variety of healthcare providers
Critique each statement to determine the true statement related to correcting errors in the paper-based health record entries. A.The addendum should be backdated B.The reason for the change should be noted C.The incorrect information should be obliterated D.The phrase late entry should be noted on the entry
B.The reason for the change should be noted
Identify the scenario where patient authorization is required prior to disclosure. A.To an insurance company for payment B.To the patient's attorney C.To public health authorities as required by law D.To another provider for treatment
B.To the patient's attorney
A provider's office calls to retrieve emergency room records for a patient's follow-up appointment. The HIM professional refused to release the emergency room records without a written authorization from the patient. Was this action in compliance? A.No; the records are needed for the continued care of the patient, so no authorization is required. B.Yes; the release of all records requires written authorization from the patient. C.No; permission of the ER physician was not obtained D.Yes; one covered entity cannot request the records from another covered entity
B.Yes; the release of all records requires written authorization from the patient.
Medical staff bylaws ____. A.govern the business conduct, rights, and responsibilities of the medical staff B.is a process that ensures the physician or other healthcare professionals has the qualifications required to perform services. C.voluntary process of institutional or organizational review. D.are the standards a healthcare organization must meet to receive Medicare funding.
B.is a process that ensures the physician or other healthcare professionals has the qualifications required to perform services.
Determine the list of names that is in the correct order for alphabetical filing. A.Carl J. SmithMary A. SmithThomas SmithPaul M. Smith B.Smith, A. MarySmith, J. CarlSmith, M. PaulSmith, Thomas C.Smith, Carl J.Smith, Mary A.Smith, Paul M.Smith, Thomas D.Smith, ThomasSmith, Carl J.Smith, Mary A.Smith Paul M.
C.Smith, Carl J.Smith, Mary A.Smith, Paul M.Smith, Thomas
Data that have been processed into usable form is referred to as _____. A.Information B.Knowledge C.Structured data D.Value
C.Structured data
Which of the following is a secondary purpose of the health record? A.Support for provider reimbursement B.Support for patient self-management activities C.Support for research D.Support for patient care delivery
C.Support for research
Which of the following is true about communicable diseases? A.The diseases to be reported are established by state law B.They must be reported by the patient to the health department C.The diseases to be reported are established by HIPAA D.They are never reported because it would violate the patient's privacy
C.The diseases to be reported are established by HIPAA
Stacie is writing a health record retention policy. She is taking into account the statute of limitations for malpractice and contract actions in her state. A statute of limitations refers to which of the following? A.A limited number of state laws B.The period of time in which a lawsuit must be filed C.The period of time that a case must be brought to trial D.The timeliness of the health records in her facility
C.The period of time that a case must be brought to trial
Explain what the accession number 21-214 means. A.This was the 21st patient entered in the registry out of 214 patients B.This is the 21st patient diagnosed with a specific type of cancer out of 214 patients C.The year that the patient was entered into the registry is 2021 and this was the 214th patient entered in the registry during 2021 D.The year that the patient was entered in the registry is 2014 and this was the 21st patient entered
C.The year that the patient was entered into the registry is 2021 and this was the 214th patient entered in the registry during 2021
A system "that arranges or organizes like or related entities." Terminology system or Classification system
Classification system
Which of the following professionals is not mentioned in this text as requiring licensing by all 50 states? A.Physical therapy B.Occupational therapy C.Respiratory therapy D.Health information management
D.Health information management
_____ are subject to the HIPAA Privacy Rule. A.Only paper records B.Only electronic records C.Both paper and electronic records D.Health records in any format
D.Health records in any format
The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record into evidence? A.Identification of the record as the one subpoenaed B.The care provided to the patient C.The qualifications of the treating physician D.Identification of the standard of care used to treat the patient
D.Identification of the standard of care used to treat the patient
Roger was admitted to the hospital through the emergency department, and he was unconscious until his second day of treatment. Identify the appropriate action for the hospital with regard to placing Roger's name in the facility directory. A.It was prohibited from including Roger in the directory. B.It could include Roger in the directory if the disclosure was consistent with his prior expressed preferences. C.It could not include Roger in the directory even if it believed inclusion was in Roger's best interest. D.If it decided to include Roger in the directory, it was not required to inform him or gain his permission once he regained consciousness
D.If it decided to include Roger in the directory, it was not required to inform him or gain his permission once he regained consciousness
A 78-year-old male patient's medical information was hacked. The hackers found out that the patient was last seen for malfunction of a pacemaker. Determine which of the following is the likely source the hackers targeted? A.Immunization Registry B.National Hospital Care Survey C.Trauma Registry D.Implant Registry
D.Implant Registry
The __________ is a component of ICD-10-CM. A.Appendix of Mental Disorders B.Ancillary Section C.Table of Morphology D.Index to External Causes
D.Index to External Causes
Which of the following is a true statement regarding abbreviations in the health record? A.The physician can use any appropriate abbreviation in the health record B.Only abbreviations approved by the state can be used C.Only abbreviations approved by Medicare can be used D.Only abbreviations approved by the healthcare organization can be used
D.Only abbreviations approved by the healthcare organization can be used
When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence? A.Adoption B.Implementation C.Meaningful use D.Optimization
D.Optimization
A covered entity's planned response to protect its information in the case of a natural disaster is known as _____. A.Administrative controls B.Audit trail C.Business continuity plan D.Physical controls
D.Physical controls
The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review? A.Proactive B.Prospective C.Concurrent D.Retrospective
D.Retrospective
A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? A.Review the subpoena and appear at the time and place supplied to give testimony B.Review the subpoena to determine what documents must be produced C.Review the subpoena and notify the hospital administrator D.Review the subpoena and alert the hospital's risk management department
D.Review the subpoena and alert the hospital's risk management department
The terminology used in computerized provider order entry systems for medications must be from. A.CPT B.ICD-10-CM C.NCPDP D.RxNorm
D.RxNorm
The objective of RxNorm is to normalize names of generic and branded drugs and attach a _________ to that name. A.RxNorm current prescribable identifier B.RxNorm atom unique identifier C.RxNorm fully specified identifier D.RxNorm concept unique identifier
D.RxNorm concept unique identifier
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set? A.ICD-10-CM B.HCPCS Level II C.ICD-10-PCS D.SNOMED CT
D.SNOMED CT
Identify the law that requires the reporting of deaths and severe complications due to devices. A.Medical Implantation and Transplantation Act of 1986 B.Medical Devices Reporting Act of 1972 C.Food and Drug Modernization Act of 1997 D.Safe Medical Devices Act of 1990
D.Safe Medical Devices Act of 1990
Which of the following is a true statement about the facility directory? A.Individuals must be given an opportunity to deny permission to place information about them in the directory. B.Individuals must provide a written authorization before information about them can be placed in the directory. C.The directory may contain only identifying information, such as the patient's name and birthdate. D.The directory may contain diagnostic information as long as it is kept confidential.
D.The directory may contain diagnostic information as long as it is kept confidential.
Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ____________. A.The quantity of healthcare services provided B.The efficiency and value of the healthcare services provided C.The quality of the healthcare services provided D.The efficiency, quality, and value of healthcare services provided
D.The efficiency, quality, and value of healthcare services provided
How do accreditation organizations such as the Joint Commission use the health record? A.To determine whether standards of care are being met. B.To serve as a source for case study information C.To provide health care service D.To determine whether the documentation supports the provider's claim for reimbursement.
D.To determine whether the documentation supports the provider's claim for reimbursement.
The role of a scribe with respect to EHR documentation is to _____. A.Document structured data into the EHR at the point-of-care B.Identify data the physician should collect as the patient is being seen for care C.Interview patients to capture their history and physical exam D.Transcribe physician speech into the EHR
D.Transcribe physician speech into the EHR
A healthcare technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? A.CARP B.DEEDS C.UACDS D.UHDDS
D.UHDDS
The data set that collects data on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services, and disposition is _____. A.Uniform Ambulatory Care Data Set (UACDS) B.Outcomes and Assessment Information Set (OASIS) C.Data Elements for Emergency Department Systems (DEEDS) D.Uniform Hospital Discharge Data Set (UHDDS)
D.Uniform Hospital Discharge Data Set (UHDDS)
List the six basic steps in the database life cycle. Design= Initial study= Testing and evaluation= Operation= Implementation= Maintenance and evaluation=
Design= 2 Initial study= 1 Testing and evaluation= 4 Operation= 5 Implementation= 3 Maintenance and evaluation= 6
The Medical Literature, Analysis, and Retrieval System Online was created by the National Library of Medicine. : True/False
True
The Social Security Act of 1935 had a healthcare component added by the Republican president, Franklin D. Roosevelt. : True/False
True
The designed record set includes health record, billing records, and more. : True/False
True
The hospital bylaws define the process for documentation within a health record for all members of the workforce. : True/False
True
The process of identifying the source of health entries by attaching a handwritten signature, the author's initials, or electronic signature is authentication. :True/False
True
With the implementation of the Affordable Care Act, there are now penalties for employers (excluding small employers) who do not offer affordable health coverage for their employees. :True/False
True
The health records association today is known as ____. A.AHIMA B.AAMRL C.AMRA D.RHIA
A. AHIMA
Who is the sponsor of the Registered Health Information Technician (RHIT) exam? A.AHIMA B.AAPC C.CAHIIM D.HIMSS
A. AHIMA
What organization is responsible for scholarships? A.AHIMA Foundation B.AHIMA Board of Directors C.CCHIIM D.CAHIIM
A. AHIMA Foundation
The national changes in HIM need to be communicated to the membership. The communication should go through the _____. A.AHIMA component state associations B.AHIMA Board of Directors C.AHIMA Engage D.AHIMA House of Delegates
A. AHIMA component state associations
Common pathways taken by HIM professionals in their HIM roles is found in _____. A.AHIMA's Career Map B.the certification guidelines C.accreditation standards D.the Code of ethics
A. AHIMA's Career Map
An RHIT is going back to earn her bachelor's degree so that she can sit for the RHIA exam. Identify the appropriate AHIMA membership classification. A.Active B.Student C.Emeritus D.New graduate
A. Active
Critique the following statements to determine the correct statement regarding certification. A.Candidates must pass an examination before obtaining any of the credentials. B.The eligibility requirements for all credentials are the same. C.Candidates must be college graduates before they can obtain any of the credentials. D.Candidates must have work experience and pass a certification exam before they can obtain any of the credentials.
A. Candidates must pass an examination before obtaining any of the credentials.
Sustained professional achievement is required by which of the following? A.Fellowship B.Certification C.Accreditation D.Engage
A. Fellowship
Valley High, a skilled nursing facility wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? A.Conditions of Participation B.Minimum Data Set C.National Commission on Correctional Health Care D.Outcomes and Assessment Information Sets
A.Conditions of Participation
A record is considered a primary data source when it _____. A.Contains information about the patient that has been documented by the professionals who provided care to the patient B.Contains data abstracted from a patient record C.Includes data stored in a computer system D.Contains data that are entered into a disease-oriented database
A.Contains information about the patient that has been documented by the professionals who provided care to the patient
Amber files a medical malpractice lawsuit against Dr. Mason, who performed her surgery. She names no other defendants in the lawsuit. Dr. Mason files a complaint against Amber. By doing this, Dr. Mason has completed the legal action of _____. A.Counterclaim B.Crossclaim C.Default judgment D.Joinder
A.Counterclaim
Select the most important present and future HIM skill(s). Choose all that apply. A.Critical thinking B.Ensuring data integrity C.Leadership D.Managing information privacy and security
A.Critical thinking B.Ensuring data integrity C.Leadership D.Managing information privacy and security
In a database the LAST_NAME column in a table would be considered a: A.Data element B.Record C.Primary key D.Row
A.Data element
Identify the software that is used for voice recognition. A.Data mining B.Voice mail C.Electronic health record D.Natural language processing
A.Data mining
Dr. Smith is being sued by a former patient. At issue is whether the care he provided the patient was consistent with that which would be provided by an ordinary and reasonable physician treating a patient in the plaintiff's condition. The concept in question is whether A.Dr. Smith owed a duty to the patient B.Dr. Smith was practicing medicine with a valid license C.There was a causal relationship between Dr. Smith's actions and the harm to the patient D.Dr. Smith met the standard of care
A.Dr. Smith owed a duty to the patient
A person who is able to take advantage of all of the aids offered by health systems is referred to as which of the following? A.End user B.Meaningful user C.Power user D.Super user
A.End user
Version control of documents in the EHR requires ___. A.Policies and procedures to control which version(s) is displayed B.The deletion of old versions and the retention of the most recent C.Signed and unsigned documents not to be considered two versions D.Previous versions to be accessible to administration only
A.Policies and procedures to control which version(s) is displayed
Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning the admission date in the EHR? A.Provide a template for entering data in the field B.Make admission date a required field C.Make admission data a numeric field D.Provide sufficient space for input of data
A.Provide a template for entering data in the field
Removing health records of patients who have not been treated at the healthcare organization for a specific period of time from the storage area to allow space for more current records is called ____ A.Purging records B.Assembling records C.Logging records D.Cycling records
A.Purging records
Identify the tool that a healthcare organization utilizes to determine which physician has the best patient outcomes. A.Qualitative analysis B.Data mining C.Quantitative analysis D.Version control
A.Qualitative analysis
In reviewing a patient chart, the coder finds that the patient's chest x-ray us suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? A.Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results. B.Code the COPD because the documentation substantiates it. C.Query the radiologist to determine whether the patient has COPD. D.Assign a code from the abnormal findings to reflect the condition.
A.Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results.
David works for an organization that utilizes health record data to prove or disapprove the efficacy of a healthcare treatment. What type of organization does David work for? A.Research B.Educational C.Policy-making D.Third-party payer
A.Research
Which of the following is true about health information retention? A.Retention periods differ among healthcare facilities B.Retention depends only on accreditation requirements C.The operational needs of a healthcare facility cannot be considered D.Retention periods are frequently shorter for health information about minors
A.Retention periods differ among healthcare facilities
The decision was made to select the algorithm that uses mathematical probabilities. This type of algorithm is: A.Rules-based B.Probabilistic C.Deterministic D.Abstracting
A.Rules-based
Cell-based technologies include _____. A.Stem cells for transplant B.Organ transplants C.Synthetic organs D.Washing cells of all organic material
A.Stem cells for transplant
Which of the following is a secondary purpose of the health record? A.Support for research B.Support for provider reimbursement C.Support for patient self-management activities D.Support for patient care delivery
A.Support for research
An employee views a patient's electronic health record. It is a trigger event if: A.The employee and patient have the same last name B.The patient was admitted through the emergency room C.The patient is over 89 years old D.A dietician views a patient's nutrition care plan
A.The employee and patient have the same last name
Which of the following definitions best describes the concept of confidentiality? A.The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose B.The protection of healthcare information from damage, loss, and unauthorized C.The right of individuals to control access to their personal health information D.The expectation that only individuals with the appropriate authority will be allows to access healthcare information
A.The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
The legal health record is defined by ___. A.The healthcare organization B.State licensing C.Medicare D.Accreditation organizations
A.The healthcare organization
The management of health information is a fundamental component of _____. A.The overall information governance model B.The EHR workflows C.The documentation standards D.Cloud Computing
A.The overall information governance model
Which of the following best represents the definition of the term data? A.The patient's laboratory value is 50. B.The patient's SGOT is higher than 50 and outside of normal limits. C.The patient's resting heartbeat is 70, which is within normal range. D.The patient's laboratory value is consistent with liver disease.
A.The patient's laboratory value is 50.
_____ is entered into electronic systems as free text and has no specific requirements or rules for data entry. A.Unstructured data B.Structured data C.Formatted data D.Unformatted data
A.Unstructured data
Which of the following is an example of a physical safeguard that should be provided for in a data security program? A.Using password protection B.Prohibiting the sharing of passwords C.Locking computer rooms D.Annual employee training
A.Using password protection
Biometrics include _____. A.Voice prints B.Passwords C.Log-in credentials D.Tokens
A.Voice prints
Individual who brings a lawsuit= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
2.Plaintiff
Medications = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
2.RxNorm
Rules developed by administrative bodies empowered by law to regulate specific activities. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
1.Administrative law
Match the specialty professional organization to what they do. Educates and certifies medical coders and billers ___ 1.AAPC 2.HIMSS 3.AHDI 4.NCRA
1. AAPC
Match the organization to its description. It's workgroups assist educators by helping educators to keep skills current and assist with establishing standards for professional practice. _____. 1.Council for Excellence in Education (CEE) 2.AHIMA House of Delegates 3.AHIMA Board of Directors 4.Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) 5.Commission on Certification for Health Informatics and Information Management (CCHIIM)
1. Council for Excellence in Education (CEE)
The security tool used to restrict access to information and information resources to only those who are authorized, by role or other means. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
1.Access Control
A program that reproduces itself and attaches itself to legitimate programs on a computer to change or corrupt data is known as ___ A.Computer worm B.Trojan horse C.Malware D.Computer virus
A.Computer worm
Keeping equipment located in secure locations and protected from natural and environmental hazards and intrusion. 1.Firewall 2.Physical safeguard 3.Intrusion detection 4.Access controls 5.Authorization
2.Physical safeguard
Is responsible for establishing the position of AHIMA on issues related to HIM and taking action. ___. 1.Council for Excellence in Education (CEE) 2.AHIMA House of Delegates 3.AHIMA Board of Directors 4.Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) 5.Commission on Certification for Health Informatics and Information Management (CCHIIM)
2. AHIMA House of Delegates
The on-call physician is able to see the radiology report of Mr. Smith. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
2.Accessibility
Data extracted from individual patient records and combined to form information about groups of patients. 1.Primary data 2.Aggregate data 3.Patient-identifiable data 4.Secondary data
2.Aggregate data
Security controls built into a computer software program to protect information security and integrity. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
2.Application controls
Algorithms that use analytics to support clinical decision-making. 1.Registry 2.Artificial intelligence 3.CRM 4.Analytics
2.Artificial intelligence
Disclosure of pertinent facts or documents to the opposing parties in a legal case. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
2.Discovery
Create processes for secure and appropriate destruction of information that is no longer needed to be maintained by the healthcare organization. 1.Compliance 2.Disposition 3.Accountability 4.Transparency 5.Retention
2.Disposition
Registry that includes only cases for a specific facility. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
2.Facility-based registry
Supports information of health through the application of information and technology ___ 1.AAPC 2.HIMSS 3.AHDI 4.NCRA
2.HIMSS
Which is derived classification of the WHO Family of International Classifications? 1.DSM-5 2.ICD-O-3 3.ICF 4.ICD-10-PCS
2.ICD-O-3
A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure performed. 1.Implied consent 2.Informed consent 3.Patient rights 4.Authorization
2.Informed consent
Safeguarding data accuracy= 1.Privacy 2.Integrity 3.Availability
2.Integrity
Addresses the patient's current complaints and symptoms and lists the patient's past medical, personal, and social history. 1.Clinical observation 2.Medical history 3.Physical exam 4.Clinical observation
2.Medical history
Provide unbias advice to decision-makers and the public. 1.Healthy People 2term-42020 2.National Institutes of Health 3.Centers for Disease Control and Prevention 4.National Academy of Medicine Reports
2.National Institutes of Health
Seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health. 1.Healthy People 2term-42020 2.National Institutes of Health 3.Centers for Disease Control and Prevention 4.National Academy of Medicine Reports
2.National Institutes of Health
Neck: Supple. Carotid pulses: 2/7. Slight jugular venous distention is noted. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
2.Physical examination
Sets the organizational strategy. ___. 1.Council for Excellence in Education (CEE) 2.AHIMA House of Delegates 3.AHIMA Board of Directors 4.Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) 5.Commission on Certification for Health Informatics and Information Management (CCHIIM)
3. AHIMA Board of Directors
Dedicated to the capture of health data and documentation 3 1.AAPC 2.HIMSS 3.AHDI 4.NCRA
3.AHDI
Create authority over the information governance process within an organization. 1.Compliance 2.Disposition 3.Accountability 4.Transparency 5.Retention
3.Accountability
Ensuring system access when needed= 1.Privacy 2.Integrity 3.Availability
3.Availability
Failure to meet the conditions specified under a legal agreement. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
3.Breach of Contract
Tracks customers (patients) and their service providers or potential service providers in their community. 1.Registry 2.Artificial intelligence 3.CRM 4.Analytics
3.CRM
Protect the public health and safety. 1.Healthy People 2020 2.National Institutes of Health 3.Centers for Disease Control and Prevention 4.National Academy of Medicine Reports
3.Centers for Disease Control and Prevention
I have recommended to Mr. Patient that we proceed with CT scan of the head to rule out bleeding. Thank you for allowing me to participate in Mr. Patient's care today. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
3.Consultation
The date of birth is to be written as month, day, and four-digit year. 1.Timeliness 2.Accessibility 3.Definition 4.Consistency 5.Currency 6.Precision
3.Definition
Procedures = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
3.HCPCS Level II
Which system would be used to classify a state of disability? 1.DSM-5 2.ICD-O-3 3.ICF 4.ICD-10-PCS
3.ICF
The process of identifying attempts or actions to penetrate an information system and gain unauthorized access. 1.Firewall 2.Physical safeguard 3.Intrusion detection 4.Access controls 5.Authorization
3.Intrusion detection
The protections afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities. 1.Implied consent 2.Informed consent 3.Patient rights 4.Authorization
3.Patient rights
Information such as age and date of birth. 1.Primary data 2.Aggregate data 3.Patient-identifiable data 4.Secondary data
3.Patient-identifiable data
Attending physician's assessment of the patient's current health status. 1.Clinical observation 2.Medical history 3.Physical exam 4.Clinical observation
3.Physical exam
Physician's findings based on an examination of the patient 1.Clinical observation 2.Medical history 3.Physical exam 4.Clinical observation
3.Physical exam
List of patients by physician, usually arranged by physician code numbers. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
3.Physician index
Unauthorized data or system access by individuals from inside or outside the covered entity. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
3.Security breaches
Court with the power to overturn the final judgments of state trial courts. 1.District court 2.State supreme court 3.State appellate court 4.Trial court 5.US Supreme Court 6.US Court of Appeals
3.State appellate court
Law enacted by a legislative body= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
3.Statute
Process by which a lawsuit is initiated= 1.Tort 2.Plaintiff 3.Statute 4.Complaint 5.Subpoena duces tecum 6.Defendant
3.Statute
Use work and play activities to improve patients' independent functioning, enhance their development, and prevent or decrease their level of disability. 1.physical therapist 2.respiratory therapist 3.occupational therapist 4.surgical technologist
3.occupational therapist
An example of a clinical documentation integrity tool is ___. A.Computer-assisted coding B.SBAR C.Data map D.IGAM
A.Computer-assisted coding
Establishes quality standards for the educational programs. ___. Dedicated to ensuring the competencies of HIM professionals ___ 1.Council for Excellence in Education (CEE) 2.AHIMA House of Delegates 3.AHIMA Board of Directors 4.Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) 5.Commission on Certification for Health Informatics and Information Management (CCHIIM)
4. Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
Security tool used to restrict access to information and information resources. 1.Firewall 2.Physical safeguard 3.Intrusion detection 4.Access controls 5.Authorization
4.Access controls
List of cases in a cancer registry arranged in the order in which the cases were entered. 1.Disease index 2.Facility-based registry 3.Physician index 4.Accession registry 5.Disease registry 6.Trauma registry
4.Accession registry
Statistical processing of data to reveal new information. 1.Registry 2.Artificial intelligence 3.CRM 4.Analytics
4.Analytics
A software program that tracks every access to data in the information system. 1.Access Control 2.Application controls 3.Security breaches 4.Audit trail 5.Data integrity 6.Administrative controls 7.Risk management
4.Audit trail
Required under the Privacy Rule for the use and disclosure of protected health information. Provides the healthcare provider the authority to use or disclose patient protected health information for a specific purpose. 1.Implied consent 2.Informed consent 3.Patient rights 4.Authorization
4.Authorization
Observations and comments of physicians, nurses, and other caregivers in order to create a chronological report of the patient's condition and response to treatment. 1.Clinical observation 2.Medical history 3.Physical exam 4.Clinical observation
4.Clinical observation
Which of the following procedure classifications include definitions? 1.DSM-5 2.ICD-O-3 3.ICF 4.ICD-10-PCS
4.ICD-10-PCS
Serves as the premier education, credentialing, and advocacy resource for cancer data professionals. ___ 1.AAPC 2.HIMSS 3.AHDI 4.NCRA
4.NCRA
Immunizations = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
4.NDC
Law that involves the government and its relationships with individuals or organizations. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
4.Public law
Data derived from the primary patient record. 1.Primary data 2.Aggregate data 3.Patient-identifiable data 4.Secondary data
4.Secondary data
Create a clear and open documentation process for the information governance strategy and activities within a healthcare organization. instruments and clinical information systems. 1.Compliance 2.Disposition 3.Accountability 4.Transparency 5.Retention
4.Transparency
Generally, term used to describe court in the lowest tier of state court systems. 1.District court 2.State supreme court 3.State appellate court 4.Trial court 5.US Supreme Court 6.US Court of Appeals
4.Trial court
Time: 0120, Temperature 98.5, Pulse 144, Respirations 46. 1.Discharge summary 2.Physical examination 3.Consultation 4.Vital signs 5.Imaging report 6.Medical history
4.Vital signs
Facilitate safe and effective conduct of invasive surgical procedures. 1.physical therapist 2.respiratory therapist 3.occupational therapist 4.surgical technologist
4.surgical technologist
Dedicated to ensuring the competencies of HIM professionals ___. 1.Council for Excellence in Education (CEE) 2.AHIMA House of Delegates 3.AHIMA Board of Directors 4.Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) 5.Commission on Certification for Health Informatics and Information Management (CCHIIM)
5. Commission on Certification for Health Informatics and Information Management (CCHIIM)
Physical and occupational therapy services = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
5. SNOMED CT
Problems = 1.LOINC 2.RxNorm 3.HCPCS Level II 4.NDC 5. SNOMED CT
5. SNOMED CT
New graduates should volunteer at the state level before moving to the national level. : True/False
True
Sworn testimony usually obtained before a trial. 1.Administrative law 2.Discovery 3.Breach of Contract 4.Public law 5.Arbitration 6.Medical malpractice 7.Express contract 8.Deposition
8.Deposition
When a vendor is no longer selling or supporting a health IT product, it is said to be _________________. A.Abandoned B.Discontinued C.Marooned D.Sunset
B.Discontinued
EHRs help providers better manage care for patients and provide better health care by ____. Select all that apply. Choose all that apply. A.Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care B.Enable providers to increase the number of patients in their practice. C.Helping promote legible, complete documentation and accurate, streamlined coding and billing D.Enabling providers to improve efficiency and meet their business goals
A. Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
Prior to hospital standardization, health records were _____. A.Not managed B.Valuable tools C.Strong communication methods D.Complete documentation of patient care
A. Not managed
Before 1918 who was responsible for the creation and management of hospital health records? A.Physician B.Hospital C.Nurse D.HIM professional
A. Physician
The first step in the process of a new HIM program's accreditation is _____. A.Self-assessment B.Report of site visit C.Decision on accreditation D.Site visit
A. Self-assessment
How many identifiers must be removed for a data to be considered de-identified under the Safe Harbor Method? A.12 B.15 C.18 D.20
A.12
Identify the number of days a covered entity has to respond to an individual's request for access to PHI under HIPAA rules: A.30 Days B. 60 Days
A.30 Days
Under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within. A.30 Days B. 60 Days
A.30 Days
Patients in hospice care are expected to live a maximum of ____ days. A.30 days B.180 days C.90 days D.120 days
A.30 days
Which of the following individuals may authorize the release of information? A.A married 15-year-old father B.An 86-year-old patient with a diagnosis of advanced dementia C.A 15-year-old minor D.The parents of an 18-year-old student
A.A married 15-year-old father
Identify the patient who is an individual per HIPAA. A.A patient about whom medical information pertains B.The patient about whom medical information pertains and the patient's parents C.The patient about whom medical information pertains and the patient's physician D.The patient about whom medical information pertains and the patient's personal representative
A.A patient about whom medical information pertains
An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? A.Access controls B.Audit controls C.Contingency controls D.Security incident control
A.Access controls
You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies he performed at your hospital last year. What type of data will you provide the physician? A.Aggregate data B.Patient-specific data C.Operating room data D.Nothing - you cannot obtain this data after the fact.
A.Aggregate data
Who uses large volumes of health data to make judgments? A.Artificial intelligence (AI) B.Big Data C.Cloud computing D.mHealth
A.Artificial intelligence (AI)
Which of the following is NOT a recommended guideline for maintaining integrity in the health record? A.Assuring documentation that is being changed is permanently deleted from the record B.Specifying consequences for the falsification of information C.Requiring periodic training covering the falsification of information and information security D.Prohibiting the entry of false information into any of the organization's records.
A.Assuring documentation that is being changed is permanently deleted from the record
_____ is a computer program that bypasses normal authentication processes and allows access to computer resources, such as programs, computer networks, or entire information systems. A.Backdoor programs B.Tailgaitng C.Trojan horse D.Computer worm
A.Backdoor programs
A subpoena duces tecum compels the recipient to: A.Bring records to a legal proceeding B.Serve on a jury C.Answer a complaint D.Testify at trial
A.Bring records to a legal proceeding
There are twelve public interest and benefit exceptions where written authorization from the patient is not required prior to the use or disclosure of PHI. Identify the exceptions. (Choose all that apply) A.Cadaveric organ donation B.Reporting of a COVID-19 positive patient C.Physical description of a fugitive for location purposes D.IRB waves the authorization requirement
A.Cadaveric organ donation B.Reporting of a COVID-19 positive patient C.Physical description of a fugitive for location purposes
Identify the part of a medical history that documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words. A.Chief complaint B.Social and personal history C.Past medical history D.Present illness
A.Chief complaint
If data aggregation is the goal of collecting the data, ______ are the best choice. A.Classifications B.Code systems C.Clinical terminologies D.Nomenclatures
A.Classifications
Identify the primary user of the health record. A.Clinical professionals who provide direct patient care B.Insurance companies that cover healthcare expenses C.Billers in the healthcare organization's business office D.Patients and their families
A.Clinical professionals who provide direct patient care
Nurse Practitioners can write prescriptions for patients. : True/False
True
The overall goal of documentation standards is to _____. A.Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient B.Ensure that the healthcare provider organization is reimbursed appropriately by payers C.Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find a reason to fine the healthcare provider organization D.Ensure physicians have access to the health record information they need to care for the patient
A.Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
The health record typically begins in the _____. A.HIM department B.Patient registration department C.Nursing unit D.Billing department
A.HIM department
The national database that includes data on all discharged patients regardless of payer is known as _____. A.Healthcare Cost and Utilization Project B.Medicare Provider Analysis and Review file C.Unified Medical Language System D.Uniform Hospital Discharge Data Set
A.Healthcare Cost and Utilization Project
Which of the following is an argument against the use of the copy and paste function in the EHR? A.Inability to identify the author B.Inability to print the data out C.The time that it takes to copy and paste the documentation D.The users will not know how to perform the copy and paste function
A.Inability to identify the author
Password policies should _____. A.Include mandatory scheduled password changes B.Permit password sharing only between good friends C.Require that passwords consist of numbers only D.Require that passwords be changed every 30 days
A.Include mandatory scheduled password changes
A patient in a rural town in Kentucky was visiting his daughter in Maine. He had a heart attack and was rushed to a hospital in Maine. Identify the best example of hospital A sharing information with Hospital B. A.Information Governance B.Quality improvement C.Health Information Exchange D.Data for performance measures
A.Information Governance
Using information to support the strategy, operations and other needs of the healthcare organization is ______. A.Information governance B.Informatics C.Data use D.Data analytics
A.Information governance
________________ focuses on principles and oversight to manage the information that is produced from the different systems within an organization. A.Information governance B.Data governance C.Data management D.Information management
A.Information governance
Another term for the electronic sharing of patient data between two healthcare systems is _____. A.Interoperability B.Data interchange standards C.Health information exchange D.Electronic data interchange
A.Interoperability
Why is the MEDPAR file limited in terms of being used for research purposes? A.It only contains Medicare patients B.It only provides demographic data about patients C.It uses ICD--CM diagnoses and procedure codes D.It breaks charges down by specific type of service
A.It only contains Medicare patients
Which of the following is included in the results provided via a results management information system? A.Lab results B.Medication outcomes C.Quality measure reports D.X-rays images
A.Lab results
The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: A.Master patient index (MPI) B.Audit trail C.Case-mix management D.Electronic document management system (EMDS)
A.Master patient index (MPI)
Which of the following is the health record component that lists the patient's social, and family history? A.Medical history B.Assessment C.Review of Systems D.Plan of Care
A.Medical history
An employee of Mercy Hospital's billing department used the financial information of 100 patients to purchase jewelry from online commercial sites. This is _____. A.Medical identity theft because the financial information was obtained from hospital records B.Not medical identity theft because only 100 patient records were compromised C.Medical identity theft because patient information was used to purchase jewelry D.Not medical identity theft because non-medical good were purchased, with financial consequences only
A.Medical identity theft because the financial information was obtained from hospital records
A physician has a patient with cancer that is not responding to treatment so he looks for research being conducted on cancer. Who developed a database that he can use to locate any existing clinical trial? A.National Library of Medicine B.National Center for Health Statistics C.Centers for Disease Control and Prevention D.Agency for Healthcare Research and Quality
A.National Library of Medicine
Traditionally, physicians alone determine the timely and effective interventions in response to a wide range of problems related to a patient's treatment, comfort, and safety. Who else are playing a wider role in this function? A.Nurses B.Physical therapist C.Utilization specialists D.Quality improvement specialists
A.Nurses
Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? A.Operative report B.Anesthesia report C.Laboratory report D.Pathology report
A.Operative report
A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst include in the database? A.Patient date of birth B.Name of attending physician C.Patient room number D.Admitting diagnosis
A.Patient date of birth
Physician Assistants (PAs) can do this under the supervision of a physician __. A.Perform medical procedures B.Take x-rays C.Perform bloodwork in the lab D.Can prescribe medications in all states
A.Perform medical procedures
A home health agency plans to implement a computer system whereby its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect the laptop and network data from viruses introduced from an external device? A.Personal firewall software B.Encryption C.Session terminations D.Biometrics
A.Personal firewall software
Protocols are the rules and procedures used in clinical trials. : True/False
True
The Master Patient Index is key to locating test results. : True/False
True
Identify the number of days a covered entity has to respond to an individual's request for access to his or her PHI when the PHI is stored off-site. A.30 Days B. 60 Days
B. 60 Days
The Subjective, Objective, Assessment Plan (SOAP) came from the _____. A.Source-oriented health record B.Problem-oriented health record C.Hybrid health record D.Depends on healthcare organization policy
B. Problem-oriented health record
Determine the sequence of health record numbers that is in terminal digit order. A.12-56-46, 13-58-39, 14-45-87, 15-85-22 B.12-56-36, 13-58-39, 14-75-87, 15-85-98 C.04-43-21, 55-32-07, 03-65-32, 19-54-02 D.33-56-45, 14-62-22, 17-77-01, 28-82-30
B.12-56-36, 13-58-39, 14-75-87, 15-85-98
The Uniform Hospital Discharge Data Set's core data elements are collected by ______. A.Outpatient mental health facilities B.Acute care, short-term stay hospitals C.Long-term care hospitals D.Ambulatory care facilities
B.Acute care, short-term stay hospitals
The HIPAA data integrity standard requires that covered entities _____. A.Keep documented logs of system access and access attempts B.Assign role-based access privileges C.Establish workstation security D.Conduct workforce training for correct data input
B.Assign role-based access privileges
AHIMA's record retention guidelines recommend that the master patient index be maintained for: A.At least five years B.At least 10 years C.At least 25 years D.Permanently
B.At least 10 years
_____ is a document that provides a complete description to patients about how PHI is used in a covered entity. A.Notice of privacy practices B.Authorization C.Consent for treatment D.Consent for operations
B.Authorization
_____ involves hackers leaving an infected USB or flash drive in a public area with the hopes that someone will come by, pick it up, and use it out of curiosity. A.Spearphishing B.Baiting C.Tailgating D.Encrypting
B.Baiting
Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity _______________. A.Must always provide access B.Can deny access to psychotherapy notes C.Can demand that the individual pay to see his or her record D.Can always deny access
B.Can deny access to psychotherapy notes
The medical staff has asked to include benign cancers in the cancer registry. This process is known as _____. A.Stage of the neoplasm B.Case definition C.Accession number D.Casefinding
B.Case definition
Two coders have found the same abbreviation on two records. One abbreviation of "O.D" was used on an eye health record to mean "right eye." The other abbreviation on another patient's record was used to mean "overdose" on an abuse record. What data quality component is lacking here? A.Currently B.Consistency C.Granularity D.Completeness
B.Consistency
The term that describes data that defines and characterizes other data within an electronic system is _____. A.Data quality B.Data element C.Metadata D.Source data
B.Data element
A dietary department donated its old microcomputer to a school. Some old patient data were still on the computer. What controls would have minimized this security breach? A.Device and media controls B.Facility access controls C.Access controls D.Workstation controls
C.Access controls
The source of law that spells out the powers of the three branches of the federal government is _____. A.US Constitution B.Statutes C.Administrative law D.Judicial decisions
C.Administrative law
Identify an example of an external user utilizing secondary data. A.Federal agencies B.Department manager C.Agency for Healthcare Research and Quality D.Administration
C.Agency for Healthcare Research and Quality
Identify the individual whose medical information is no longer protected by the HIPAA Privacy Rule. A.Carrie, who has been deceased 10 B.Ray, who has been deceased 25 years C.Charles, who has been deceased 50 years D.Roxanne, who has been deceased 75 years E.Both Charles and Roxanne
C.Charles, who has been deceased 50 years
For a hospital to generate a claim for reimbursement by a health plan, the EHR must have which of the following components? A.Business intelligence B.Charge capture C.Claim clearinghouse D.Encoder
C.Claim clearinghouse
Information assets are: A.Information considered to add value to an organization B.Data entered into a patient's health record by a provider C.Clearly defined elements required to be documented in the health record D.A list of all data elements added within a record
C.Clearly defined elements required to be documented in the health record
Online transaction processing is conducted in which of the following? A.Clinical data repository B.Clinical data warehouse C.Data analytics system D.Online analytical processor
C.Data analytics system
In Lindsay's lawsuit against her physical therapist, her attorney (a) obtained copies of most documents that he requested such as medical records, contracts, email communications, bills, and receipts. However, at trial, Lindsay was surprised to learn that (b) several of these documents were not permitted to be considered by the jury as evidence. The concepts associated with (a) and (b) are _____. A.Subpoena; default B.Counterclaim; discovery C.Discovery; admissibility D.Deposition; voir dire
C.Discovery; admissibility
An example of a specialty clinical system is _____. A.Clinical document architecture B.Core clinical application C.Emergency medicine system D.Monitoring equipment
C.Emergency medicine system
Current medical practice emphasizes performing healthcare services in the least costly setting possible. Based on this statement, which of the following is correct? A.Increased utilization of emergency services B.Increased utilization of hospital admissions C.Increased utilization of nonemergency ambulatory facilities D.Decreased primary care services
C.Increased utilization of nonemergency ambulatory facilities
The organization you work for just concluded an investigation of a USB thumb drive that was lost and contained a file with the information of 765 patients on it, including name, address, telephone number, and social security number. As the privacy officer, you are required to manage the notification process for the data breach. All the following would need to be notified of this data breach within 60 days of the discovery except: A.Attending physicians of the patients B.Individual patients C.Local media D.Department of Health and Human Services
C.Local media
The chief security officer is responsible for _____. A.Conducting audits B.Conducting training C.Managing the security program D.Installing the anti-virus software
C.Managing the security program
EHRs support evidence-based medicine, which refers to which of the following? A.Clinical decision support B.Clinical documentation integrity C.Medical quality improvement D.Recommendations for care based on research
C.Medical quality improvement
Two types of practitioners can hold the degree of Doctor of Medicine. They are _____. A.Chiropractor and surgeon B.Physician and podiatrist C.Physician and surgeon D.Physician and osteopath
C.Physician and surgeon
Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? A.Present an authorization that at least one of them (Ted or Mary) has signed B.Wait until Susan is 19 C.Present an authorization signed by the court that granted the adoption D.Present an authorization signed by Susan's natural (birth) parents
C.Present an authorization signed by the court that granted the adoption
The acronym PHI stands for ______. A.Personal health information B.Protected health information C.Primary health information D.Past health information
C.Primary health information
The standard used in e-prescribing systems to transmit a prescription to a retail pharmacy is which of the following? A.Accredited Standards Committee X12 B.National Drug Code C.RxNorm D.SCRIPT
C.RxNorm
The creation of the National Practitioner Data Bank was mandated by the _____. A.Social Security Act B.Privacy Act C.Health Insurance Portability and Accountability Act D.Health Care Quality Improvement Act
D.Health Care Quality Improvement Act
A healthcare facility uses ________________ to manage the information needed to meet the needs of the organization. A.Informatics B.Data analytics C.Data use D.Information governance
D. Information governance
The average length of stay (LOS) for acute care hospitals is ____. A.Greater than 30 days B.Less than 20 days C.Greater than 45 days D.25 days or less
D.25 days or less
Dr. Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? A.A disease index B.A master patient index C.An operative index D.A physician index
D.A physician index
The UHDDS's core data elements were incorporated into the ___________ prospective payment system. A.Outpatient B.Long-term care C.Inpatient rehabilitation D.Acute inpatient
D.Acute inpatient
A new employee has been hired to link patient information such as patient name to a scanned document. This employee will be _____. A.Analyzing B.Versioning C.Indexing D.Assembling
D.Assembling
Cancer registries are maintained by hospitals: A.By federal law or state law B.Voluntarily or by state law C.Voluntarily or by federal law D.By mandate from the American College of Surgeons
D.By mandate from the American College of Surgeons
The healthcare organization has decided to treat Medicare patients therefore, they must meet the A.Terms of Accreditation B.Regulations for Licensure C.Requirements for Service The healthcare organization has decided to treat Medicare patients therefore, they must meet the A.Terms of Accreditation B.Regulations for Licensure C.Requirements for Service D.Conditions of Participation
D.Conditions of Participation
A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a heart attack. The combined data is referred to as _______________. A.Information B.Components C.Characterization D.Data
D.Data
A visual process to understand the data being collected in two different systems and how it is linked to one another is known as _____. A.Data evaluation B.Data warehousing C.Data mining D.Data mapping
D.Data mapping
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a ____ A.Data chargemaster report B.Data map C.Data dictionary D.Database management system
D.Database management system
In designing an input screen for an EHR, which of the following would be best to capture data? A.Speech recognition B.Natural language processing C.Drop-down menus D.Document imaging
D.Document imaging
To capture data in a specific manner, the EHR should use _____. A.Database B.Template C.Core measures D.Document imaging
D.Document imaging
HIPAA administrative requirements include _____. A.Designating a privacy officer B.Designating a contact department to receive complaints about violations C.Hiring an attorney to handle all aspects of HIPAA compliance D.Establishing HIPAA privacy training for clinical employees only
D.Establishing HIPAA privacy training for clinical employees only
Which of the following is the standard for healthcare equipment under HIPAA? A.HCPCS Level I B.CPT C.ICD-10-PCS D.HCPCS Level II
D.HCPCS Level II
Interoperability is a process that integrates all health information into one database. : True/False
False
Long-term care is mainly rehabilitative and supportive rather than curative. : True/False
False
The AMA is responsible for the publishing and maintaining HCPCS Level II. :True/False
False
The Component state associations are the group(s) in charge of AHIMA's volunteer structure. :True/False
False
The HIPAA consent is usually obtained at the time of patient discharge. : True/False
False
List in order the steps of the Systems Development Life Cycle: Identify need: Specify requirements: Design or acquire: Develop or implement: Monitor results: Maintain:
Identify need: 1 Specify requirements: 2 Design or acquire: 3 Develop or implement: 4 Monitor results: 6 Maintain: 5
Review health record for missing signatures. Quantitative or Qualitative?
Qualitative
Review of health record for approved abbreviations. Quantitative or Qualitative?
Qualitative
Review of health record for timeliness of documentation. Quantitative or Qualitative?
Qualitative
Review health record for legibility. Quantitative or Qualitative?
Qualitative
Review health record for missing reports. Quantitative or Qualitative?
Quantitative
A list of recommended data elements with uniform definitions is a code system. : True/False
True
A risk analysis is useful to identify a security breach. : True/False
True
A standard is a concept that represents fixed rules that must be followed :True/False
True
An electronic health record (EHR) allows access to evidence-based tools that providers can use to make decisions about a patient's care. : True/False
True
Artificial intelligence is a form of big data that helps make specific recommendations. : True/False
True
Blue Cross and Blue Shield is an institutional user of the health record. :True/False
True
CONNECT is a more sophisticated structure that enables both receipt of data and the ability to query a health information exchange for the availability of data. : True/False
True
Data warehousing is the process of extracting information stored in structured data formats within a database. : True/False
True
Document imaging was eliminated by the electronic health record system. : True/False
True
Documentation that tells the nurses and others what to do is the diagnostic and therapeutic orders. :True/False
True
HIPAA represents an attempt to establish best practices and standards for health information security. : True/False
True
If a covered entity does not wish to calculate actual or average costs for electronic PHI, the Office for Civil Rights recommends $10.00 as a flat fee. : True/False
True
Ingredient plus strength plus does form is known as the Semantic clinical drug term type. : True/False
True
J codes are used for drugs administered other than by oral method. : True/False
True
Managed care organizations deliver medical care and manage all aspects of patient care by limiting providers of care, discounting payments to providers of care, or limiting access to care. : True/False
True
