RHIA exam
A database rule that states "patient gender must be recorded as M=male, F=female, and U= unknown" is referred to as: A. Authorization management B. Data map C. Application control D. Knowledge management
C
A health record that includes all health-related information generated for an individual during his or her lifetime is called: A. Electronic health record B. Latitudinal health record C. Longitudinal health record D. Personal health record
C
Average number of AR days
30-70
A hospital is reviewing the quantity and type of resources being used in the provision of chemotherapy treatments. This is an example of: A. FOCUS-PDCA review B. Accreditation review C. Medication reconciliation D. Utilization management review
A
A medical staff committee wants to compare long-term survival rates for breast cancer by comparing outcomes for the mastectomy versus lumpectomy approaches. The best source of this information is the: A. Cancer registry B. Disease index C. Master patient index D. Operative index
A
A patient was admitted to the hospital for treatment of a myocardial infarction (heart attack) and the MS-DRG assigned was 236 Coronary bypass without cardiac cath without MCC. During the patient's admission a bypass procedure was performed on day 2. On day 4, the patient was diagnosed with sepsis that was not present on admission. Sepsis is a major complication. This case was identified as coded incorrectly in a recent audit by the coding manager. What error was made by the coder? A. The sepsis was not coded and so an MCC was missed. B. The coronary bypass procedure was coded incorrectly. C. The claim was coded correctly, and no error was made. D. The cardiac catheterization procedure was not coded.
A
A patient who was admitted for treatment of an intervertebral disk injury developed a urinary tract infection and fever several days after undergoing surgery. In this situation the urinary tract infection would be classified as: A. Healthcare-associated infection B. Hospital sickness C. Community-acquired infection D. Community sickness
A
A physician takes the health records of a group of HIV-positive patients out of the hospital to complete research tasks at home. The physician mistakenly leaves the records in a restaurant where they are read by a newspaper reporter who publishes an article that identifies the patients. The physician can be sued for: A. Invasion of privacy B. Libel C. Slander D. Willful infliction of mental distress
A
A secretary in the nursing office was recently hospitalized with ketoacidosis. She comes to the HIM department and requests to review her health record. Of the options listed, what is the best course of action? A. Allow her to review her record after obtaining authorization from her. B. Refer the patient to her physician for the information. C. Tell her to go through her supervisor for the information. D. Tell her that hospital employees cannot access their own health records.
A
A security breach has been reported. What concept describes the process used to gather evidence? A. Forensics B. Risk assessment C. Security incident D. Security event
A
"Mother died of breast cancer, father still living but has heart disease" is an example of what type of health record documentation? A. Discharge summary B. History report C. Physician's order D. Physician's progress note
B
A transcription manager is assigned to a project team that is implementing a voice-recognition system. He reports to the director of health information services for regular job functions and to the project manager for tasks related to the project. This is an example of which type of project management structure? A. Matrixed B. Projectized C. Functional D. Hybrid
A
An HIM professional who releases health information that he or she knows will result in genetic discrimination is violating the ethical principle of: A. nonmaleficence B. Autonomy C. Beneficence D. Justice
A
As the corporate director of HIM Services and enterprise privacy officer, you are asked to review a patient's health record in preparation for a legal proceeding for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being lackadaisical with record completion practices. Previous concerns regarding this physician's record maintenance practices had been reported to the facility's Credentialing Committee. Are the summaries of the two procedures admissible in court? A. This information could be rejected since the physician dictated the procedure note after the malpractice suit was filed. B. This information will be admissible in court because it is part of the patient's health record. C. This information could be rejected because it is not relevant to the malpractice case. D. This information will be rejected because the patient did not authorize its release
A
At the end of March, the HIM department has a year to date (YTD) payroll budget of $100,000. The actual YTD amount paid is $95,000 because a coder resigned in February. For the past two months, the position has been filled through outsourcing. Therefore, the actual YTD amount for consulting services is $5,000, although no money was budgeted for consulting services. The reporting threshold for variances is 4%. The fiscal year-end is December. What is the best description of the payroll variance for this year? A. Favorable, permanent B. Unfavorable, permanent C. Favorable, temporary D. Unfavorable, temporary
A
Coding accuracy is best determined by: A. A predefined audit process B. Medicare Conditions of Participation C. Payer audits D. Joint Commission Standards for Accreditation
A
Detailed procedures should be able to: A. Create consistent outcomes for tasks done B. Eliminate the need for process improvement C. Eliminate the need to train a new employee D. Replace policies
A
Highland Hospital requires all dates be recorded in its clinical information system as MM/DD/YYYY. This required data definition and format should be part of the________. A. data dictionary B. database administration system C. decision support system D. tacit information system
A
If a physician coerces a patient into undergoing experimental treatments, the contract between them may be void based on which defense for nonperformance? A. Duress B. Fraud C. Illegality D. Mistake of fact
A
In its payment notice (remittance advice), the healthcare plan lists that the payment for an individual laboratory test is $39. The bill that the pathologist's office submitted for the laboratory test was $45. What does the amount of $39 represent? A. Allowable charge B. Capitated rate C. Cost D. Premium
A
It is important to evaluate a health information system implementation. All of the following are recommended as measures to determine appropriate performance except for the: A. Amount of electricity used B. Percentage of system downtime C. Unintended consequences D. Number of alerts triggered
A
Of the following disclosures of PHI, which one allows an individual the option to agree or disagree with the disclosure of the information? A. Facility directory B. Treatment, payment, and operations C. Workers' compensation D. Information regarding decedents
A
Protected health information, subject to HIPAA protection, is defined by all of the following criteria except: A. It must be identifiable health information regardless of who holds or uses it B. It must either identify the person or provide a reasonable basis to believe the person could be identified from the information given C. It must relates to one's past, present, or future physical or mental health condition; the provisions of healthcare or payment for the provision of healthcare D. It must be held or transmitted by a covered entity or its business associate
A
The HIM manager at Anywhere Hospital has contracted with an outside vendor to handle the complete cancer registry function for the facility. This type of contract for services would be considered: A. Full service B. Project based C. Temporary D. Specialty function
A
The HIPAA Security Awareness and Training administrative safeguards require all but one of the following addressable implementation programs for an entity's workforce. A. Disaster recovery plan B. Login monitoring C. Password management D. Security reminders
A
The Joint Commission measures that are standardized metric tools that provide an indication of an organization's performance are called: A. Core Performance Measures B. Measures of Central Tendency C. Performance Improvement Measures D. Vital Statistics Measures
A
The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems except which of the following? A. Alphabetical B. Middle-digit C. Terminal-digit D. Straight numerical
A
The most important information to include in an informed consent in biomedical research is the: A. Description of risk B. Name of the sponsor C. Specific names of drugs and substances used D. Timeline for the project
A
The process of reviewing and validating a physician's education and experience prior to granting medical staff membership is called: A. Credentialing B. Outcomes management C. Surveillance D. Utilization review
A
This EHR implementation strategy identifies the sequence of implementing the EHR with regard to various inpatient units, departments, physicians, or other categories of users or sites. A. Phased rollout B. Big bang rollout C. Pilot D. Straight turnover
A
The SOAP format is an example of a structured progress note commonly used with the ______ health record. A. integrated system B. patient-oriented C. problem-oriented D. source-oriented
C
What factor is medical necessity based on? A. The beneficial effects of a service for the patient's physical needs and quality of life B. The cost of a service compared with the beneficial effects on the patient's health C. The availability of a service at the facility D. The reimbursement available for a given service
A
What information might be displayed on a histogram? A. Discharges by age B. Discharges by sex C. Discharges by third-party payer D. Discharges by service
A
When an Entity Relationship Diagram (ERD) is implemented as a relational database, an attribute will become a(n): A. Field B. Object C. Query D. Table
A
Which of the following basic services provided by an HIE organization provides authentication? A. Identity management B. Person identification C. Registry and directory D. Secure data transport
A
Which of the following fields of informatics largely focuses on developing tools and processes to empower patients? A. Consumer B. Health C. Medical D. Nursing
A
Which of the following is an example of a technical safeguard? A. Assigning passwords that limit access to information stored electronically B. A policy that states that only authorized people can access the data center C. A policy that states that passwords cannot be shared D. Locking the door of the data center
A
Which one of the following facility types is required to release information under the Freedom of Information Act? A. Military B. Private C. Proprietary D. State
A
Why are metadata essential in information systems? A. They provide the means to locate, retrieve, use, and manage data B. They identify the organization's most important data assets C. They provide data safeguards D. They identify the disposition of data
A
Data warehouse
A centralized database that consolidates company-wide data from a variety of operational systems
Closed record review
A review of records after a patient has been discharged from the organization or treatment has been terminated - no new submissions
In this level of interoperability, the receiving computer has some information regarding the nature of the information being exchanged, but does not have complete and shared understanding with the sending system. A. Basic B. Functional C. Semantic D. Process
B
Medicare requires that a history and physical examination be completed within what time frame after a patient's admission to a hospital? A. 12 hours B. 24 hours C. 48 hours D. 72 hours
B
Basic interoperability
Ability for different systems to connect and exchange information
Define unfavorable variance
Actual costs are higher than projected costs
Define AR days
Amount of time it takes to receive payment on a claim
Define solicitation
An act by an employee to convince a patient to obtain services from somewhere other than the employer's practice
Define beneficence
An act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation
Define arbitration
An arrangement in which a patient waives rights to sue a healthcare worker.
Define data mining
Analysis of large data sets to discover patterns and use those patterns to predict the likelihood of future events
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper-GI series and laboratory evaluation of CBC and urinalysis. The x-ray revealed possible cholelithiasis and the urinalysis showed an elevated white blood count. The patient was taken to surgery for an exploratory laparotomy and a ruptured appendix was discovered. After an appendectomy was performed and appropriate postoperative care given, the patient was discharged from the hospital on 1/20. According to Joint Commission standards, the surgeon's operative report must be written or dictated and filed on the patient's health record: A. Before discharge B. Immediately after surgery C. Within 24 hours D. Within 48 hours
B
A hospital has experienced an increase in third-party payer denials for lack of pre-authorization for certain services. Which of the following departments should hospital administration scrutinize to ensure that proper procedures are in place? A. Health information management B. Patient registration C. Patient accounts D. Utilization management
B
A hospital's utilization review committee would like to see data that show the monthly admissions to five different units over the past year. Which of the following techniques for data display would work best? A. Histogram B. Line chart C. Pie chart D. Stem and leaf plot
B
A patient's name is typically stored in a database as three data elements-last name, first name, and middle name-and not as a single data element. Which dimension of data quality is being applied when this occurs? A. Accuracy B. Granularity C. Precision D. Currency
B
A pharmacist who submits Medicaid claims for reimbursement of brand name drugs when less expensive generic drugs were actually dispensed has committed the crime of: A. Criminal negligence B. Fraud C. Perjury D. Products' liability
B
A visitor walks through the IT department and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? A. Device and media controls B. Facility access controls C. Workstation use controls D. Workstation security controls
B
Allowing employees to solve problems within the scope of their job is a characteristic of: A. Adult learning B. Empowerment C. Flexing D. Outsourcing
B
Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors for which of the following Code of Ethics principle? A. Advocate and uphold the right to privacy B. Put service before self-interest C. Represent the profession accurately to the public D. Respect the inherent dignity and worth of every person
B
An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should have been implemented that could minimize this security breach? A. Audit controls B. Information access controls C. Facility access controls D. Workstation security
B
Community Hospital is implementing a hybrid record. Some documentation will be paper-based and digitally scanned after discharge. Other parts of the record will be totally electronic. The Medical Record Committee is discussing how interim reports in the health record should be handled. Some on the committee think that all interim reports should be discarded and only the final reports retained in the scanned record. Others take the opposite position. Which of the following is a best practice that the health information management (HIM) director should suggest to the committee? A. Discarding all final reports is the best option B. Maintaining all interim reports provides the greatest measure of security. C. Discarding all interim reports is the best option. D. Maintaining only final reports results in a high volume of duplicate reports.
B
Consumer education about the PHR must include which of the following items in order for consumers to embrace it? A. Direct electronic tie-in with the consumers' insurance provider B. Information about security and confidentiality C. Standardized form and presentation D. Web-based tools
B
Extracting data from a data set to determine trends and identify patterns is referred to as _____. A. Access control B. Data mining C. Portal entry D. E-commerce
B
Facility-based cancer registries receive approval as part of the facility cancer program from which of the following agencies? A. American Cancer Society B. American College of Surgeons C. National Cancer Institute D. National Cancer Registrars Association
B
If a nurse uses the abbreviation CPR to mean cardiopulmonary resuscitation one time and computer-based patient record another time, which leads to confusion, what would be a concern when applying this dimension of data quality? A. Accuracy B. Consistency C. Currency D. Precision
B
If a patient is readmitted to a facility after a recent admission, CMS allows the facility to use the existing history and physical from the first admission if it is for a related condition and was completed within _____ of the second admission and if an interval note updating any changes to the patient's condition has been documented. A. 7 days B. 30 days C. 48 hours D. 72 hours
B
If the agreement rate on retrospective queries for a physician is 100 percent, this could be a sign of: A. A lack of responsiveness B. Leading queries C. Cooperation D. Exceptionally well-written queries
B
In a typical acute-care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error-free claims (clean claims) are submitted to third-party payers? A. Accounts receivable B. Claims processing C. Claims reconciliation or collections D. Pre-claims submission
B
In data quality management the purpose for which data are collected is: A. Analysis B. Application C. Collection D. Warehousing
B
In project management terminology, what is the definition of variance? A. The scope-limiting statements B. The difference between the original project plan (in terms of work, cost, and schedule estimates) and the actual progress or revised estimates C. The process of making actual progress and the remaining efforts from project team members D. The requests for changes to the original project scope
B
The Joint Commission requires a varying number of safety functions and plans depending on the license or services provided by an organization. The standards require the assessment of safety features for patients, staff, and visitors. Which of the following lists are required safety standard plans for the environment of care? A. Emergency management, security management, and patient management B. Medical equipment management, life safety management, and emergency management C. Employment management, hazardous materials and waste management, and life safety management D. Utilities management, employment management, and medical equipment management
B
The four major issues that have an impact on the record retention policy of a healthcare facility are patient care, research, space, and: A. Destruction policy B. Legal and statutory requirements C. Microfilm costs D. Readmission rates
B
The medical transcription improvement team wants to identify the cause of poor transcription quality. Which tool could help them accomplish this objective? A. Flowchart B. Fishbone diagram C. Pareto chart D. Force field analysis
B
The period of time between discharge and claim submission, which a facility defines by policy, is called the: A. AR days B. Bill hold C. Cash flow days D. Denial period
B
What data set provides the underpinning of the home health prospective payment system (HH PPS)? A. HAVEN B. OASIS C. MHDS D. UHDDS
B
What is the term to describe whether a person can obtain, process, and understand basic health information and services needed to make suitable health decisions? A. Patient experience B. Health literacy C. Activation D. HealthyPeople 2020
B
What is the unique impact HIM professionals have on coded data? A. Attention to data quality provides unique identification of patients in a healthcare enterprise. B. Combining knowledge of the clinical content, documentation principles, coding systems, and data use provides accurate information for the industry. C. Providing current literature and research outcomes enhances clinical knowledge at the point of care. D. Understanding the clinical context of costs and the rules for reimbursement improves organizational decision making.
B
When managing the master patient index (MPI) which of the following would be the biggest concern for the health information professional? A. Physical space to house the server B. Duplicate record numbers C. Maintaining the database D. Number of computers in registration
B
Which activity would typically occur during the analysis phase of the systems development life cycle (SDLC)? A. Building interfaces B. Defining deficiencies in the existing system C. Researching vendor qualifications D. Submitting RFI to vendors
B
Which of the following clinicians would use the DSM-V system to assist with establishing a diagnosis? A. Physical therapists B. Practicing psychiatrists C. Registered dietitians D. Registered nurses
B
Which of the following describe the EHR product's data architecture, analytical processes supported, necessary interfaces, reliability and security features, system capacity, expansion capabilities, response time, downtime, and other issues associated with system maintenance? A. Functional specifications B. Operational requirements C. Organizational profile D. Vendor information
B
Which of the following is a factor that affects the cost of release of information? A. Labor and malpractice insurance B. Labor and postage C. Malpractice insurance and copies D. Postage and hospital charges
B
Which of the following is a retention concern with electronic health records? A. Durability B. Hardware obsolescence C. Storage space D. Statute of limitations
B
Which of the following is an example of a 1:M relationship? A. Patients to consulting physicians B. Patients to hospital admissions C. Patients to hospital health records D. Primary care physicians to patients
B
Which of the following is not an element of the external environmental assessment that should be part of a manager's routine scanning? A. The opinions of industry experts B. The opinions of employees C. Changes in healthcare policy and regulation D. What is happening in similar organizations in the community
B
Which of the following statements is true regarding HIPAA security? A. All institutions must implement the same security measures. B. HIPAA allows flexibility in the way an institution implements the security standards. C. All institutions must implement all HIPAA implementation specifications. D. A security risk assessment must be performed every year.
B
Which of the following statements most accurately characterizes the primary reason why today's managers must be able to think and act strategically? A. Traditional strategic planning has been very effective. B. The pace of change has compressed organizational response times. C. Senior management has more important things to do. D. Competitors are doing it.
B
Which of the following would be part of the release of information system? A. A letter asking for additional information on a patient previously treated at the hospital B. A letter notifying an individual that the authorization was invalid C. A letter notifying a physician that he has delinquent medical records D. A letter asking a physician to clarify a primary diagnosis
B
Which type of record is arranged in strictly chronological order? A. Sectional B. Correct Integrated C. Consolidated D. Source-oriented
B
Which work design tool uses an office layout to visualize the interaction of various work procedures? A. Job procedure B. Movement diagram C. Work distribution chart D. Workflow process
B
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case? A. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. B. Code urinary tract infection with sepsis as the principal diagnosis. C. Query the physician to ask if the patient has septicemia because of the symptomatology. D. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.
C
An HIM director wants to conduct research to learn about the physicians' view of the department's image. What type of scale should be used to collect data? A. Meta-analytical scale B. Purposive scale C. Semantic differential scale D. Two-point scale
C
An analyst was testing the hypothesis that there is an association between physician gender (M/F) and the willingness to use or not use CPOE. The value of the chi-square test statistic is 7.23. If the acceptable level of type I error was set to 0.01, what is the conclusion of the hypothesis test? A. Accept the null hypothesis B. Reject the alternative hypothesis C. Reject the null hypothesis D. Accept the alternative hypothesis
C
At Medical Center Hospital, HIM professionals are located in the nursing stations, where they are responsible for all aspects of health record processing. While the patient is in the facility, the HIM professional does a daily review of the record to ensure complete documentation. This approach is called a _____. A. Retrospective review B. Closed record review C. Concurrent review D. Post-discharge review
C
Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? A. Assign a code for the staph infection B. Put a note in the chart C. Query the physician D. Tell her supervisor
C
Coding compliance programs focus on preventing accusations of fraud and abuse in healthcare. Which organization from the Department of Health and Human Services provides guidance for healthcare organizations in developing compliance programs? A. Joint Commission B. American Health Information Management Association (AHIMA) C. Office of the Inspector General (OIG) D. Centers for Medicare and Medicaid Services (CMS)
C
Establishing security, confidentiality, retention, integrity, and access standards are examples of which HIM function? A. Classification and coding B. Data modeling C. Policy development D. Strategic planning
C
How does mentoring differ from coaching as a career development practice? A. Offers specific job-related training B. Reviews the work of the employee C. Most often performed by a senior employee D. Involves performance appraisal
C
How many days does a covered entity have to respond to an individual's request for access to his or her protected health information (PHI) when the PHI is stored off-site? A. 10 days B. 30 days C. 60 days D. 90 days
C
In a recent coding audit, the coding manager discovered the following issue: A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documented skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take in order to correctly code this encounter? A. Code basal cell carcinoma B. Code benign skin lesion C. Code skin lesion D. Query the dermatologist
C
In most cases, minors are deemed legally incompetent to access, use, or disclose their health information. What resource should be consulted in terms of who may authorize the ability to access, use, or disclose the health records of minors? A. HIPAA, because there are strict HIPAA rules regarding minors B. A hospital attorney, since they know the rules of the hospital C. State law, since HIPAA defers to state laws on matters related to minors D. State rules of evidence related to minors
C
In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals who want to see their own health information? A. When access to psychotherapy notes is requested B. When the covered entity is a correctional institution C. When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual D. When the covered entity has acted under the direction of a correctional institution
C
Key to the implementation of an effective performance improvement program is a written plan that systematically describes the structure and approach the organization will follow in the continuous assessment and improvement of its important systems, processes, and outcomes of care. Which of the following activities should be included in this plan? A. The patients decide the scope and focus of performance monitoring and data collection activities. B. The performance improvement reviews are arbitrary and focused on one service line. C. The organization sets priorities for performance improvement, ensuring that the scope of care, treatment, and services are represented across all disciplines. D. Data are systematically collected, aggregated, and analyzed on an infrequent basis.
C
Placing a condition about the award of a contract for laboratory services on the provision of an "under the table" percentage payback to a physician who has the ability to influence the decision about who is awarded the contract is called a(n): A. Arbitration B. Criminal bribery C. Kickback D. Solicitation
C
Problems that would be faced by an HIM professional responsible for _____ include curious employees who should not have access to health information, failures to log off electronic systems, and inappropriate data being stored on a personal laptop. A. data resource management B. e-Health systems C. information security D. software development and implementation
C
The HIM manager at Community Hospital needs to choose a database model that allows the facility to store images, video, and data. Which of the following should the HIM manager choose? A. Hierarchical database B. Network database C. Object-oriented database D. Relational database
C
The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this an example of? A. Authorization B. Consent C. Minimum necessary D. Notice of Privacy Practice
C
The Uniform Health-Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes: A. Adult sibling, adult child, spouse, parent B. Parent, spouse, adult child, adult sibling C. Spouse, adult child, parent, adult sibling D. Spouse, parent, adult sibling, adult child
C
The amount of money owed a healthcare facility when claims are pending is called: A. Bad debt B. Delayed revenue C. Dollars in accounts receivable D. Write-off account
C
The distinguishing feature of a results management application is that it: A. Captures charges for diagnostic studies and sends them to a billing system B. Directs the work of the departments that produce results of diagnostic studies C. Enables results of a diagnostic study to be compared and displayed with other data D. Provides diagnostic study information in viewable form
C
The first and most fundamental strategy for minimizing security threats is to: A. Establish access controls B. Implement an employee security awareness program C. Establish a security organization D. Conduct a risk analysis
C
The performance standard to "Deliver the record to the requester of a STAT request within 10 minutes of receiving the request" is an example of a: A. Compliance standard B. Joint Commission standard C. Quality standard D. Quantity standard
C
The primary purpose of a Minimum Data Set in healthcare is to: A. Define reportable data for federally funded programs B. Mandate all data that must be contained in a health record C. Recommend common data elements to be collected in health records D. Standardize medical vocabulary
C
The process of prescreening vendors before detailed vendor proposals are requested is called: A. Outsourcing analysis B. Proposal framing C. Request for information D. Systematic design
C
The standard that requires covered entities and business associates to have an agreement regarding use, disclosure, and security of protected health information is the: A. Business Associate Agreement Standard B. Covered Entity Contracts and Other Arrangements Standard C. Business Associate Contracts and Other Arrangements Standard D. Covered Entity and Business Associate Agreement Standard
C
This report should be written or dictated immediately after the procedure is done and filed in the patient's health record as soon as possible: A. Consultation report B. Discharge report C. Operative report D. Pathology report
C
Violations of the need-to-know principle and misuse of blanket authorizations are ethical problems pertaining to _____. A. Data resource management B. Genetic discrimination C. Release of information D. Requests for proposals
C
What work measurement tool uses random sample observations to obtain information about the performance of an entire department? A. Performance measurement B. Work distribution C. Work sampling D. Performance controls
C
When the Medicare Recovery Audit Contractor (RAC) has determined that incorrect payment has been made to an organization what document is sent to the provider notifying them of this determination? A. Appeal request B. Claims denial C. Demand letter D. Medicare Summary Notice
C
Which of the following is a solution to the problem of staff recruitment for coding and transcription? A. Cross-training B. Job rotation C. Telecommuting D. Web-based training
C
Which of the following is the key to the identification and location of a patient's health record in a numerical filing system? A. Deficiency slip B. Disease index C. Master patient index D. Outguide
C
Which of the following is the process of probing and extracting business data and information from a data warehouse and then quantifying and filtering the data for analysis purposes? A. Application systems analysis B. Multidimensional OLAPs C. Data mining D. Clinical data reporting
C
MPI
master patient index
Object-oriented database
Can work with complex data with different properties and methods
Define temporary variance
Changes in the planned timing of an activity due to delays or rescheduling
Decision support system
Computerized program used to supper determinations, judgements, and courses of action
Concurrent review
Continuing review to make sure the patient is getting the appropriate care
Define integrated
Coordinating care
A drug interaction alert would be a typical function of a _____. A. Data warehouse B. Data repository C. Data mart D. Decision support system
D
A leader who was using path-goal theory and determined that a worker was not performing well because of a lack of self-confidence would most likely use which of the following leadership behaviors to correct the situation? A. Achievement-oriented leadership B. Directive leadership C. Participative leadership D. Supportive leadership
D
An activity useful in diversity training that involves learners acting out a response to a hypothetical situation is known as: A. A classroom lecture B. Keyboarding C. Programmed learning D. Role playing
D
Competent individuals have which of the following rights in regard to healthcare? A. Right to consent to treatment and the right to destroy their original health record B. Right to destroy their original health record and the right to refuse treatment C. Right to access his or her own PHI and the right to take the original record with them D. Right to consent to treatment and the right to access his or her own PHI
D
Compliance with the Conditions of Participation allows a hospital to achieve: A. Commercial insurance reimbursement B. Joint Commission accreditation C. State licensure D. Medicare certification
D
Disciplinary action: A. Should vary based on to whom the employee reports B. Cannot be taken when employees are unionized C. Should be taken whenever there is a performance problem D. Should be documented at each step in the process
D
Electronic prescribing is used in: A. Computerized provider order entry B. Hospital order entry systems C. Pharmacy systems D. Physician's office prescription writing
D
Emphasis on group rather than individual achievement is stressed in the training topic called: A. Ethics B. Diversity C. Offshoring D. Team-building
D
In order to determine the hospital's expected MS-DRG payment, the hospital's blended rate is multiplied by the MS-DRG's ______ to determine the dollar amount paid. A. case mix number B. length of stay C. major diagnostic category D. relative weight
D
Providers should be queried regarding information in the health record for all of the following except: A. Conflicting documentation B. Ambiguous documentation C. Incomplete information D. Insignificant information
D
Securing the authorization of the attending physician, in addition to the patient's authorization, for the release of medical information to the patient's insurance company is: A. A legal requirement under the privileged communication statute B. A legal requirement under common law C. Necessary only if the patient is a minor D. Not legally required
D
Site surveyors always look for evidence of three trigger issues including very high percentages of patients suffering from dehydration, decubitus ulcers in low-risk residents, and fecal impaction within which type of healthcare setting? A. Acute-care hospital B. Ambulatory surgery center C. Behavior health facility D. Skilled nursing facility
D
The Contingency Plan Standard includes all of the following as required implementation standards except for which plan? A. Data backup plan B. Disaster recovery plan C. Emergency mode operation plan D. Environmental risk plan
D
The EMTALA regulations include all of the following except which? A. Transfers of non-stabilized patients must only occur under certain specific conditions. B. Every patient arriving at the emergency department must receive an appropriate "medical screening exam." C. If an emergency medical condition exists, the hospital must treat and stabilize that condition or transfer the patient. D. Non-Medicare indigent patients must be transferred to the nearest level-1 trauma center
D
The HIM manager is conducting a study that compares the ICD-9-CM and ICD-10-CM diabetes mellitus codes and documents variations in order to assess the impact on the organization. This process creates a: A. Data chargemaster report B. Data dictionary C. Database management system D. Data map
D
The ____ is an application within an organization's registration system that uniquely identifies the individuals who have received services. A. document management system B. EHR C. encoder D. master patient index (MPI)
D
The charge description master relieves the HIM department of ________ that does not require documentation analysis. A. Duplicate coding B. Manual coding C. Procedure coding D. Repetitive coding
D
The director of Health Information Services is allowed access to the health record tracking system when providing the proper login and password. Under what kind of access security mechanism is the director allowed access to the system? A. Context-based B. Role-based C. Situation-based D. User-based
D
The health information manager is conducting a patient satisfaction survey in an outpatient clinic. Because the clinic typically sees about 300 people per day, the manager decides to have the interviewers administer the questionnaire on every tenth patient. This is an example of what type of sampling: A. Cluster sampling B. Convenience sampling C. Stratified sampling D. Systematic sampling
D
The legal health record must meet requirements from the following: A. Federal regulations and AHIMA B. State laws and insurance companies C. AHIMA and accreditation body standards D. State laws and accreditation body standards
D
The management of a high-quality, error-free master patient index (MPI) requires constant maintenance. A comprehensive MPI maintenance program would include all of the following except: A. Ongoing processes to identify and address existing errors B. Mechanisms for efficiently detecting, reviewing, and resolving potential errors C. Reliable links to different health record numbers and other identifiers for the same person D. Correct Ways to find out where the patient's health information has been shared for purposes other than care
D
The primary goals of which of the following groups are to enable health information to follow the consumer, to make health information available for clinical decision making, and to support appropriate use of healthcare information beyond direct patient care? A. EHR Collaborative B. Health Level Seven C. National Committee on Vital and Health Statistics D. National Health Information Network
D
What application of data mining is used to identify potential fraudulent Medicare claims? A. Database modeling B. Knowledge management C. Total quality management D. Predictive modeling
D
What information does not have to be included in a covered entity's notice of privacy practice? A. A description with one example of disclosures made for treatment, payment, and healthcare operations B. A description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization C. A statement of individual's rights with respect to PHI and how the individual can exercise these rights D. The signature of the patient and date the notice was given to the patient
D
What project management tool focuses on the percentage completion of a task but does not show a link between one or more tasks? A. PERT chart B. Project management C. Planning and design D. Gantt
D
Which of the following is a continuous quality improvement (CQI) tool frequently used to display data? A. Brainstorming B. Multivoting C. Nominal group technique D. Scatter diagram
D
Which of the following provides a complete description to patients about how PHI is used in a healthcare facility? A. Authorization B. Consent for treatment C. Minimum necessary D. Notice of Privacy Practices
D
Which of the following purchases would most likely be considered a capital budget item? A. A cost of less than $50 with life expectancy of 5 years B. A cost of more than $50 with a life expectancy of 6 months C. A cost of more than $1,000 with a life expectancy of 3 months D. A cost of more than $1,000 with a life expectancy of 3 years
D
Which of the following statements about compiling a directory of patients being treated in the hospital is true? A. A written authorization from the patient is required before any information about him or her is placed in a hospital directory of patients. B. Because this is considered a normal hospital operation, an individual may not restrict or prohibit any uses of the directory. C. Only the patient's last and first name may be placed in a directory without his or her consent or authorization. D. The covered entity must inform the individual what information is maintained in a directory and to whom this information may be disclosed.
D
Which of the following would likely head the list of important performance measures for evaluating the results of strategic change? A. Satisfaction and attitudes B. Relationship of cost to benefits achieved C. Relative competitive advantage D. Results compared to performance targets
D
Which term describes the ability of one information system to exchange data with another information system? A. Certified B. Deterministic C. Integrated D. Interoperable
D
Which terminology provides a common language that enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care for electronic health record (EHR) adoption? A. DEEDS B. ICD-10-CM C. OTLP D. SNOMED CT
D
Return of investment (ROI) formula
investment gain/initial investment
Data mart
Data focused on a specific department - a defined group
Hierarchical database
Data is organized in a tree-like structure
Straight turnover implementation
Designated groups go live one at a time
Retrospective review
Determining coverage after treatment has been given
Define blanket authorization
Direct authority to act without having to gain approval for action
Process interoperability
Diverse processes working together by merging functionality at certain shared elements and points
Phased rollout
Done in increments
Matrix management
Dual-reporting
Define minimum necessary
Evaluation of practices to enhance safeguards needed to limit unnecessary, or inappropriate, access to, and disclosure, of protected health information
Define bill hold
Facility-defined number of days in which an account will be held from billing so charges can be entered after the patient is discharged.
Define justice
Fair treatment of patients to be treated without discrimination by medical professionals
Rate of compliance formula
actual/suspected
Define systematic sampling
Fixed starting point, target population
Longitudinal health record
Generated by one or more encounters in any care setting
Define favorable variance
Generated more revenue than expected
PERT chart
Graph that shows representation of a project's timeline
Define interoperable
Health systems working together
Define kickback
Healthcare worker using payment, or any type of compensation, to encourage patients to come to their practice
Semantic interoperability
Highest level Structures data exchange and codes the data including vocabulary needed to interpret
Define criminal negligence
Ignoring a known risk in disregards of the life and safety of a patient
Define perjury
Knowingly and intentionally making false statements under oath, or signing a document that is misleading
Tacit information system
Knowledge derived from direct experience and action
Define Slander
Libel, but VERBAL
Define libel
Making a WRITTEN report on the health of a patient to another person
Define products' liability
Manufacturers, distributors, suppliers, retailers, and others who make products available to the public are held responsible for the injuries those products cause.
Define mistake of fact
Material error in facts or circumstances
Define cash flow days
Monitoring the cash collections and expenses generated from operations
Functional management
Most common Grouped by areas of specialties
Network database
Multiple member records can be linked to multiple owners -upside down tree
Define permanent variance
Once occurred, cannot be corrected and spending/income will not recover without action
Data repository
Place that holds data, makes it readily available to use, and organized in a logical manner
Define nonmaleficence
There is an obligation not to inflect harm on others
Example of infliction of emotional distress
Racial insults, sexual discrimination, false imprisonment, etc.
Define cluster sampling
Random Used in a larger population
Define stratified sampling
Random as well Splits off the population into smaller groups based on similarities
Define denial period
Refusal of an insurance company to honor a request by an individual to pay for services
Define purposive scale
Research that relies on personal judgement
Relational database
Stores and provides access to data points that are related to one another
Define semantic differential scale
Survey that asks people to provide ratings
Pilot implementation
System is tested in a realistic setting
Define fraud
The filing of dishonest healthcare claims in order to turn a profit
Define autonomy
The right of patients to make decisions about their medical care without their healthcare provider trying to influence the decision
Functional interoperability
Two or more systems working together to fulfill end-to-end processes
Define duress
Unlawful pressure put upon a person to coerce them to perform an act not necessarily wanted
Big bang rollout
implementation happens in a single instance
Granularity
refers to the level of detail
SOAP format
subjective, objective, assessment, plan
debt ratio formula
total liabilities/total assets