Term
The first computer sytems used in healthcare were used primarily to perform payroll and ___ functions
a. Performance improvement
b. Data processing
c. Decision making
d. Patient accounting |
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Definition
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Term
The concept of systems integration refers to the healthcare organization's ability to ___.
a. Combine information from any system within the organization
b. Use information from one system at a time
c. Combine information from sytems outside the organization
d. Use information strictly for administrative purposes |
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Definition
a. Combine information from any system within the organization |
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Term
In addition to patient care, clinical information systems may be used for ___.
a. Peer review
b. Research
c. Quality Improvement
d. All of the above |
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Definition
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Term
In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ___ systems.
a. MIS
b. CDS
c. ADT
d. ABC |
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Definition
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Term
A management information system is different from a strategic decision support system in that it produces reports for ___ and tactical decision making.
a. Educational
b. Operational
c. Clinical
d. Quality |
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Definition
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Term
The chief information officer is a senior-level executive who is responsible for ____.
a. Managing the security of all patient-identifiable information.
b. Ensuring the organization's compliance with federal, state, and accrediting body rules and regulations on confidentiality
c. Ensuring the IS implementation plans are in line with the organization's strategic vision
d. Leading the organization's strategic IS planning process. |
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Definition
d. Leading the organization's strategic IS planning process |
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Term
Which of the following systems is designed primarily to support patient care by providing healthcare professionals access to timely, complete, and relevant information for patient care purposes?
a. Administrative information system
b. Clinical information system
c. Management Support system
d. Strategic information system |
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Definition
b. Clinical information system |
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Term
Which of the following information systems is used for collecting, verifying, and reporting test results?
a. Laboratory information system
b. Nursing information system
c. Pharmacy information system
d. Radiology information system |
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Definition
a. Laboratory information system |
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Term
Which of the following information systems is used to assist healthcare providers in the actual diagnosis and treatment of patients?
a. Clinical decision support system
b. Laboratory information system
c. Management information system
d. Pharmacy information system |
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Definition
a. Clinical decision support system |
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Term
Which of the following information systems is considered an administrative information system?
a. Financial information system
b. Laboratory information system
c. Nursing information system
d. Radiology information system |
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Definition
a. Financial information system |
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Term
Who is the top information executive responsible for strategic information systems planning and overseeing the organizationb's information resources management?
a. Chief executive officer
b. Chief information officer
c. Chief privacy officer
d. Chief security officer |
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Definition
b. Chief information officer |
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Term
Which of the following systems focuses on providing reports and information to managers for day-to-day operations of the organization?
a. Executive information system
b. Clinical decision support system
c. Management information system
d. Strategic decision support system |
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Definition
c. Management information system |
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Term
The concept of information resource management assumes ____.
a. That the organization will employ computer technology
b. Information sources are readily identifiable and under the control of the organization
c. That information is a valuable resource that must be managed no matter what form it takes
d. All of the above |
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Definition
c. That information is a valuable resource that must be managed no matter what form it takes |
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Term
Which of the following IS positions has evolved into a more important position since the passage of HIPAA regulations?
a. CIO
b. CSO
c. HIA
d. ISA |
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Definition
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Term
Which of the following best describes the function of a management information system?
a. Supports day-to-day activities
b. Supports long-range planning
c. Proves unstructured decisions
d. Provides ad-hoc reports |
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Definition
a. supports day-to-day activities |
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Term
Which of the following is NOT a characteristic of a DSS?
a. Provides ad-hoc reports
b. Provides day-to-day reports
c. Uses statistical modeling
d. Answers what-if questions |
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Definition
b. Provides day-to-day reports |
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Term
Which of the following is used primarily for monitoring performance?
a. DSS
b. EIS
c. ES
d. MIS |
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Definition
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Term
Which of the following best describes an EIS?
a. Produces periodic, exception, and demand reports
b. Provides analytical tools and statistical methods to analyze data
c. Is used to solve problems in a narrowly focused knowledge area
d. Provides immediate access to information relating to the organization's key success factors |
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Definition
a. Produces periodic, exception, and demand reports |
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Term
Which of the following best describes a data warehouse?
a. A large storage of data used for strategic decision support
b. Data stored on multiple PCs
c. A complete storage of data about all transactions in a healthcare organization
d. A complete storage of data used for day-to-day decisions |
|
Definition
a. A large storage of data used for strategic decision support |
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Term
The coding supervisor wants a daily report of health records that need to be coded. Which of the following systems would be best in meeting the supervisor's needs?
a. CDSS
b. DSS
c. EIS
d. MIS |
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Definition
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Term
A physician wants an automated system that allows input of signs, symptoms and results of laboratory tests and provides a list of provisional diagnoses. Which of the following would best meet the physician's needs?
a. CDSS
b. DSS
c. EIS
d. MIS
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Definition
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Term
The average length of stay for Hospital A is 4.3 and for Hospital B is 5.1. This is an example of what type of information:
a. Patient specific
b. Aggregate
c. Expert knowledge-base
d. Comparitive information |
|
Definition
d. Comparitive information |
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Term
A number of healthcare organizations share information. These organizations have disparate systems. This describes a(n):
a. electronic health record
b. health information exchange
c. shared system
d. clinical information system |
|
Definition
b. health information exchange |
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Term
The physician records his findings while still in the patient's room. This is called:
a. computers on wheels
b. alerts
c. point-of-care documentation
d. embedded guidelines |
|
Definition
c. point-of-care documentation |
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Term
Smart ID. The duplicates tab is used to display information about:
a. potential identity fraud cases
b. records that are potential matches
c. duplicate copies of chart documents
d. duplicate tests performed in the system |
|
Definition
b. records that are potential matches |
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Term
What tool does SmartID use to identify possible matches?
a. Deterministic algorithms
b. Probabalistic algorithms
c. Pattern matching
d. Deterministic algorithms |
|
Definition
b. Probabalistic algorithms |
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Term
What visual tool does Smart ID use to indicate the probability of a duplicated pair?
a. Font
b. Graphs
c. Percentages
d. Colors |
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Definition
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Term
|
Definition
*Most accurate algorithm
*Smart ID assigns a score of weight to each record
* Uses complex mathematical formulas to analyze the MPI data |
|
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Term
|
Definition
* Allows the organization to assign weights to particular data |
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Term
|
Definition
* Requires an exact match on a combination of data elements
* Weak in identifying individuals where there is a transposition of numbers or letters |
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Term
| True or False: SmartID uses a mainframe architecture |
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Definition
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Term
SmartID is:
a. a server/client relationship with a facility's registration system.
b. a registration software
c. an advanced person search software
d. a deterministic algorithm |
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Definition
c. an advanced person search software |
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Term
Whose responsibility is it to complete the medical record?
a. HIM staff
b. Administration
c. Patient accounting
d. Provider |
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Definition
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Term
McKesson - What is the purpose of the aging basis button?
a. tracks the age of the patient
b. tracks the date the patient was discharged
c. tracks the timely completion of the deficiency
d. tracks the number of deficiencies in the record |
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Definition
c. tracks the timely completion of the deficiency |
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Term
| McKesson - Which four common deficiency types are included in the simulation? |
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Definition
missing signature, missing text, misfiled report, missing dictation |
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Term
If a deficiency is not corrected within the facility's established time-frame, the record becomes:
a. automatically complete
b. unbillable
c. remains incomplete and becomes an inactive record
d. delinquent |
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Definition
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Term
| McKesson T or F - When a report is missing, the responsible provider must complete it. The provider's name is entered into the system by using a radio button to select his/her name |
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Definition
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Term
McKesson - The charts ready for analysis have been placed in:
a. personal
b. queues
c. to do
d. discharges |
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Definition
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Term
| McKesson T or F: The chart index lists the document in the chart? |
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Definition
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Term
| McKesson T or F: The missing text deficiency is also used to alert physicians when there are blanks in a dictated report |
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Definition
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Term
McKesson - Which is an example of an indexing error?
a. a document being scanned into the wrong patient's chart
b. the wrong medical record number on a patient report
c. a report filed in the wrong patient's chart
d. all of the above are examples of indexing errors
e. a and b only
f. a and c only |
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Definition
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Term
The stakeholders of the health information exchange:
a. Include only healthcare providers
b. Include healthcare providers and insurers only
c. Are government agencies only
d. Include a wide variety of entities interested in patient information |
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Definition
d. Include a wide variety of entities interested in patient information |
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Term
The physician is able to look up the patient's health information from another physician practice and a hospital across town. He must be using a:
a. Shared system
b. Clinical information system
c. Turnkey system
d. Health information exchange |
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Definition
d. Health information exchange |
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Term
Which of the following is a role played by a health information manager in information systems?
a. Select the information system
b. Program the information system
c. Network the information system
d. Develop firewall |
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Definition
a. Select the information system |
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Term
Which of the following is a true statement?
a. The US leads the way in the EHR implementation
b. The US lags behind other countries in the EHR implementation
c. The US has the EHR in 75 percent of hospitals and 80 percent of physician offices
d. The US is working with Canada to implement the EHR across the two countries |
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Definition
b. The US lags behind other countries in the EHR implementation |
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Term
Which of the following is a true statement?
a. Clinical systems were the first to be implemented in healthcare
b. Financial information systems were first purchased as a turnkey system
c. Administrative systems were the first type developed and utilized in healthcare
d. Shared systems are no longer utilized |
|
Definition
c. Administrative systems were the first type developed and utilized in healthcare |
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Term
| T or F: Health information exchanges are designed specifically to benefit only healthcare providers |
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Definition
|
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Term
| T or F: Health information exchanges must be operated by governmental entities |
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Definition
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Term
| T or F: Clinical information systems collect and store information related to patient care |
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Definition
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Term
Which clinical information system assists the physician in recording orders and in the decision-making process?
a. Clinical provider order entry
b. Order entry/results reporting
c. Clinical decision support system
d. Point-of-care charting |
|
Definition
a. Clinical provider order entry |
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Term
I need a system that allows me to treat patients located at a different site. I should use:
a. patient monitoring system
b. multi-professional care pathways
c. clinical decision support systems
d. telematics |
|
Definition
|
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Term
A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n):
a. reminder
b. order entry/results reporting
c. alert
d. clinical decision support system |
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Definition
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Term
Dr. Rogers is sitting in his home office and reviewing digital images from a patient's MRI. He must be using a(n):
a. Laboratory information system
b. Radiology information system
c. Picture archival communication system
d. Electronic documentation |
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Definition
c. Picture archival communication system |
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Term
Which of the following systems would be an intermediate step toward the EHR?
a. Digital dication
b. Multi-professional care pathways
c. Document imaging
d. Point-of-Care documentation |
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Definition
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Term
| T or F: I need to look up the results of an H1N1 blood test. I would look this up on an emergency medical system |
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Definition
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Term
| T or F: A clinical decision support system will identify a medication contraindication |
|
Definition
|
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Term
| T or F: Document imaging is the same as the EHR |
|
Definition
|
|
Term
| T or F: Telematics is an example of a clinical information system |
|
Definition
|
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Term
| T or F: Embedded guidelines are recommendations for patient care |
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Definition
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Term
Which of the following systems would be used to manage productivity?
a. Financial information system
b. Human resource system
c. Embedded guidelines
d. Facility management |
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Definition
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Term
What is the difference between the executive information system and the decision support system?
a. There is no real difference since both are decision support systems
b. The decision support system is designed to be used by high-level management
c. The executive information system is designed to be used by high-level management
d. The executive information system is a strategic support system, and the decision support system is a clinical decision support system |
|
Definition
c. The executive information system is designed to be used by high-level management |
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Term
I will be conducting some analysis of data, but I only need a limited amount of data that are contained in the data warehouse. What system shall I utilize?
a. Data mart
b. Data mining
c. Online analytical process
d. Management information system |
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Definition
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Term
We receive a report each morning listing all of the admissions from the day before. This is an example of what type of report?
a. Ad hoc
b. Demand
c. Exception
d. Periodic scheduled |
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Definition
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Term
Which of the following is an example of when a decision support system should be used?
a. To develop the nursing schedule
b. To order food and other supplies for the cafeteria
c. To identify a new service for the hospital to implement
d. To prepare for hospital accreditation |
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Definition
c. To identify a new service for the hospital to implement |
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Term
Human resource management system |
|
Definition
Tracks productivity and turnover |
|
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Term
|
Definition
Uses models and statistical analysis to help decision makers solve problems |
|
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Term
|
Definition
Is updated periodically and used for strategic decision support |
|
|
Term
Executive information system |
|
Definition
Displays concise information and may be called a dashboard report |
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Term
Management information system |
|
Definition
Creates reports needed to manage the day-to-day activities of the organization |
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Term
What individual or group assists the CIO in developing the strategic vision for the organization's information?
a. steering committee
b. chief information security officer
c. chief medical information system officer
d. health information management department |
|
Definition
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Term
Information resource management addresses information in what form?
a. information stored electronically
b. information stored on paper
c. information stored in both electronic and paper formats
d. information stored in any format |
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Definition
d. information stored in any format |
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Term
Which role works with physicians to assist in the implementation of the EHR?
a. chief information officer
b. chief information security officer
c. chief medical information system officer
d. chief privacy officer |
|
Definition
c. chief medical information information system officer |
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Term
What individual or group is knowledgeable on accreditation and classification systems?
a. Chief information officer
b. Health information management department
c. Chief medical information system officer
d. Information systems department |
|
Definition
b. Health information management department |
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Term
Fifty percent of patients treated at our facilities have Medicare as their primary payer. This is an example of what type of information?
a. patient-specific
b. expert knowledge
c. comparitive
d. aggregate |
|
Definition
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Term
What HIM role determines what functions should be added to an information system?
a. data quality
b. data collection and analysis
c. electronic system design and development
d. data management |
|
Definition
c. electronic system design and development |
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Term
What HIM role is involved with the personal health record?
a. data quality
b. data collection and analysis
c. consumer health informatics
d. data managment |
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Definition
c. consumer health informatics |
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Term
Critique the following statement: Ambulatory information systems are the same as inpatient information systems.
a. False, they have many functions in common, but they each have unique functions as well
b. True
c. False, ambulatory systems do not have a need for administrative systems like inpatient systems do
d. False, ambulatory systems do not allow for electronic documentation like inpatient systems do |
|
Definition
a. False, they have many functions in common, but they each have unique functions as well |
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Term
In what type of setting(s) are mobile devices critical to the efficient use of information systems?
a. home health
b. long-term care
c. ambulatory care
d. both home health and long-term care |
|
Definition
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Term
As data quality coordinator for our facility, when does my responsibility/concern for data quality begin?
a. at the time of patient discharge
b. after the data are entered
c. at the time of data usage
d. at the time that the data are collected |
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Definition
d. at the time the data are collected |
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Term
The first professional association for health information managers was established in:
a. 1900
b. 1905
c. 1928
d. 1970 |
|
Definition
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Term
2. The hospital standardization program was started by the American College of Surgeons in:
a. 1900
b. 1905
c. 1918
d. 1928 |
|
Definition
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Term
3. The formal approval process for academic programs in health information management is called:
a. Accreditation
b. Certification
c. Registration
d. Standardization |
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Definition
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Term
4. The formal process for conferring a health information management credential is called:
a. Accreditation
b. Certification
c. Registration
d. Standardization |
|
Definition
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Term
5. Which of the following are elected to their positions by AHIMA members?
a. AHIMA Board of Directors
b. Members of the Council on Certification
c. Members of the Commission on Accreditation for Health Informatics and Information Management Education
d. All of the above |
|
Definition
|
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Term
6. Which of the following functions as the legislative body of AHIMA?
a. AHIMA Board of Directors
b. AHIMA Commission on Certification for Health Informatics and Information Management
c. AHIMA House of Delegates
d. AHIMA Foundation |
|
Definition
| c. AHIMA House of Delegates |
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Term
7. Which of the following make up a virtual network of AHIMA members?
a. AHIMA Board of Directors
b. AHIMA Council on Certification
c. AHIMA Communities of Practice
d. AHIMA House of Delegates |
|
Definition
| c. AHIMA Communitites of Practice |
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Term
8. Which of the following is an arm of AHIMA that promotes education and research in health information management?
a. AHIMA Board of Directors
b. AHIMA CAHIIM
c. AHIMA Foundation
d. AHIMA Commission on Certification for Health Informatics and Information Management |
|
Definition
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Term
9. Which of the following best describes the mission of the AHIMA?
a. Community of professionals providing support to members and strengthening the industry and profession
b. Community of professionals whose major purpose is lobbying Congress to change laws
c. Community of credentialed members who monitor the credentialing process
d. Community of credentialed members whose purpose is to ensure jobs for their members |
|
Definition
| a. Community of professionals providing support to members and strengthening the industry and profession |
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Term
10. Which of the following is true about the AHIMA?
a. Values a code of ethical health information management practice
b. Values the public’s right to private and high-quality health information
c. Celebrates and promotes diversity
d. All of the above |
|
Definition
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Term
Which of the following is a secondary purpose of the health record?
a. to document patient care delivery
b. to assist caregivers in patient care management
c. to aid in billing and reimbursement functions
d. to generate a report to be used in performance improvement |
|
Definition
| d. to generate a report to be used in performance improvement |
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Term
Which of the following is an institutional user of the health record?
a. patient care provider
b. third-party payer
c. coding and billing staff
d. government policy maker |
|
Definition
|
|
Term
How do patient care managers and support staff use the data documented in the health record?
a. to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
b. to communicate vital information among departments and across disciplines and settings
c. to generate patient bills and/or third-party payer claims for reimbursement
d. to determine the extent and effects of occupational hazards |
|
Definition
| a. to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided |
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|
Term
Which of the definitions below best describes the concept of confidentiality?
a. the right of individuals to control access to their personal health information
b. the protection of healthcare information from damage, loss, and unauthorized alteration
c. 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
d. the expectation that only individuals with the appropriate authority will be allowed to access healthcare information |
|
Definition
| c. 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 |
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Term
Which of the following statements does not pertain to paper-based health records?
a. They have a built-in access control mechanism
.b .They are kept in locked storage areas that are accessible only to authorized staff.
c. They are logged out according to the organization’s prescribed procedure.
d. They are forwarded to the appropriate service area when needed for patient care purposes. |
|
Definition
| a. they have a built-in access control mechanism |
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Term
Which of the following is an advantage offered by computer-based clinical decision support tools?
a. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature.
b. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends.
c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives.
d. all of the above |
|
Definition
|
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Term
The hospital where I work is transitioning to a EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as:
a. integrated health record format
b. a hybrid record
c. a resident record
d. integrated health record format |
|
Definition
|
|
Term
Critique this statement: Data and information mean the same thing.
a. This is a true statement.
b. This is false as data is used for administrative purposes and information is used for clinical purposes.
c. This is a false statement as data is raw facts and figures and information is data converted into a meaningful format
d. This is a true statement as information is raw facts and figures and data is information converted into a meaningful format. |
|
Definition
| c. This is a false statement as data is raw facts and figures and information is data converted into a meaningful format |
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|
Term
Which of the following statements does not pertain to electronic health records (EHRs)?
a. EHR technologies and systems must not intrude on the patient and provider relationship.
b. EHRs are filed in paper folders.
c. In the United States, a national health information infrastructure is being designed to support EHRs. |
|
Definition
| b. EHR's are filed in paper folders |
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|
Term
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 |
|
Definition
|
|
Term
Use of the health record by a clinician to facilitate quality patient care is considered
a. a primary purpose of the health record
b. patient care support
c. a secondary purpose of the health record
d. patient care effectiveness |
|
Definition
| a. a primary purpose of the health record |
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|
Term
Use of the health record to monitor bioterrorism activity is considered
a. a primary purpose of the health record
b. a secondary purpose of the health record
c. a patient use of the health record
d. a healthcare licensing agency function |
|
Definition
| b. a secondary purpose of the health record |
|
|
Term
How do accreditation organizations use the health record?
a. to serve as a source for case study information
b. to determine whether the documentation supports the provider’s claim for reimbursement]
c. to provide healthcare services
d. to determine whether standards of care are being met |
|
Definition
| d. to determine whether standards of care are being met |
|
|
Term
How do research organizations use the health record?
a. to examine results of experimental protocols
b. for reporting of communicable diseases
c. to investigate domestic violence
d. to manage disability insurance benefits |
|
Definition
| a. to examine results of experimental protocols |
|
|
Term
Attorneys for healthcare organizations use the health record to
a. support claims for medical malpractice
b. protect the legal interests of the facility and its health care providers
c. plan and market services
d. locate missing persons |
|
Definition
| b. protect the legal interests of the facility and its health care providers |
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Term
Our record has all of the lab filed together, all of the progress notes file together, and so on. What format are we using?
a. Source oriented health record
b. Integrated health record
c. Patient-oriented health record
d. Problem-oriented health record |
|
Definition
| a. source oriented health record |
|
|
Term
Inaccurate data recorded in the health record could
a. compromise quality patient care
b. contribute to incorrect assumptions by policy makers
c. invalidate research findings
d. all of the above |
|
Definition
|
|
Term
The term used to describe expected data values is
a. data definition
b. data currency
c. data precision
d. data relevancy |
|
Definition
|
|
Term
Protection of healthcare information from damage, loss, and unauthorized alteration is also known as
a. privacy
b. results management
c. security
d. data accuracy |
|
Definition
|
|
Term
Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using?
a. Computerized physician/provider order entry
b. Electronic health record
c. Results management
d. Clinical decision support |
|
Definition
| a. Computerized physician/provider order entry |
|
|
Term
The paper-based health record format that organizes all forms in chronological order is known as
a. the problem-oriented health record
b. the integrated health record
c. the patient-oriented health record
d. the source-oriented health record |
|
Definition
| b. the intergrated health record |
|
|
Term
Critique this statement: The health record documents services provided by allied health professionals and a patient’s family.
a. This is a true statement.
b. This is a false statement as the health record only document’s physician’s care.
c. This is a false statement as the health record only documents care provided by patient families.
d. This is a false statement as the health record documents the care provided by healthcare professionals |
|
Definition
| d. This is a false statement as the health record documents the care provided by healthcare professionals |
|
|
Term
An individual’s right to control access to his or her personal information is known as
a. security
b. confidentiality
c. privacy
d. all of the above |
|
Definition
|
|
Term
When all required data elements are included in the health record, the quality characteristic for ______ is met.
a. data security
b. data accessibility
c. data flexibility
d. data comprehensiveness |
|
Definition
| d. data comprehensiveness |
|
|
Term
Critique this statement: Patient care managers are individual users of health records.
a. This is a true statement.
b. This is a false statement as they do not require patient information to do their job.
c. This is a false statement as they require patient information to do their job.
d. This is a false statement as patient care managers are institutional users. |
|
Definition
| a. This is a true statement |
|
|
Term
Which of the following is a function of the health record?
a. planning and managing care
b. evaluating the adequacy and appropriateness of care
c. substantiating reimbursement claims
d. protecting the legal interests of both patient and healthcare provider
e. all of the above |
|
Definition
|
|
Term
Which of the following clinical data elements is not usually documented in the acute care health record?
a. clinical observations
b. discharge information
c. medical history
d. records of immunizations |
|
Definition
| d. records of immunizations |
|
|
Term
Which of the following is not a function of the discharge summary?
a. providing information about the patient’s insurance coverage
b. ensuring the continuity of future care
c. providing information to support the activities of the medical staff review committee
d. providing concise information that can be used to answer information requests |
|
Definition
| a. providing information about the patient’s insurance coverage |
|
|
Term
In which of the following ways can the patient’s consent to undergo treatment be expressed?
a. by his or her submission to treatment
b. by written agreement
c. by verbal agreement
d. all of the above |
|
Definition
|
|
Term
Which of the following would not be considered clinical data?
a. progress notes
b. physician orders
c. admission diagnosis
d. name of insurance company |
|
Definition
| d. name of insurance company |
|
|
Term
Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?
a. The Health Information Access and Disclosure Act
b. The Health Insurance Portability and Accountability Act
c. The Patient Self-Determination Act
d. The Social Security Act |
|
Definition
| b. The Health Insurance Portability and Accountability Act |
|
|
Term
Which of the following 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. pathology report
d. laboratory report |
|
Definition
|
|
Term
Which of the following is an example of an advance directive?
a. a living will
b. an authorization to release information
c. a treatment consent
d. a patient’s rights acknowledgement |
|
Definition
|
|
Term
Which of the following materials is not documented in an emergency care record?
a. patient’s instructions at discharge
b. time and means of the patient’s arrival
c. patient’s complete medical history
d. emergency care administered before arrival at the facility |
|
Definition
| c. patient’s complete medical history |
|
|
Term
Which of the following types of facility is not governed by Medicare long-term care documentation standards?
a. subacute care facilities
b. assisted living facilities
c. skilled nursing facilities
d. intermediate care facilities |
|
Definition
| b. assisted living facilities |
|
|
Term
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
a. patient assessment instrument
b. minimum data set for long term care
c. resident assessment protocol
d. Outcomes and Assessment Information Set |
|
Definition
| d. Outcomes and Assessment Information Set |
|
|
Term
Which regulations are most commonly applied in end stage renal disease treatment?
a. Medicare Conditions for Coverage
b. Commission on Accreditation of Rehabilitation Facilities
c. Accreditation Association for Ambulatory Healthcare
d. Joint Commission |
|
Definition
| a. Medicare Conditions of Coverage |
|
|
Term
Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?
a. The correction should be dated and signed or initialed.
b. The reason for the change should be noted.
c. The incorrect information should be obliterated.
d. The word error should be noted on the entry. |
|
Definition
| c. The incorrect information should be obliterated. |
|
|
Term
Which of the following types of healthcare facilities may seek accreditation from the Joint Commission ?
a. acute care hospitals
b. psychiatric hospitals
c. home care providers
d. ambulatory care organizations
e. all of the above |
|
Definition
|
|
Term
The federal Conditions of Participation apply to which type of healthcare organization?
a. any organization that is accredited
b. any organization that treats Medicare or Medicaid patients
c. any organization that provides acute care services
d. any organization that is subject to the Health Insurance Portability and Accountability Act |
|
Definition
| b. any organization that treats Medicare or Medicaid patients |
|
|
Term
Which of the following is not a traditional health record format?
a. integrated health record
b. problem-oriented health record
c. source-oriented health record
d. process-oriented health record |
|
Definition
| d. process-oriented health record |
|
|
Term
Which health record format is most commonly used by healthcare settings as they transition to electronic records?
a. integrated records
b. problem-oriented records
c. hybrid records
d. paper records |
|
Definition
|
|
Term
Which of the following is not an example of a data capture technology?
a. bar code readers
b. data dictionaries
c. optical character readers
d. continuous voice recognition |
|
Definition
|
|
Term
The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:
a. subjective
b. objective
c. assessment
d. plan |
|
Definition
|
|
Term
Which of the following factors should be considered when designing a data retrieval system for an EHR?
a. presentation of data
b. quick-search capabilities
c. need to know
d. analytical capabilities
e. all of the above |
|
Definition
|
|
Term
What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization?
a. certification
b. licensure
c. accreditation
d. deemed status |
|
Definition
|
|
Term
Progress notes of physicians, nurses, therapists and other authorized individuals
would be found together in chronological sequence in a(an) ____________ paper
record.
a. integrated
b. source-oriented
c. problem-oriented
d. hybrid |
|
Definition
|
|
Term
Which part of a medical history 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. present illness
b. social and personal history
c. past medical history
d. chief complaint |
|
Definition
|
|
Term
Which of the following creates a chronological report of the patient’s condition
and response to treatment during a hospital stay?
a. physical examination
b. physician order
c. progress notes
d. medical history |
|
Definition
|
|
Term
Which of the following determines who can receive and transcribe verbal orders?
a. accreditation standards
b. certification regulations
c. medical staff bylaws
d. licensure standards |
|
Definition
|
|
Term
Which of the following is an example of an ancillary system:
a. CDS
b. EDMS
c. Lab system
d. PHR |
|
Definition
|
|
Term
Discrete data are generally entered into an EHR via:
a. Codes
b. COLD
c. Digital dictation
d. Templates |
|
Definition
|
|
Term
The ability to electronically put tasks into a queue for someone to perform is called:
a. Coding
b. Content management
c. Process mapping
d. Work flow |
|
Definition
|
|
Term
What technology is used to manage data from different source systems, including discrete data, scanned images, and digital forms of data:
a. CDR
b. CDS
c. DBMS
d. PACS |
|
Definition
|
|
Term
In a regional health information organization (RHIO), patients would most likely be identified using:
a. Master person index
b. Medical record number
c. Record locator service
d. Unique patient identifier |
|
Definition
| c. Record locator service |
|
|
Term
A special Web page that offers secure access to data is a(n):
a. Access control
b. Home page
c. Intranet
d. Portal |
|
Definition
|
|
Term
To run an analysis on a large set of data from many patients, the best tool is a(n):
a. CDR
b. CDW
c. DBMS
d. EHR |
|
Definition
|
|
Term
An interface is:
a. Device to enter data
b. Protocol for describing data
c. Program to exchange data
d. Standard vocabulary |
|
Definition
| c. Program to exchange data |
|
|
Term
Standards from which organization would be used for enabling exchange of clinical images:
a. ASTM
b. DICOM
c. HL7
d. NCPDP |
|
Definition
|
|
Term
Semantics refers to:
a. Controlled vocabulary
b. Format of a healthcare message
c. Meaning of a clinical concept
d. Use of encoded data in an EHR |
|
Definition
| c. Meaning of a clinical concept |
|
|
Term
Which of the following vocabularies is likely to be used to describe drugs in clinically relevant form:
a. CPT
b. LOINC
c. RxNorm
d. SNOMED |
|
Definition
|
|
Term
When some computers are used primarily to enter data and others to process data the architecture is called:
a. Client/server
b. Local area network
c. Mainframe
d. Web services |
|
Definition
|
|
Term
Which form of wireless technology is used to beam data between devices in close proximity to one another:
a. Bar coding
b. Bluetooth
c. Ethernet
d. IEEE 802.11 |
|
Definition
|
|
Term
What can a healthcare organization implement to help significantly reduce downtime:
a. Acquire storage management software
b. Send data to a remote site via the Internet
c. Store data on RAID
d. Use mirrored processing on redundant servers |
|
Definition
| d. Use mirrored processing on redundant servers |
|
|
Term
Data that describes the data to be entered into an EHR is called:
a. Audit trails
b. Data dictionary
c. Definitional modeling
d. Metadata |
|
Definition
|
|
Term
When a hospital uses many different vendors to support its information system needs, the IT strategy being used is called:
a. Best of breed
b. Best of fit
c. Hospital information system
d. Legacy architecture |
|
Definition
|
|
Term
A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:
a. Implementation plan
b. Migration path
c. Readiness assessment
d. Strategic plan |
|
Definition
|
|
Term
Which form of system testing ensure that each data element is captured correctly:
a. Acceptance testing
b. Integration testing
c. System testing
d. Unit testing |
|
Definition
|
|
Term
Which of the following describes the step during implementation when data from an old system are able to be incorporated into the new system:
a. Chart conversion
b. Data conversion
c. System build
d. Table definition |
|
Definition
|
|
Term
How are health plans incentivizing providers to use EHRs:
a. Denying paper claims
b. External reporting
c. Paying for performance
d. Requiring use of clinical guidelines |
|
Definition
| c. Paying for performance |
|
|
Term
If a judge asks a record custodian to attest to the permanence of an EHR, the custodian should:
a. Attest to a retention schedule
b. Describe contingency plans
c. Produce paper back-ups
d. Request IT support |
|
Definition
| b. Describe contingency plans |
|
|
Term
An example of how security of an EHR is afforded is via:
a. Access controls
b. Paper back-up system
c. Policies on use and disclosure
d. Stress testing |
|
Definition
|
|
Term
A high level overview of when EHR components will be implemented is:
a. Benefits realization study
b. Implementation plan
c. Migration path
d. Timeline for EHR adoption |
|
Definition
|
|
Term
A means to reduce the data entry burden for providers but still capture discrete data is:
a. Digital dictation
b. Optical character recognition
c. Patient data entry
d. Speech recognition |
|
Definition
|
|
Term
Ensure accurate and timely data entry is:
a. Data comparability
b. Data quality
c. Interoperability
d. Knowledge management |
|
Definition
|
|
Term
The name of the government agency that has led the development of basic data sets for health records and computer databases is the ___.
a. Centers for Medicare and Medicaid Services
b. Johns Hopkins University
c. American National Standards Institute
d. National Committee on Vital and Health Statistics |
|
Definition
| d. National Committee on Vital and Health Statistics |
|
|
Term
The primary purpose of a minimum data set in healthcare is to ___.
a. recommend common data elements to be collected in health records
b. mandate all data that must be contained in a health record
c. define reportable data for federally funded programs
d. standardize medical vocabulary |
|
Definition
| a. recommend common data elements to be collected in health records |
|
|
Term
Data that are collected on large populations of individuals and stored in databases are referred to as ___.
a. statistics.
b. information
c. aggregate data
d. standards |
|
Definition
|
|
Term
The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the ___.
a. Ambulatory Care Data Set
b. Uniform Hospital Discharge Data Set
c. Minimum Data Set for Long-Term Care
d. Health Plan Employer Data and Information Set |
|
Definition
| b. Uniform Hospital Discharge Data Set |
|
|
Term
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ___.
a. performance improvement programs
b. billing and claims data processing
c. developing hospital discharge abstracting systems
d. developing individual care plans for residents. |
|
Definition
| a. performance improvement programs |
|
|
Term
A National Health Information Network is:
a. A national database of patient information
b. A standard used by the Internet
c. A network of networks
d. An electronic health record |
|
Definition
|
|
Term
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of ___.
a. transaction standards
b. content and structure standards
c. vocabulary standards
d. security standards |
|
Definition
|
|
Term
The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the ___.
a. Medicare Act
b. Prospective Payment Act
c. Health Insurance Portability and Accountability Act of 1996
d. Social Security Act |
|
Definition
| c. Health Insurance Portability and Accountability Act of 1996 |
|
|
Term
The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the ___.
a. Social Security number
b. unique physician identification number
c. health record number
d. national provider identifier |
|
Definition
| a. Social Security number |
|
|
Term
Most healthcare informatics standards have been implemented by ___.
a. federal mandate
b. consensus
c. state regulation
d. trade association requirement |
|
Definition
|
|
Term
A critical early step in designing an EHR is to develop a(n) ___ in which the characteristics f each data element are defined.
a. accreditation manual
b. core content
c. continuity of care record
d. data dictionary |
|
Definition
|
|
Term
According to the UHDDS definition, ethnicity should be recorded on a patient record as ___.
a. Race of mother
b. Race of father
c. Hispanic, non-Hispanic, unknown
d. Free text descriptor as reported by patient |
|
Definition
| c. Hispanic, non-Hispanic, unknown |
|
|
Term
Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?
a. DEEDS
b. UACDS
c. MDS Version 2.0
d. OASIS |
|
Definition
|
|
Term
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on ___.
a. reason for admission.
b. reason for encounter.
c. discharge diagnosis.
d. activities of daily living. |
|
Definition
|
|
Term
In long term care, the resident’s care plan is based on data collected in the ___.
a. UHDDS
b. OASIS
c. MDS Version 2.0
d. HEDIS |
|
Definition
|
|
Term
Reimbursement for home health services in dependent of data collected from ___.
a. HEDIS.
b. UHDDS.
c. OASIS.
d. MDS Version 2.0. |
|
Definition
|
|
Term
A consumer interested in comparing the performance of health plans should review data from ___.
a. HEDIS
b. OASIS
c. ORYX
d. UHDDS |
|
Definition
|
|
Term
I need a standard that allows data to be transferred across the Internet. Which of the following is my choice?
a. CCR
b. XML
c. NCD
d. NCPDP |
|
Definition
|
|
Term
Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for ___.
a. government regulations.
b. core data elements.
c. privacy controls.
d. technology requirements. |
|
Definition
|
|
Term
A statewide cancer surveillance system is an example of which of the NHII dimensions?
a. personal
b. provider
c. community
d. payer |
|
Definition
|
|
Term
In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?
a. X12N
b. LOINC
c. IEEE 1073
d. DICOM |
|
Definition
|
|
Term
A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is ___.
a. X12N.
b. LOINC.
c. IEEE 1073.
d. DICOM. |
|
Definition
|
|
Term
A core data set developed by ASTM to communicate a patient’s past and current health information as the patient’s transitions from one care setting to another is ___.
a. Continuity of Care Record.
b. Minimum Data Set.
c. Ambulatory Care Data Set.
d. Uniform Hospital Discharge Data Set. |
|
Definition
| a. Continuity of Care Record |
|
|
Term
Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?
a. X12N
b. LOINC
c. RxNorm
d. DICOM |
|
Definition
|
|
Term
As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for ___.
a. developing unique provider identifiers.
b. finalizing the extensible markup language.
c. harmonization of standards from multiple sources.
d. building software systems to support EHR development. |
|
Definition
| c. harmonization of standards from multiple sources |
|
|
Term
Removing health records 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. |
|
Definition
|
|
Term
Which type of microfilm does not allow for a unit record to be maintained?
a. roll microfilm
b. jacket microfilm
c. microfiche
d. micrographics |
|
Definition
|
|
Term
Which of the following is not true about document imaging?
a. allows random access for retrieval of documents
b. can be viewed by more than one person at a time
c. can be viewed from locations remote from the HIM department
d. is a paperless system |
|
Definition
|
|
Term
Which system records the location of health records removed from the filing system and documents the return of the health records?
a. chart deficiency system
b. chart tracking system
c. abstracting system
d. none of the above |
|
Definition
|
|
Term
“Loose” reports are health record forms that ___.
a. are maintained separately from the health record
b. are not part of the legal health record
c. are received by the HIM department and added to the health record after it has been processed
d. are misfiled |
|
Definition
| c. are received by the HIM department and added to the health record after it has been processed |
|
|
Term
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the ____.
a. incomplete record file
b. permanent file
c. temporary file
d. remote storage file |
|
Definition
| a. incomplete record file |
|
|
Term
In which of the following systems are all encounters or patient visits kept in one folder?
a. serial numbering system
b. unit numbering system
c. straight numerical filing system
d. middle-digit filing system |
|
Definition
|
|
Term
Which of the following is the key to the identification and location of a patient’s health record?
a. disease index
b. outguide
c. deficiency slip
d. MPI |
|
Definition
|
|
Term
Which of the following numbering systems is best for maintaining the encounters of a patient together?
a. unit
b. serial-unit
c. serial
d. alphabetic |
|
Definition
|
|
Term
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?
a. unit
b. serial
c. terminal-digit
d. alphabetic |
|
Definition
|
|
Term
Which of the following is not usually a part of quantitative analysis review?
a. checking that all forms contain the patient’s name and health record number
b. checking that all forms and reports are present
c. checking that every word in the record is spelled correctly
d. checking that reports requiring authentication have signatures |
|
Definition
| c. checking that every word in the record is spelled correctly |
|
|
Term
Which of the following is not true of good forms design for paper forms?
a. Every form should have a unique identification number.
b. Every form should have a clear, concise title.
c. Bright colors should be used to identify forms.
d. Paper ranging from twenty to twenty-four pounds in weight should be used for forms that will be copied, faxed, or scanned. |
|
Definition
| c. Bright colors should be used to identify forms |
|
|
Term
Which of the following is not true of good forms design for electronic forms?
a. Keystrokes should be minimized by using pop-up menus.
b. Electronic forms should use completeness checks.
c. Electronic forms should use radio buttons for multiple selections of items.
d. Electronic forms should use text boxes to enter text. |
|
Definition
| c. Electronic forms should use radio buttons for multiple selections of items. |
|
|
Term
Which of the following is a disadvantage of alphabetic filing?
a. Easy to train new personnel to file
b. Uneven expansion of file shelves or cabinets
c. Ease of creation
d. No reliance on an index or authority file |
|
Definition
| b. Uneven expansion of file shelves or cabinets |
|
|
Term
In healthcare organizations, what is the database that is used to locate the medical record number usually called?
a. MPI
b. disease index
c. physician index
d. patient registry |
|
Definition
|
|
Term
Which of the following is a request from a clinical area to charge out a health record?
a. outguide folder
b. requisition
c. MPI
d. patient registry |
|
Definition
|
|
Term
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
a. 42 inches
b. 3600 inches
c. 252 inches
d. 216 inches |
|
Definition
|
|
Term
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.
a. prospective
b. retrospective
c. concurrent
d. peer |
|
Definition
|
|
Term
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record.
a. suspended
b. delinquent
c. pending
d. illegal |
|
Definition
|
|
Term
In which department/unit does the health record typically begin?
a. HIM department
b. patient registration
c. nursing unit
d. billing department |
|
Definition
|
|
Term
When a hospital accredited by Joint Commission is considered to be in compliance with Medicare’s Conditions of Participation, this is called ___________.
a. adjuvant accreditation
b. deemed status
c. conditional accreditation
d. dual accreditation |
|
Definition
|
|
Term
Which of the typical HIM functions assist in monitoring and compliance of the health care facility with Joint Commission standards?
a. release of information
b. record processing
c. transcription
d. all of the above |
|
Definition
|
|
Term
What component of the budget would include money for the purchase of a EHR?
a. revenue budget
b. expense budget
c. capital budget
d. cash budget |
|
Definition
|
|
Term
The future role of the HIM professional is expected to change due to __________.
a. advances in technology
b. implementation of new clinical coding system
c. evolution of the EHR
d. all of the above |
|
Definition
|
|
Term
Specific performance expectations and/or structures and processes that provide detailed information for each Joint Commission standard are called __________.
a. elements of performance
b. fact sheets
c. ad hoc reports
d. registers |
|
Definition
| a. elements of performance |
|
|
Term
HIM has been recognized as an allied health profession since:
a. 1910
b. 1918
c. 1928
d. 2006 |
|
Definition
|
|
Term
The hospital standardization movement was inaugerated by the:
a. American Health Information Management Association
b. American College of Surgeons
c. Record Librarians of North America
d. American College of Physicians |
|
Definition
| b. American College of Surgeons |
|
|
Term
Throughout the years, HIM roles have:
a. remained the same
b. broadened in scope
c. become more focused
d. diminished |
|
Definition
|
|
Term
The traditional model of HIM practice was:
a. department based
b. information based
c. electronically based
d. analytically based |
|
Definition
|
|
Term
The new model of HIM practice is:
a. Information focused
b. Record focused
c. Department focused
d. Traditionally focused |
|
Definition
|
|
Term
What evolving role oversees the process that begins at the time of documentation through billing?
a. HIM director
b. Health record reviewer
c. Health data analyst
d. Revenue cycle management |
|
Definition
| d. revenue cycle management |
|
|
Term
The organization that accredits HIM programs is:
a. Joint Commission
b. CAHIIM
c. AHIMA
d. CCHIIM |
|
Definition
|
|
Term
What evolving role assesses quality in health record banking?
a. physician group consultant
b. health record reviewer
c. health data analysit
d. terminology manager |
|
Definition
| b. health record reviewer |
|
|
Term
The primary focus of AHIMA is to:
a. ensure that health records are complete
b. implement an electronic record in hospitals
c. foster professional development of its members
d. set and implement standards |
|
Definition
| c. foster professional development of its members |
|
|
Term
Active members of AHIMA include those who:
a. hold an AHIMA credential
b. are graduate members
c. are currently students in an accredited HIM program
d. are senior members |
|
Definition
|
|
Term
Which of the following functions as the legislative body of AHIMA?
a. Board of Directors
b. House of Delegates
c. CCHIIM
d. CAHIIM |
|
Definition
|
|
Term
Which of the following promotes education and research?
a. CCHIIM
b. CAHIIM
c. AHIMA
d. AHIMA Foundation |
|
Definition
|
|
Term
The virtual network used by AHIMA members is:
a. certification
b. fellowship
c. house of delegates
d. communities of practice |
|
Definition
| d. communities of practice |
|
|
Term
We had 324 Medicare patients last month. This statement represents which of the following:
a. information
b. data
c. content of the PHR
d. patient-specific information |
|
Definition
|
|
Term
I am a patient. My medical history including information from myself and my physicians is stored on the internet. This is an example of which of the following:
a. Health record
b. EHR
c. PHR
d. Data |
|
Definition
|
|
Term
Which of the following is an example of a primary purpose of the medical record?
a. education
b. policy making
c. research
d. patient care management |
|
Definition
| d. patient care management |
|
|
Term
Examples of patient care delivery usage of the medical record include which of the following uses?
a. development of practice guidelines
b. communication between caregivers
c. reimbursement for patient care
d. getting patients involved in their own care |
|
Definition
| b. communication between caregivers |
|
|
Term
Critique this statement: The PHR and EHR are synonyms
a. True: both are controlled by the patient
b. False, as the PHR is controlled by the care provders and the EHR is controlled by the patient
c. False, as the PHR is controlled by the patient and the EHR is controlled by the care providers
d. True: both are controlled by the health care provider |
|
Definition
| c. False, as the PHR is controlled by the patient and the EHR is controlled by the care providers |
|
|
Term
| T or F: The health record is the principal repository for data and information about the healthcare services provided to individual patients |
|
Definition
|
|
Term
| T or F: The lab test "hemoglobin: 14.6 gm/110ml" is considered information |
|
Definition
|
|
Term
| T or F: All the primary purposes of the health record are associated directly with the provision of patient care |
|
Definition
|
|
Term
| T or F: Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record |
|
Definition
|
|
Term
| T or F: Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record |
|
Definition
|
|
Term
Which of the following users of the health record is an example of an institutional user?
a. third-party payer
b. accreditation organization
c. physician
d. employer |
|
Definition
|
|
Term
Which of the following users would utilize aggregate data?
a. patient care providers
b. coding and billing staff
c. law enforcement offers
d. patient care managers and support staff |
|
Definition
| d. patient care managers and support staff |
|
|
Term
I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
a. healthcare delivery
b. medical review
c. research
d. education |
|
Definition
|
|
Term
Critique the following statement: A user of health records includes only care providers who document in the health record or refer to it for patient care
a. true, as defined by the IOM
b. false, as the information is used for other purposes such as analysis
c. true, as defined by AHIMA
d. false, as the information contained in the health record is also used for patients to document in their own health record |
|
Definition
| b. false, as the information is used for other purposes such as analysis |
|
|
Term
I work for CMS; how would I use the health record?
a. Make decisions on healthcare reimbursement
b. Medical research
c. Issuing hospital and medical staff licenses
d. Accrediting healthcare organizations |
|
Definition
| a. Make decisions on healthcare reimbursement |
|
|
Term
| T or F: A physical therapist documenting in the health record is an institutional health record user |
|
Definition
|
|
Term
| T or F: An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user |
|
Definition
|
|
Term
| T or F: CMS uses data to accredit hospitals |
|
Definition
|
|
Term
| T or F: A researcher uses data to determine the recommended treatment |
|
Definition
|
|
Term
| T or F: Patients do not have the right to add missing information to the health record |
|
Definition
|
|
Term
A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool?
a. clinical decision support
b. electronic records
c. results management
d. order-entry/order management |
|
Definition
| a. clinical decision support |
|
|
Term
I just told my physician something embarassing about myself. I told him because I expect him to use the information for my care only. This concept is called:
a. data relevancy
b. security
c. privacy
d. confidentiality |
|
Definition
|
|
Term
Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be the justification for not collecting this information?
a. accuracy
b. consistency
c. granularity
d. relevancy |
|
Definition
|
|
Term
It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this, but rather sharing information between the systems?
a. accuracy
b. consistency
c. granularity
d. relevancy |
|
Definition
|
|
Term
According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?
a. data applications
b. data collection
c. data warehousing
d. data analysis |
|
Definition
|
|
Term
| A characteristic of data whose values are defined at the appropriate level of detail |
|
Definition
|
|
Term
| A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records |
|
Definition
|
|
Term
| A characteristic of data where the data are useful |
|
Definition
|
|
Term
| An individual's right to control access to his or her personal information |
|
Definition
|
|
Term
| A characteristic of data that includes every required data element |
|
Definition
|
|
Term
Which two types of data are contained in the health record?
a. nursing and physician
b. administrative and clinical
c. demographic and financial
d. surgical and medical |
|
Definition
| b. administrative and clinical |
|
|
Term
Which of the following terms refers to state or country regulations that healthcare facilities must meet to be permitted to provide care?
a. accreditation
b. bylaws
c. certification
d. licensure |
|
Definition
|
|
Term
Which of the following would not be found in a medical history?
a. chief complaint
b. vital signs
c. present illness
d. review of systems |
|
Definition
|
|
Term
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report?
a. consultation
b. progress not
c. operative report
d. discharge summary |
|
Definition
|
|
Term
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
a. flow record
b. vital signs record
c. care plan
d. surgical note |
|
Definition
|
|
Term
Written or spoken permission to proceed with care is classified as:
a. expressed consent
b. acknowledgement
c. advance directive
d. implied consent |
|
Definition
|
|
Term
Which of the following reports provides information on tissue removed during a procedure?
a. operative report
b. laboratory report
c. pathology report
d. anesthesia report |
|
Definition
|
|
Term
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
a. obstetric
b. newborn
c. surgical
d. emergency |
|
Definition
|
|
Term
Which of the following is not considered patient demographic information?
a. patient's date of birth
b. name of next of kin
c. type of admission
d. admitting diagnosis |
|
Definition
|
|
Term
Which of the following administrative documents names the patient's choice of legal representative for healthcare purposes?
a. advance directive
b. patient's bill of rights
c. notice of privacy practices
d. authorization of release of information |
|
Definition
|
|
Term
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?
a. ambulatory care
b. emergency care
c. long-term care
d. rehabilitative care |
|
Definition
|
|
Term
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?
a. ambulatory care
b. emergency care
c. long-term care
d. rehabilitative care |
|
Definition
|
|
Term
The ambulatory surgery record contains information most similar to:
a. physician's office records
b. emergency care records
c. hospital operative records
d. hospital obstetric records |
|
Definition
| c. hospital operative records |
|
|
Term
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?
a. Outcomes and Assessment Information Set (OASIS)
b. Resident Assessment Plan (RAP)
c. Patient Assessment Instrument (PAI)
d. Minimum Data Set (MDS) |
|
Definition
| c. Patient Assessment Instrument (PAI) |
|
|
Term
Interdisciplinary care plans are an important part of which type of health record?
a. emergency department
b. ambulance
c. hospice care
d. ambulatory care |
|
Definition
|
|
Term
Portions of a treatment record may be maintained in a patient's home in which two types of settings?
a. hospice and behavioral health
b. home health and end-stage renal disease
c. obstetric and gynecologic care
d. rehabilitation and correctional care |
|
Definition
| b. home health and end-stage renal disease |
|
|
Term
A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?
a. rehabilitative care
b. ambulatory care
c. behavioral health
d. personal health |
|
Definition
|
|
Term
Paper records may require thinning in which two settings?
a. home health and hospice
b. rehab and end-stage renal disease
c. ambulatory care and behavioral health
d. long-term care and correctional services |
|
Definition
| d. long-term care and correctional services |
|
|
Term
A growth and development record may be found in what type of record?
a. rehabilitative care
b. pediatric
c. behavioral health
d. obstetric |
|
Definition
|
|
Term
The document that indicates current and past medical conditions is:
a. MDS
b. RAPs
c. Problem list
d. PAI |
|
Definition
|
|
Term
Which of the following is an accrediting organization?
a. state regulating agencies
b. American Health Information Management Association
c. DNV
d. Centers for Medicare and Medicaid Services |
|
Definition
|
|
Term
An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation under its guidelines do not need to:
a. meet licensure standards
b. undergo Medicare certification surveys
c. undergo accreditation surveys
d. meet Medicare certification standards |
|
Definition
| b. undergo Medicare certification surveys |
|
|
Term
Which group focuses on accreditation of managed care and preferred provider organizations?
a. Accreditation Association for Ambulatory Healthcare
b. National Committee for Quality Assurance
c. Commission on Accreditation of Rehabilitation Facilities
D. Joint Commission on Accreditation of Healthcare Organizations |
|
Definition
| b. National Committee for Quality Assurance |
|
|
Term
Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient's record?
a. facility rules and regulations
b. accreditation standards
c. licensure standards
d. conditions of participation |
|
Definition
| a. facility rules and regulations |
|
|
Term
Which of the following groups has instituted a health record-prohibited abbreviation list?
a. National Committee for Quality Assurance
b. Joint Commission on Accreditation of Healthcare Organizations
c. American Osteopathic Organization
d. Centers for Medicare and Medicaid Services |
|
Definition
| b. Joint Commission on Accreditation of Healthcare Organizations |
|
|
Term
Which type of health record includes both paper and computerized components?
a. hybrid
b. electronic
c. problem-oriented
d. source-oriented |
|
Definition
|
|
Term
Which of the following is a disadvantage of an EHR over a paper-based record?
a. allows customization to user needs
b. permits multiple users at the same time
c. enables duplicate copies to be make easily
d. requires privacy and security measures |
|
Definition
| d. requires privacy and security measures |
|
|
Term
In an integrated health record, documentation by health professionals is organized:
a. in sections by type of professional
b. in sections by problem number
c. intermixed in date sequence
d. depends on facility policy |
|
Definition
| c. intermixed in date sequence |
|
|
Term
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
a. subjective
b. objective
c. assessment
d. plan |
|
Definition
|
|
Term
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?
a. database management
b. image processing
c. text processing
d. vocabulary standards |
|
Definition
|
|
Term
Which of the following is true of paper-based records?
a. they are susceptible to damage from fire or floods
b. they lack standardization
c. they are easy to access and update
d. they require a limited number of personnel to process |
|
Definition
| a. they are susceptible to damage from fire or floods |
|
|
Term
A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:
a. electronic records
b. integrated records
c. paper records
d. hybrid records |
|
Definition
|
|
Term
In a problem-oriented health record, problems are organized by:
a. letter
b. number
c. patient name
d. body system |
|
Definition
|
|
Term
Health Level Seven (HL7) has developed guidelines that address which aspect of the electronic record?
a. a standard vocabulary
b. network communications standards
c. definition of functions
d. overcoming resistance |
|
Definition
| c. definition of functions |
|
|
Term
Which type of data input mechanism is commonly used in both paper and electronic environments?
a. voice recognition
b. transcription
c. bar code readers
d. automated templates |
|
Definition
|
|
Term
A transition technology used by many hospitals to increase access to medical record content is:
a. EHR
b. EDMS
c. ESA
d. PACS |
|
Definition
|
|
Term
Systems used by nurses and physicians to document assessments and findings are called:
a. computerized provider order entry
b. electronic medical records
c. electronic medication administration record
d. patient care charting |
|
Definition
|
|
Term
A clinical data repository is a(n):
a. archive technology back up and store information
b. database to manage data from multiple sources
c. electronic health record
d. location for storing and retrieving medical images |
|
Definition
| b. database to manage data from multiple sources |
|
|
Term
Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered?
a. knowledge databases
b. standard order set
c. evidence-based guidance
d. EMAR |
|
Definition
|
|
Term
A system that provides alerts and reminders to clinicians is:
a. clinical decision support system
b. electronic data interchange
c. point of care charting system
d. knowledge database |
|
Definition
| a. clinial decision support system |
|
|
Term
| T or F: EMARs that utilize bar codes or RFID technology support medication "five rights" |
|
Definition
|
|
Term
| T or F: In 2010, about half of all physician practices had an EHR |
|
Definition
|
|
Term
| T or F: Speech recognition systems automatically convert diction to text |
|
Definition
|
|
Term
| T or F: Templates utilize free text but not data entry tools like drop down boxes |
|
Definition
|
|
Term
| T or F: Notifying a coder that the physician has completed the discharge summary is an example of workflow |
|
Definition
|
|
Term
Exchange of a standard set of health information content between providers and with patients is facilitated by:
a. continuity of care document
b. data set
c. electronic health record
d. peronal health record |
|
Definition
| a. continuity of care document |
|
|
Term
How can I encourage patients to become more active in their health information?
a. Have the patient use a point of care system
b. Have the patient create a PHR
c. Utilize a pay for performance plan
d. Provide each patient with a personal digital assistant |
|
Definition
| b. Have the patient create a PHR |
|
|
Term
Using standards protocols to get different computers system to communicate is:
a. certification
b. data set
c. interoperability
d. meaningful use |
|
Definition
|
|
Term
I need to locate electronic records for a patient across a health information exchange. What tool should I utilize?
a. certification
b. identity matching algorithm and record locator service
c. interoperability and certification
d. meaningful use |
|
Definition
| b. identity matching algorithm and record locator service |
|
|
Term
What is used in a health information exchange to compile information about a given patient from multiple sources?
a. ASC X12 standards
b. HL7 EHR system functional requirements
c. identity matching algorithm and record locator service
d. vocabulary standards and data sets |
|
Definition
| c. identity matching algorithm and record locator service |
|
|
Term
I need to manage the storage and retrieval from email and efax. Which of the following is necessary to accomplish this?
a. enterprise report management
b. results retrieval and management technology
c. data capture technology
d. natural language processing |
|
Definition
| a. enterprise report management |
|
|
Term
A computer that has minimal processing capability of its own is a:
a. human-computer interface
b. thin client
c. server
d. web service architecture |
|
Definition
|
|
Term
I need to use a human-computer interface that captures data via point and click fields and drop down menus. this type of interface is called:
a. direct data capture
b. patient data entry
c. discrete data entry
d. natural language processing |
|
Definition
|
|
Term
A system that enables processing of diagnostic studies results into tables, graphs, or other structures is:
a. results retrieval and management technology
b. data capture technology
c. clinical decision support
d. electronic document/content management |
|
Definition
| a. results retrieval and managment technology |
|
|
Term
Which of the following technologies would reduce the risk that information is not accessible during a server crash:
a. RAID
b. storage area network
c. server redundancy
d. tape or disk backup |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
Which of the following is a reason to implement the EHR?
a. improve patient safety
b. cost of EHR
c. time required implementing the EHR
d. simplicity of implementation |
|
Definition
| a. improve patient safety |
|
|
Term
We are not satisfied with the imformation that we currently have. We decided to replace everything with the products from one vendor. This strategy is called:
a. best of fit
b. best of breed
c. dual core
d. rip-and-replace |
|
Definition
|
|
Term
Our hardware has been placed on back-order and the network team is having trouble getting the network to functional properly. Addressing these issues and more is called:
a. system build issues management
b. issues management
c. integration testing
d. technical infrastructure |
|
Definition
|
|
Term
Which of the following issues associated with EHR should I plan to help patients learn more about?
a. availability of information when needed
b. costs of system
c. privacy and security
d. readiness of organization |
|
Definition
|
|
Term
The type of testing that ensures that the system can handle a large number of users is:
a. acceptance
b. unit
c. integration
d. stress |
|
Definition
|
|
Term
| T or F: In the dual core strategy, we have one vendor for clinical systems and one for administrative systems. |
|
Definition
|
|
Term
| T or F: Chart conversion is not needed when implementing an EHR |
|
Definition
|
|
Term
| T or F: The migration path describes our strategy for the implementation of the major components of the EHR |
|
Definition
|
|
Term
The CIA of security includes, confidentiality, data integrity, and:
a. accessibility
b. authentication
c. accuracy
d. availability |
|
Definition
|
|
Term
Which of the following statements is true about HITECH?
a. It eliminated business associates
b. It eliminated the patient right to restrict information
c. It added a data breach notification requirement
d. It reduced the focus on privacy and security |
|
Definition
| c. It added a data breach notification requirement |
|
|
Term
Audit logs and alert pop ups are examples of:
a. metadata
b. encryption
c. admissibility
d. data integrity |
|
Definition
|
|
Term
Which of the following make data entry easier but may harm data quality?
a. use of templates
b. copy and paste
c. drop down boxes
d. structured data |
|
Definition
|
|
Term
I am concerned about whether the data transmitted across our network is altered during the transmission. The concept that concerns me is:
a. admissibility
b. disclosures
c. availability
d. data integrity |
|
Definition
|
|
Term
| T or F: Because of concerns regarding permanence, electronic data is being destroyed sooner than paper records |
|
Definition
|
|
Term
| T or F: Amendments to content in the electronic health record could result in poor data quality if handled inappropriately |
|
Definition
|
|
Term
| T or F: If a document is not identified as part of the legal record, it cannot be subpoenaed |
|
Definition
|
|
Term
Which of the following is designed to collect a minimum set of data about inpatients?
a. DRGs
b. NCHS
c. UACDS
d. UHDDS |
|
Definition
|
|
Term
Which of the following is used to collect data about ambulatory care patients?
a. DRGs
b. MDS
c. ORYX
d. UACDS |
|
Definition
|
|
Term
Which of the following is used to collect data about long-term care residents?
a. NCHS
b. MDS
c. UACDS
d. UHDDS |
|
Definition
|
|
Term
Which of the following provides a structured way to develop a long-term care resident care plan?
a. MDS
b. OASIS-C
c. UACHD
d. UHDDS |
|
Definition
|
|
Term
Which of the following is used to gather data about Medicare beneficiaries receiving home care?
a. MDS
b. NCHS
c. OASIS-C
d. UHDDS |
|
Definition
|
|
Term
Which of the following best describes the DEEDS data set?
a. uses data for home health outcomes research
b. collects data about hospital emergency encounters
c. uses data for inpatient analysis
d. collects data for ambulatory care |
|
Definition
| b. collects data about hospital emergency encounters |
|
|
Term
Which of the following is a set of performance measures used to compare the performance of healthcare plans?
a. DEEDS
b. HEDIS
c. ORYX
d. UHDDS |
|
Definition
|
|
Term
Which of the following was developed by the Joint Commission?
a. HEDIS
b. MDS
c. OASIS-C
d. ORYX |
|
Definition
|
|
Term
Which part of the NHIN focuses on the patient entering data?
a. Personal health dimension
b. Healthcare provider dimension
c. Population health dimension
d. Core data set |
|
Definition
| a. Personal health dimension |
|
|
Term
The Resident Assessment Protocol is triggered by the data collected by the:
a. Core measures
b. DEEDS
c. MDS
d. HEDIS |
|
Definition
|
|
Term
Which of the following best describes an SDO?
a. coordinates standards groups
b. develops standards
c. develops data sets
d. develops best practices |
|
Definition
|
|
Term
Which of the following should be used to communicate information from one provider to another for referral, transfer, or discharge of the patient?
a. CDA
b. CCR
c. HL7
d. ORYX |
|
Definition
|
|
Term
Which of the following was adopted as the federal health information interoperability messaging standard for imaging?
a. DEED
b. DICOM
c. IEEE
d. NHIN |
|
Definition
|
|
Term
Which SDO develops messaging, data content, and document standards to support the exchange of clinical information?
a. IEEE
b. DSMO
c. NUBC
d. HL7 |
|
Definition
|
|
Term
Which of these standards is a technical/interoperability standard?
a. ASTM CCR
b. LOINC
c. HL7 CDA
d. DICOM |
|
Definition
|
|
Term
One of the two official HHS advisory groups established as a result of ARRA responsible for making recommendations to the National Coordinator is:
a. Certification Commission for Health Information Technology
b. HL7
c. HIT Policy Committee
d. Accredited Standards Committee Health Care Task group |
|
Definition
|
|
Term
Which standard assists in the sharing of information from one provider to another for patient care?
a. ASTM CCR
b. LOINC
c. HL7 CDA
d. DICOM |
|
Definition
|
|
Term
What organization coordinates the efforts of other SDOs?
a. ANSI
b. HL7
c. ASTM
d. ARRA |
|
Definition
|
|
Term
What type of standard is utilized to control the format and sequence of data while the data crosses a network?
a. functional/EHR
b. technical/interoperability
c. structure and content
d. transmission standards |
|
Definition
| d. transmission standards |
|
|
Term
The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:
a. serial numbering system
b. unit numbering system
c. serial-unit numbering system
d. terminal digit filing system |
|
Definition
|
|
Term
The primary guide to locating a record in a numerical filing system is the:
a. master patient index
b. admission register
c. discharge register
d. physician index |
|
Definition
|
|
Term
All forms should:
a. contain a unique identifier
b. identify the patient's age
c. list allergies
d. be 8.5 x 14 inches |
|
Definition
| a. contain a unique identifier |
|
|
Term
The health record number is typically assigned by:
a. patient registration
b. nursing
c. billing
d. HIM staff |
|
Definition
|
|
Term
Which of the following is used to locate an electronic health record?
a. health record number
b. bar code
c. color code
d. terminal digit |
|
Definition
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Term
John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:
a. duplicates
b. overlay
c. overlap
d. integrity |
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Definition
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Term
Which of the following should be part of a comprehensive MPI maintenance program?
a. advanced person search
b. issuing medical record numbers
c. deletion capabilities
d. employee training |
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Definition
| a. advanced person search |
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Term
Which of the following is true about the social security number?
a. AHIMA supports using the social security number as the health record number
b. The social security administration supports using the social security number as the health record identifier
c. Both AHIMA and the social security administration oppose using the social security number as the health record identifier
d. both AHIMA and the social security administration support using the social security number as the health record identifier |
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Definition
| c. both AHIMA and the social security administration oppose using the social security number as the health record identifier |
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Term
The most common numbering system used in healthcare is:
a. serial numbering
b. unit numbering
c. serial-unit numbering
d. alphabetic |
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Definition
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Term
Which identification system is at a disadvantage when there are two patients with the same name?
a. serial numbering
b. unit numbering
c. serial-unit numbering
d. alphabetic |
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Definition
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Term
The master patient index (MPI) is necessary to locate health records withing the paper-based storage system for all the types of filing systems, except:
a. straight numerical
b. terminal-digit filing
c. middle-digit filing
d. alphabetical filing |
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Definition
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Term
The term used to describe a combination of paper-based and electronic health records is:
a. flexible
b. joint
c. mixed
d. hybrid |
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Definition
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Term
Which of the following is an advantage of a centralized unit filing system?
a. having the records close to the specialized patient care area
b. one location in which to look for records
c. different file folders for each area of specialty
d. having different rules for each area |
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Definition
| b. one location in which to look for records |
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Term
Which filing system is considered to be the most efficient?
a. straight numeric
b. terminal digit
c. middle-digit
d. alphabetic |
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Definition
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Term
What type of paper based storage system conserves floor space by eliminating all but one or two aisles?
a. open-shelf units
b. carousel systems
c. mobile filing units
d. filing cabinets |
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Definition
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Term
In a paper-based system, the HIM department routinely delivers health records to:
a. patient registration
b. nursing units
c. billing department
d. administration |
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Definition
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Term
Which of the following paper weights would be the most durable for the medical record folder?
a. 11
b. 14
c. 20
d. 8 |
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Definition
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Term
What microfilm format is inefficient when patients have multiple admissions on microfilm?
a. roll
b. jacket
c. microfiche
d. both roll and jacket |
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Definition
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