HIM FINAL EXAM PRACTICE

A radilogy information system is which of the following?
Source system
When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence?
Adoption
Which of the following is a fundamental change in how medicine is practiced using health IT?
Clinical transformation
Which of the following is a program that assures there is documented approval for altering an application?
Change control
What health information exchange is a sophisticated structure that enables both receipt of data and the ability to query an exchange for data?
CONNECT
What is interoperability?
The ability to share health information with other health IT systems
Revenue cycle management is accomplished through use of which of the following systems?
Form creation system
Structured data are which of the following?
Infusion pumps and robotics are examples of which of the following?
Smart peripherals
Ideally, clinical documentation in an EHR should be performed
At the point of care
The source of drug-drug contraindication information in a computerized provider order entry system is
Drug knowledge databases
Which of the following is an example of clinical decision support?
Workgroup tool
A standard vocabulary is used to achieve what type of interoperability?
Semantic
A way to send secure message over the internet is which of the following?
Virtual private network (VPN)
Healthcare information is primarily for which of the following?
Provider use in the management of care
To arrive at information______ are required.
Data
______ data analytics is where health information is captured, reviewed, and used to measure the quality of care provided.
Clinical
What is the first stage of transforming raw data into meaningful analytics?
Data capture
Which of the following may be used to capture the data for storage in a database?
Data mining
Which of the following data visualization tool is used when displaying trends?
Graphs
The _____ is a management report of process measures.
Dashboard
Which of the following is where a nurse enter data using a tablet computer when conducting a patient assessment while at the bedside?
Human-computer charting
_____ is key to the knowledge discovery process.
Data mining
The clinical data_____ lends itself to data mining as it encompasses multiple source of data.
Warehouse
Which decision support systems could deliver a reminder to a physician that it is time for the patients flu shot?
Clinical
The _____ would be used to help find actionable insights to drive enterprise performances.
Executive information system
A _____ generated scorecard could be used by manager to monitor readmission rates in order to track trends and identify opportunities for improvement
Decision support system
The exchange of email communication between the patient and physician on a question regarding medication is an example of _____ health informatics.
Consumer
True or False. In all cases, a covered entity may deny an individual’s request to restrict the use or disclosure of his or her PHI
False
Which of the following is a covered entity under the HIPAA Privacy Rule?
Pharmacy
Which types of health records are subject to the HIPAA Privacy Rule?
Health records in any format
What does the acronym PHI stand for?
Protected Health Information
Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity ____.
Can deny access to psychotherapy notes
In which of the following situations must a covered entity provide an appeal process for denials to requests from individuals to see their own health information.
When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual.
Which of the following statements is true in responding to request from individuals who wish to access their PHI?
A cost based fee may be charged for making copy of the PHI
How many days does a covered entity have to respond to an individual’s request for access to PHI under HIPAA rules?
30 days
How many days does a covered entity have to respond to an individual’s request for access to his or her PHI?
60 days
Which of the following provide a complete description to patients about how PHI is used in a healthcare facility?
Authorization
Which of the following statements is true of the notice of privacy practices?
It must be provided to every individual at the first time of contact or service with the covered entity.
Which of the following is unsecured PHI?
PHI that is present on a stolen device such as a laptop or cellphone.
The primary reason that healthcare organizations develop business continuity plan is to minimize the effects of which of the following?
Computer downtime
Critique this statement: HIPAA represents an attempt to establish best practices and standards for health information security.
This is a true statement
A risk analysis is useful to _____
Identify security threats
Which of the following is a technique that can be used to determine what information access privileges an employee should have?
Context-based
The HIPAA data integrity standard requires that organization do which of the following?
Keep documented logs of system access and access attempts
Which of the following is required by HIPAA standards?
A written contingency plan
Which of the following is true regarding HIPAA security provisions?
Covered entities must conduct employees security training sessions every six months for all employees.
The Hospital standardization movement was inaugurated by the
American College of Surgeons
HIM has been recognized as a profession since
1928
The HIM profession is changing due to
Changes in technology
The new model of HIM practice is
Information focused
The traditional model of HIM practice was
Department based
The organization that accredits HIM education program is
CAHIM
Our college has applied to become accredited by CAHIM. Which of the following is the name of the interim stage of accreditation?
Candidacy
Which of the following is the virtual network used by AHIMA members?
Engage
Which of the following functions governs the HIM profession?
House of Delegates
The primary focus of AHIMA is to
Foster professional development of its members
Which of the following certifications is administering by CCHIM?
Registered Health information Technician
The acronym IDS refers to
Integrated delivery systems
Which healthcare professional assists physicians in clinical assessments and patient education?
Physician Assistant
Which of the following medical practitioner is not considered a generalist?
Cardiology
Which healthcare provider utilizes ultrasound, computed tomography, or MRIs?
Radiologic technologist
Which of the following is a surgical specialty?
Orthopedics
Which of the following statements is true about registered nurses (RNs)?
RNs are required to have a license in the state in which they practice
Which of the following perform a wide array of tests on body fluids, tissues, and cells to assist in the detection, diagnosis, and treatment of diseases and illnesses?
Clinical laboratory scientists
Respiratory therapists treat patients with limited mobility
False
Audiologists provide comprehensive diagnostic and treatment /rehabilitative services for authority, vestibular, and related impairments.
True
Physical therapy assistants carry out the treatment plans created by the physical therapists.
True
Which of the following laws created the HITECH Act?
American Recovery and Reinvestment Act
Until the World War II, where was. Pat healthcare provided?
Home
An HIM student has asked you why Medicare reimburses healthcare providers through prospective payment systems. Which of the following pieces of legislation would you use as your explanation?
Tax Equity and Fiscal Responsibility Act of 1982
Which of the following legislation authorized the creation of the Office of National Coordinator for Health information Technology?
ARRA
Which of the following best describes Medicaid?
Federally mandated healthcare program for low income people
Required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement.
Tax Equity and Fiscal Responsibility Act of 1982
Gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children general public health work, and aid for dependent children under age 16
Social Security Act of 1935
Required concurrent review of Medicare and Medicaid patients
Public law 92-603 of 1972
Patient protection and Affordable Care Act of 2010
Provided an individual mandate to have minimum acceptable coverage or pay a tax penalty.
Utilization Review Act of 1977
Required that hospitals conduct continued stay reviews for Medicare and Medicaid patients
Which of the following is NOT an example of an administration support services?
HIM
Who has the primary responsibility to guide the direction of the hospital?
Chief Executive Officer
Which of the following is an example of a federally run hospital?
VA
Which service diagnosed and treats patients who have acute and/or chronic sling disorders?
Respiratory Therapy
Dr. Smith has. Even granted permission by Community hospital to perform cardiac Catheterizations. This permission is called
Clinical privileges
Acute care hospitals provide a short term care to diagnose or treat an illness
True
A registered nurse performs patient assessments, creates care plans, and evaluates the appropriateness of treatment and effectiveness of care
True
Pharmaceutical services are considered part of the clinical support services
True
The average length of stay for an acute care hospitals is 21 days or less
False
Physical therapies are only one member of the rehabilitation service team.
True
Which of the following statements is true about behavioral health?
Insurance coverage generally places restrictions on the psychiatric care such as a limit on the number of outpatient visits.
My daughter fell and cut herself tonight. Though it is not an emergency, I believe she needs stitches and she should see someone tonight for treatment. What type of setting would I most likely access?
Freestanding ambulatory care center
Most patients in long term care facilities require impatient nursing and related services for more than how many consecutive days?
30
What type of facility offer palliative care for end of life care so that the patient may live life as fully and as comfortable as possible?
Hospice
Which of the following settings provides ambulatory care to low income patients and receives funding from many sources?
Voluntary agency
Manages cost, quality, and access to services
Managed care
A 13 yr long international effort with three principal goals (1) to determine the sequence of the three billion DNA subunits (2) to identify all human genes, and (3) to enable genes to be used in further biological study
Human Genome Project
Provided emergency services and urgent care for walk in patients
Freestanding ambulatory care centers
Care that offers patients access to constant nursing care while recovering at home
Subacute Care
Care provided by different caregivers at several different levels of the healthcare systems
Continuum of care
The publication To Error is Human stated that as many as how many patients die each year from preventable medical mistakes?
98,000
To “create social and physical environments that promote good health for all” is a goal of which of the following organizations?
Healthy people 2020
Which of the following is a nonprofit, no governmental organized?
National Academy of Medicine
Which federal agency monitors healthy precautions for international travelers?
CDC
Which of the following documents from the National Academy of Medicine addresses the duplication and contrasting approaches to performance measures by the six major governmental healthcare programs that serve nearly 100 millions Americans?
Leadership by example
There are six federal agencies that provide healthcare to over 100 million people
True
Healthcare policy is only formulated at the federal level
False
The delivery of healthcare in the United States is based on a well researched master lab designed to contain costs, increases patients access to providers, and ensure excellent quality of care
False
Healthy people 2020 is the third iteration of this document.
True
Comparative effectiveness research is a major focus of the patient centered outcomes research institute
True
Which of the following is an example of a primary purpose of the health record?
Patient Care
I work for an organization that utilizes health record data to prove or disprove the efficacy of a health care treatment. What type of organization do I work for?
Research
Which of the following is an example of an institutional user of the health record?
Third party payer
Which of the following is an example of an individual user?
Patient
Health departments use the health record to monitor outbreaks of diseases. Which type of use is this?
Public health and research
What microfilm format is inefficient when patients have multiple admissions on microfilm?
Roll
What type of paper based storage system conserves floor space by eliminating all but one or two aisle?
Mobile filing units
What feature of the filing folder helps locate misfiled within the paper based filing system?
Color coding
Who’d of the following is a tool used to track paper based health records?
Outguide
What should be done when the HIM department error or accuracy rate is too high based on policy?
Corrective action should be taken.
The forms design committee
Provides oversight for the development, review, and control of forms and computer screens.
In a paper based system, individual health records are organized in a standardized order in which of the following processes?
Assembly
Reviewing a health record for missing signatures and missing medical reports is called
Analysis
Two patient’s records were filed together by mistake. This is an example of
Overlay
Which of the following describes incomplete records that are not completed by the physician within the time frame specified in the healthcare facility’s policies?
Delinquent records
One of the advantages of a DMS is that it can
Control workflow
How are amendments handled in the EHR?
The amendment must have a separate signature, date, and time.
Version control of documents in the EHR requires?
Policies and procedures to control which versions is displayed
Which of the following is a risk of copying and pasting?
Copying the note in the wrong patient’s record
When I key in 10101063, the computer displays it as 10/10/1963. What enables this?
Input mask
Which of the following is controlled by patients?
Personal health record
Where will you find clinical decision support?
Electronic health record
Which of the following systems is used to track whether or not a request for information has been processed?
Release of information
With which department does the HIM department interact to perform audits and monitor outcomes?
Quality improvement
What type of speech recognition is used when the physician edits the document?
Front end
The overall goal of documentation standards is
To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.
A hospital that participates in the Medicare and Medicaid programs must follow
The Conditions of Participation
When defining its legal health record, a healthcare provider organization must do which if the following?
Assess the legal environment
Which of the following is the health record component that addresses the patient’s current complaints and symptoms and lists the patient’s past medical, personal, and family history??
Medical history
General documentation guidelines apply to
All categories of healthcare records
Health record entries should be documented at the time the services they describe are rendered
True
Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record
True
When an error is made, the erroneous information can be obliterated
False
Auto authentication is the preferred method of authentication.
False
A patient’s gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?
Administrative data
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?
Ambulatory record
What type of health records may contain family and caregiver input?
Behavioral Health Records
The ambulatory surgery record contains information most similar to which of the following?
Hospital operative records
Which group focuses solely on accreditation of rehabilitation programs and services?
CARF
Which types of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?
Emergency care
A patient’s registration forms, property list, RAI, care plan, and discharge or transfer for documentation would be found most frequently in which type of health record?
Long term care
Which of the following would not be found in a physical exam?
General condition
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records his or her evaluation in what type of report?
Consultation
Written or spoken permission to proceed with care is classified as
Expressed consent
What specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Care plan
Which of the following reports provides information on tissue removed during a procedure?
Pathology report
A growth and development record may be found in what type of record?
Pediatric
Many services such as surgery, infusions, and other diagnostics procedures that once required an over night hospital stay for the patient, no longer requires that level of care.
True
CMS requires that healthcare providers inform their patients about general patient rights afforded to them.
True
Healthcare provider organizations normally have patients sign an acknowledgment acknowledging that the healthcare provider organization is kit responsible for the loss of or damage to the patient’s valuables.
True
The subjective, objective, assessment, plan (SOAP) method came from the
Problem oriented health record
Which of the following electronic record technological capabilities would allow paper based health records to be incorporated into a patient’s EHR?
Documentation imaging technology
The problem list is part of which of the following?
Problem oriented health record
The paper health record has been scanned and is now available digitally. What is this known as?
It is known as imaging
Nursing documentation within the health record will be
Both subjective and objective
payers and the government are not concerned with how a physician documents in a health record.
False
Only physicians document in the health record
False
HIM professionals document in the health record
False
Management of health record information is a fundamental component of information governance
True
If data granularity is the goal of collecting the data, clinical terminologies is the best choice
False
The SNOMED CT preferred term includes the semantic tag
True
The three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and descriptions.
False
Category I CPT includes E/M, Anesthesia, surgery, radiology, pathology, and laboratory band medicine.
True
Nursing terminologies are used for reimbursement of nursing care for Medicare patients.
False
Mental disorders
DSM-5
Diseases of Oncology
ICD-O-3
Inpatient procedures
ICD-10-PCS
States of functioning
ICF
Diseases for morbidity
ICD-10-CM
Which of the following is standard for drugs under the meaningful use program?
RxNorm
Which of the following is standard for supplies under HIPAA?
HCPCS
Which of the following is standard for clinical lab test results?
LOINC
Which type of HCPCS level II code is not published by CMS?
Dental procedures
RxNorm names for clinical drugs contain information on which of the following?
Ingredients
The core clinical data set definitions are incorporated into the inpatient prospective payment.
False
Data elements specified in OASIS-C1 are collected on long term care patients.
False
HEDIS collects standardized data from health records in clinics and hospitals.
True
The UMLS includes terminologies but excludes classifications.
False
The common clinical data set is used in home healthcare settings.
False
A data element is a single or individual fact that represents the smallest unique subset of larger data.
True
A data set is which of the following ?
A recommended list of data elements that support a specific healthcare industry.
Which of the following is a purpose of the creation of data dictionary?
Create support for structured data collections.
Which of the following are the two most common types of database found in healthcare?
Relational and object oriented data bases?
An index creates a definition for terms that are within a database.
False
There is usually only one source of data within a healthcare organization.
False
Refers to the creation of business owners over a specific areas of the data. Based on the business need, the business owners are responsible to create business rules and definitions when collecting specific data to support patient care and their business operations.
Data ownership
Data quality focuses on entering data into the system that is true, accurate, and relevant to patient care needs and business operations needs.
Data quality
Data stewardship is the evaluation of the data collection based on business need and strategy to ensure the data meets the requirements of patient care and organizational needs. Data stewardship and data ownership are closely connected.
Data stewardship
Refers to the creation of documentation to justify business decisions made based on the different data collection and storage systems that are used within an organization.
Data modeling
This concept focuses on how the data is being entered into the system, where the data is going within the system, where the same data might exist in multiple areas, and how it is being integrated into other applications.
Data standardization and integration
Correct
The first professional association for health information managers was established in what year?
The first professional association for health information managers was established in what year?
1928
The hospital standardization program was started by _______
American College of Surgeons
The formal approval process for academic programs in health information management is called which of the followin
Accreditation
Which of the following is the formal process for conferring a health information management credential?
Certification
Which of the following is a traditional HIM role?
Tracking record completion
Which of the following functions governs the HIM profession?
AHIMA house of Delegates
Which of the following make up a virtual network of AHIMA members?
AHIMA Engaged
Which of the following is an arm of AHIMA that promotes research in health information management?
AHIMA Foundation
Which of the following best describes the mission of AHIMA?
Community of professionals providing support to members and strengthening the industry and professoin
Which professional organization sponsors
the CTR certification?
NCRA
Which of the following places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers?
Continuum of care
Someone who wishes to sit for the Certified Professional Coder (CPC) certification should contact which organization?
AAPC
In order to qualify for an AHIMA fellowship, what minimal educational level is needed?
Associates Degree
Which of the following qualify for CEUs?
College course
.as of 2014, what percent of the U.S. Economy was represented by healthcare spending?
17.5
What is the ideal ratio of medical generalist to specialist?
40:60
Which of the following is considered an Allied Health professional?
Licensed Practical Nurses
Which of the following laws created Medicare and Medicaid?
Public law 89-97 of 1965
What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified
Utilization review
HITECH was a portion of which bill?
American Recovery and Reinvestment Act of 2009
Critique this statement: Once someone has earned the registered health information technician (RHIT) credential, it is a lifetime certification.
This is incorrect as RHITs have to become recertified.
What is the name of the type of beds in a hospital that are defined by those authorized by the state?
Licensed
The “C” in CIO stands for:
Chief
Health information management department are considered which of the following
Ancillary Support Service
Which of the following is the fastest growing sector to offer services for Medicare recipients?
Home Health
Which of the following is the health profession that focuses on the eyes and related structures?
Optometry
Public law 89-97 of the 1965 created a number of amendments to which Act?
Social Security Act
The Office of the National Coordinator for Health Information Technology was created as part of which Act?
American Recovery and Reinvestment Act
Which of the following is a secondary purpose of the health record?
Educate Medical Students
Which of the following is an institutional user of the health record?
Third party payers
How do patient care managers and support staff use the data documented in the health record?
Evaluate the performance of employees
An HIM student asked an HIM director why the hybrid record is so challenging. What is the HIM directors response?
It is because we have to Manage both the electronic and paper media.
What is the process of ensuring that a record is available for every patient seen at the healthcare facility?
Reconciliation
Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used?
Front end
Critique this statement: Data and information mean the same thing.
This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.
The use of the health record by a clinician to facilitate quality patient care is considered ______ .
A primary purpose of the health record
How do accreditation organizations use the health record?
To determine whether standards are being met
How long should the MPI be retained?
Permanently
Deficiencies in a health record include which of the following ?
Missing document
Which of the following is true about document imaging?
Documents can be indexed
Which of the following is part of qualitative analysis review?
Checking that only approved abbreviations are used
Which of the following is the most efficient filing system?
Unit numbering filing system
Which of the following creates a chronological report of the patient’s condition and response treatment during a hospital stay.
Progress notes
Which the health format is the most commonly used by healthcare settings as they transition to electronic records?
Hybrid records
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non profit organization?
Accreditation
Which part of the medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in the patient’s own words?
Chief complaint
Which of the following is an example of administration information?
Patient’s address
Which of the following statements is true of the process that should be followed in making corrections in paper based health record entires?
The reason for the change should be noted
Which of the following types of facilities is generally governed by long term care documentation standards?
Subacute care
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimen ms removed?
Operative report
A patient’s registration forms, personal property list, RAI/MDS and care lab and discharge or transfer documentation would be found most frequently in which type of health record?
Long term care
Exhibit group focuses on accreditation of rehabilitation programs and services?
CARF
A healthcare organization, when defining its legal health record must:
Assess the legal environment, system limitations, and HIE agreements
Written or spoken permission to proceed with care is classified as _____.
Express consent.
The subjective, objective, Assessment plan (SOAP) came from the:
Problem oriented health record
The management of health information is a fundamental component of which of the following ?
The overall information governance model
Who responsible for communicating information relevant to national issues and keeping members informed of regional affairs that affect HIM?
AHIMA component Associations
Which group brings together stakeholders to address issues related to the future of the HIM profession and education?
Council for excellence in education
Whack of the following is the accreditation organization for HIM. Programs?
CCAHIM
Which of the following is true about AHIMA certification program?
Candidates must pass an examination before obtaining any of the credentials
Which of the following classes of AHIMA membership requires that individuals have interest in HIM and will abide by the AHIMA code of ethics?
Active membership
Which of the following. Entities are at head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA?
Board of the Directors
The accreditation program of AHIMA is concerned with which if the following ?
Establishing standards for the content of college programs in health information management
Which organization should be contacted regarding the Certified healthcare documentation specialist exam?
Association for healthcare documentation integrity
Which of he following make up virtual network of AHIMA members who communicate via web based program managed by AHIMA?
Engage
Which of the following. Is a surgical specialty?
Anesthesiology
Which of he following carries out the operational tasks necessary to support the organization mission and goals?
Staff
Two types of practitioners can hold the degree of Doctor of Medicine. They are:
Physician and surgeon
Patients in hospice care are expected to live a maximum of ____ days.
180