question

1. The information system that assigns an ICD-10-CM code is called a(n): A. encoder B. grouper C. data quality indicator D. master patient index

answer

Encoder

question

2. Which of the functionalities below is more likely to be found in a birth certificate system designed by a vendor than the state? A. productivity B. submit birth certificate data C. request social security number D. order copies of birth certificates

answer

Productivity

question

3. Which product would identify that Dr. Smith needs to sign a discharge summary? A. chart locator B. quality indicator system C. chart deficiency D. release of information

answer

chart deficiency

question

4. Which of the following systems would be used primarily by physicians, rather than HIM Department staff? A. cancer registry system B. data quality indicators system C. transcription system D. dictation system

answer

dictation system

question

5. A request for an accounting of disclosure has been received. I should access which of the following to fulfill this request? A. data quality indicators system B. release of information system C. encoder/grouper D. disclosure management system

answer

disclosure management system

question

6. Which of the letters listed below would be part of the release of information system? A. letter asking for additional information on a patient previously treated at the hospital B. letter notifying individual that the authorization was invalid C. letter notifying physician that he has delinquent medical records D. letter asking physician to clarify primary diagnosis

answer

letter notifying individual that the authorization was invalid

question

7. Which of the following systems would track follow-up rates? A. release of information system B. encoder/grouper C. trauma registry D. dictation system

answer

trauma registry

question

8. Which of the following systems could have voice recognition as a feature? A. release of information system B. encoder/grouper C. trauma registry D. dictation system

answer

dictation system

question

9. Collaborative staging and TNM staging may be a part of which of the following systems? A. release of information system B. encoder/grouper C. data quality indicator D. tumor registry

answer

tumor registry

question

10. The user is entering the number of units of blood given to a patient during surgery, the presence or absence of a nosocomial infection and other information from the patient's chart. The user must be abstracting into which system: A. release of information system B. encoder/grouper C. quality indicator D. tumor registry

answer

quality indicator

question

11. The user is entering the newborn's APGARs, the weight of the baby, request for social security number, name of parents, and other information. What system is being used? A. dictation B. birth certificate C. data quality indicator D. tumor registry

answer

birth certificate

question

12. The data element principal diagnosis is found in: A. transcription system B. encoder/grouper C. data quality indicator D. tumor registry

answer

encoder/grouper

question

13. Based on functionality, which of the following systems would you expect to become obsolete in the short term with an EHR? A. chart locator B. data quality indicator C. encoder/grouper D. tumor registry

answer

chart locator

question

14. Where would you find a field entitled document type? A. transcription system B. encoder/grouper C. data quality indicator D. tumor registry

answer

transcription system

question

15. As a general rule, which of the following systems would be utilized by departments other than HIM? A. transcription system B. encoder/grouper C. master patient index D. tumor registry

answer

master patient index

question

16. Which of the following statements is true? A. The release of information system's letters are only used to send letters to administration. B. The release of information system's letters communicates with the requester. C. The release of information staff rarely utilize the reporting function. D. The release of information staff probably do not use the letter capabilities as communication with those outside the department.

answer

The release of information system's letters communicates with the requester.

question

17. Which of the following statements is true about the encoder? A. There is only one type of encoder. B. Encoders can only be used for ICD-10-CM C. Encoders assign the MS-DRG D. Encoders assign the code for both diagnoses and procedures.

answer

Encoders assign the code for both diagnoses and procedures.

question

18. Which of the following is a term used to describe a type of encoder? A. rules-based B. grouper C. alert D. NCCI edit

answer

rules-based

question

19. A user needs to enter Macon General Hospital as one of the requesters of health information into the disclosure management system. Which table would be used to enter the name of the facility, address and other information? A. charge table B. report table C. requester table D. forms table

answer

requester table

question

20. Which of the following is a function of the release of information software? A. track status of patient discharge B. track status of request C. duplicate medical record numbers D. resequencing diagnosis and procedure codes

answer

track status of request

question

21. Reports designed specifically for one time use is called what type of report? A. standing B. routine C. ad hoc D. temporary

answer

ad hoc

question

22. Which of the following is an example of a function of the cancer registry software? A. checking social security death index B. entering the device implanted C. resequencing diagnoses D. invoicing requester

answer

checking social security death index

question

23. The chart location system would help the healthcare facility with which of the following? A. security B. privacy C. accessibility D. documentation

answer

accessibility

question

24. Patient follow-up is a key part of which HIM system? A. chart locator B. disclosure management C. release of information D. cancer registry software

answer

cancer registry software

question

25. Which of the following is a management use of the chart locator? A. productivity reporting B. accounting of disclosures C. patient follow-up list D. looking for trends in type of accidents

answer

productivity reporting

question

26. True or False: A registry tracks multiple diseases and conditions rather than specialize.

answer

FALSE

question

27. True or False: The dictation system has implications for physicians and HIM staff

answer

TRUE

question

28. True or False: The transcription system should collect the date of transcription.

answer

TRUE

question

29. True or False: The grouper should only be able to utilize the current Medicare grouper.

answer

FALSE

question

30. True or False: Quality indicator systems collect voice from the dictation system to capture data.

answer

FALSE

question

In order for an organization to ensure it has the necessary infrastructure to support an EHR, it should first: A. Assess data requirements B. Conduct a functional needs assessment C. Create a request for proposal D. Perform a technology assessment Pg. 221

answer

Conduct a functional needs assessment

question

31. Which organization requires that hospitals base their information management processes on an assessment of internal and external information needs? A. American Hospital Association (AHA) B. Centers for Medicare & Medicaid Services (CMS Conditions of Participation) C. Certification Commission for Health Information Technology (CCHIT) D. The Joint Commission (Comprehensive Accreditation Manual for Hospitals)

answer

The Joint Commission (Comprehensive Accreditation Manual for Hospitals)

question

32. Which of the following is a primary use of an EHR as defined by the IOM's report, "Key Capabilities of an Electronic Health Record System?" A. Education B. Patient care management C. Public health D. Research

answer

Patient care management

question

33. As defined by the IOM's report, "Key Capabilities of an Electronic Health Record System," which of the following is a secondary use of an EHR? A. Patient care delivery B. Financial and other administrative processes C. Patient self management D. Regulation

answer

Regulations

question

34. As defined by the IOM's report, "Key Capabilities of an Electronic Health Record System," results reporting, results notification, multiple views of data/presentation, and multimedia support are examples of which core functionality: A. Administrative processes B. Electronic communication and connectivity C. Health information and data D. Results management

answer

Results management

question

Match the functionalities in the HL7 EHR System Functional Model with their major categories: A. Direct Care B. Supportive C. Information Infrastructure 35. Operations management and communication

answer

Direct Care

question

Match the functionalities in the HL7 EHR System Functional Model with their major categories: A. Direct Care B. Supportive C. Information Infrastructure 36. Health record information and management

answer

Information Infrastructure

question

Match the functionalities in the HL7 EHR System Functional Model with their major categories: A. Direct Care B. Supportive C. Information Infrastructure 37. Clinical decision support

answer

Direct Care

question

Match the functionalities in the HL7 EHR System Functional Model with their major categories: A. Direct Care B. Supportive C. Information Infrastructure 38. Administrative and financial

answer

Supportive

question

Match the functionalities in the HL7 EHR System Functional Model with their major categories: A. Direct Care B. Supportive C. Information Infrastructure 39. Workflow management

answer

Information Infrastructure

question

41. What is the CCHIT's purpose? A. Accelerate the adoption of robust, interoperable HIT throughout the U.S. B. Certify professionals who would be leaders in the implementation of EHR C. Develop a decision matrix for building an ideal EHR system D. Provide a standard definition of EHR

answer

Accelerate the adoption of robust, interoperable HIT throughout the U.S.

question

42. When did CCHIT first begin certifying products? A. 2003 for core EHR B. 2005 for inpatient C. 2006 for ambulatory D. 2007 for health information exchange

answer

2006 for ambulatory

question

43. Which of the following is not a reason for an organization to conduct its own functional needs assessment? A. Different organizations have different needs B. Every organization starts from a different point C. Performing a functional needs assessment helps users learn about EHR D. Vendors can claim they are certified to specific criteria when they are not

answer

Vendors can claim they are certified to specific criteria when they are not

question

44. Why does a functional needs assessment begin with a survey of users? A. Aids in educating users about functionality B. Every user has different needs C. Product certification is not sufficiently detailed D. Users are uniquely qualified to understand their needs

answer

Aids in educating users about functionality

question

45. A use case: A. Confirms user needs against CCHIT criteria B. Describes an EHR's behavior in response to a user process C. Diagrams the flow of information throughout an EHR D. Documents the federal government initiatives for EHR Pg. 207

answer

Describes an EHR's behavior in response to a user process

question

46. A functional needs assessment is compiled into what document in order to evaluate products: A. Applications inventory B. Process map C. Request for proposal D. Use case diagram

answer

Request for proposal could be D not sure

question

47. In order to verify that functional needs requirements are complete after surveying users and developing use cases, an organization should next: A. Compare functions to benefits B. Conduct an applications inventory C. Inventory current functional capabilities D. Perform a retrospective analysis of clinical decision making

answer

Inventory current functional capabilities

question

48. An applications inventory helps an organization determine that it: A. Can interface administrative functions to clinical functions B. Has necessary source systems to supply data to the EHR C. Produce necessary reports from its EHR D. Will have functions to meet benefits expectations

answer

Has necessary source systems to supply data to the EHR

question

49. A retrospective analysis of decision making helps organizations recognize: A. Data requirements for decision making B. Errors and near misses from past experience C. Information requirements for reports D. Rules for processing clinical decision making

answer

Data requirements for decision making

question

50. Which of the following is not included in a use case? A. Actors that perform a process B. Preconditions to a process C. Specific products that support a process D. Triggers to a process

answer

Specific products that support a process Could be C not sure

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 51. Medication reconciliation

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 52. Order set templates

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 53. Medication administration

answer

Inpatient

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 54. Access control

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 55. Alerts for disease management

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 56. Pharmacy communication

answer

Ambulatory

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 57. Clinical task management/assignment and routing

answer

Ambulatory

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 58. Capture patient-originated data

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 59. Receive and store laboratory results

answer

Both

question

For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 60. Legal business record

answer

Both

EHR: Chapter 7 & 8 Study Guide – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards