question

1918

answer

The hospital standardization program was started by the American College of Surgeons in:

question

1928

answer

HIM has been recognized as an allied health profession since:

question

6 months

answer

The Consortia's education program is designed to be completed in what amount of time?

question

Accreditation Commission for Health Care (ACHC)

answer

a private non-profit accreditation organization offering services for home health care, hospice, and alternative site healthcare (ie: infusion nursing, home/ durable med. equip. supplies.)

question

American College of Surgeons

answer

ACS

question

Administrative and clinical

answer

The two major types of data that are contained in the health record

question

Advance directive

answer

The administrative documents that provide information on the patient's desires for healthcare for use if he/she is incapacitated?

question

American Health Information Management Association

answer

AHIMA

question

AHIMA Communities of Practice

answer

a virtual network of AHIMA members

question

AHIMA Foundation

answer

an arm of AHIMA that promotes education and research in health information management?

question

AHIMA House of Delegates

answer

Which of the following functions as the legislative body of AHIMA?

question

AHIMA Values:

answer

*The public's right to accurate and confidential personal health information *Innovation and leadership in advancing health information management practices and standards worldwide *Adherence to the AHIMA Code of Ethics *Advocacy and interdisciplinary collaboration with other professional organizations

question

AHIMA Vision

answer

Quality healthcare through quality information

question

American Medical Association

answer

AMA

question

American Academy of Professional Coders

answer

provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations

question

American Associate of Medical record Librarians (AAMRL)

answer

The name adopted by the Association of Record Librarians of North America in 1944; precursor of AHIMA

question

American College of Surgeons

answer

The hospital standardization movement was inaugurated by the:

question

American College of Surgeons (ACS)

answer

The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice

question

American Health Information Management Association

answer

An association whose purpose is to ensure quality, confidentiality and availability of HI across diverse organizations, settings, and disciplines

question

American Health Information Management Association (AHIMA)

answer

The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, certification, and educational services

question

American Medical Record Association

answer

AMRA name adopted by AAMRL/1970

question

American Recovery and Reinvestment Act of 2009 (ARRA)

answer

Previously known as the stimulus bill or HR1. The actions related to health information technology are spread throughout the law; however the bulk of the items are in Title XIII - Health Information Technology; also called Health Information Technology for Economic and Clinical Health Act or HITECH

question

Blue Cross/Blue Shield

answer

BCBS

question

CAHIIM

answer

The organization that accredits HIM education programs is:

question

Care Plan

answer

a summary of the patient's problems from the nurse or other professional's perspective w/ a detailed plan for interventions.

question

Committee on Accreditation of Rehabilitation Facilities (CARF)

answer

Which group focuses on accreditation of rehabilitation programs and services?

question

Center for Disease Control and Prevention

answer

CDC

question

Certification

answer

The formal process for conferring a health information management credential is called:

question

Certification

answer

the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. an evaluation performed to established the extent to which a particular computer syste, network design, or application implementation meets a prespecified set of requirements

question

Certified Documentation Improvement Practitioner (*CDIP)

answer

An individual who has achieved specialized skills in the cancer registry

question

Chief information officer CIO)

answer

responsible for evaluation and acquisition of clinical and nonclinical technological systems that best meet the business needs of the organization

question

Clinical Information Systems (CIS)

answer

an automated system that the function is medical record processing (e.g chart assembly), medical record data collection and analysis, information confidentialtiy and security

question

Center for Medicare and Medicaid Services

answer

CMS

question

Code of Ethics

answer

A statement of ethical principles regarding business practices and professional behavior.

question

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

answer

The accrediting organization for educational programs in health informatics and information management.

question

Commission on Certification for Health Informatics and Information Management (CCHIIM)

answer

oversees AHIMA's certification process and for setting policies and procedures pg18

question

Communities of Practice

answer

The virtual network used by AHIMA members is:

question

To be the professional community that improves healthcare by advancing best practices and standards for HIM and the trusted source for education, research, and professional credentialing.

answer

Mission of AHIMA

question

Component state associations

answer

(CSAs) promote the mission and purpose of AHIMA in its state

question

Consultation

answer

An attending physician requests the advice of a second physician who then review the health record and examines the patient. The second physician records impressions in what type of report?

question

Communities of Practice

answer

CoP

question

Credentialing

answer

The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services.

question

Curriculum

answer

A prescribed course of study in an educational program.

question

data

answer

the dates, numbers, images, symbols, letters, and words that represent the basic facts and observations about people, processes, measurements, conditions, and conditions.

question

Department based

answer

The traditional model of HIM practice was:

question

Det Norske Veritas

answer

an international accrediting organization

question

Department of Health and Human Services

answer

DHHS

question

Enterprise content and information manager

answer

Manages an organization's non clinical paper and electronic documents including developing systems to index and track the location of content and information within the enterprise

question

Expressed consent

answer

Written or spoken permission to proceed with care is classified as:

question

Food and Drug Administration

answer

FDA

question

Fellowship Program

answer

Program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession through meritorious service, exellence in professional practice, education, and advancement of the profession through innovation and knowledge sharing.

question

Foster professional development

answer

The primary focus of AHIMA is to:

question

Health data analyst

answer

Retrieves, analyzes and reports health data using appropriate software and statistical techniques

question

Health Information Management (HIM)

answer

An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions.

question

Health record

answer

the principal repository for information and data about the health care services provided to an individual patient.

question

Health record receiver

answer

responsible for monitoring quality of health information and reconciling information within health record banks and monitoring records for quality

question

HIM director

answer

works with the design development and implementation of the EHR monitoring and reconciling interfaces running electronic data integrity audits and supervising a staff of individuals in a "virtual" HIM department

question

Health Insurance Portability and Accountability Act

answer

HIPAA

question

Health Maintenance Organization

answer

HMO

question

Hospital Standardization Program

answer

an early twentieth-century survey mechanism instituted by the American College of Surgeons and aimed at identifying quality of care problems and improving patient care

question

House of Delegates

answer

An important component of the volunteer structure of AHIMA that conducts the official business of the organization and functions as its legislative body.

question

information

answer

factual data that have been collected, combined, analyzed, interpreted, &/or converted into a form that can be used for a specific purpose.

question

Information focused

answer

The new model of HIM practice is:

question

licensure

answer

refers to state or county regulations that healthcare facilities must meet to be permitted to provide care

question

Master Patient Index (MPI)

answer

a list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility.

question

National Cancer Registrars Association (NCRA)

answer

An organization of cancer registry professionals that promotes research and education in cancer registry administration and practice.

question

National Committee for Quality Assurance

answer

Which group focuses on accreditation of managed care?

question

NCRA

answer

Which professional organization sponsors the Certified Tumor Registrar (CTR) certification

question

New Graduate Membership

answer

status for new graduate/ full 1 year membership at a reduced rate

question

Newborn

answer

Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in what records?

question

Occupational Safety and Health Administration

answer

OSHA

question

Pathology report

answer

A report that provides information on tissue removed during a procedure

question

personal health record (PHR) liasion or consultant

answer

assists individuals in completion of their personal health records

question

Physician's group consultant

answer

Aids in EHR system implementation, auditing documentation practices, or assisting with revenue cycle management

question

Privacy officers

answer

creates the rules for exchange of health information and ensures that the health information remains confidential

question

Preferred Provider Organization

answer

PPO

question

Registered Health Information Administrator

answer

RHIA certification after 4 year program in HIM and credentialing examination

question

Registered Health Information Technician

answer

RHIT certification after 2 year program in HIM and credentialing examination

question

Registration

answer

The act of enrolling.

question

Revenue Cycle Management (RCM)

answer

an automated system's functions are: >admitting, patient access management >case management >charge capture >health info. management >patient financial services, business office >finance >compliance >Info. Technology

question

Revenue cycle manager

answer

oversees all of the processes that make up the revenue cycle from documentation, coding through billing to improve efficiency in the cycle

question

Social Security Administration

answer

SAS

question

Student Membership

answer

AHIMA membership category for students enrolled in an AHIMA accredited or approved program.

question

Terminology modeler

answer

creates digital links among various terminologies and classification systems

question

The electronic health record system (EHR)

answer

An automated system that the function is medical records processing (e.g., chart assembly), Medical record analysis and completion, release of information, medical record file services, medical record data collection and analysis, department organization and management, forms management (format and content), information confidentiality and security

question

The House of Delegates

answer

Which functions as the legislative body of AHIMA

question

The Mission of AHIMA

answer

To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.

question

undergo Medicare certification surveys

answer

An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to:

question

Voice/text/speech system (VTS)

answer

an automated system that the function is medical record report dictation and transcription

question

Accreditation organization

answer

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations.

question

aggregate data

answer

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed.

question

Allied health professional

answer

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietician, social worker, or occupational therapist)

question

Centers for Medicare and Medicaid Services

answer

The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001

question

Coding specialist

answer

The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements.

question

Confidentiality

answer

A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure

question

Data

answer

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions.

question

Data accessibility

answer

The extent to which healthcare data are obtainable.

question

Data accuracy

answer

The extent to which data are free of identifiable errors.

question

Data comprehensiveness

answer

The extent to which data are complete.

question

Data consistency

answer

The extent to which healthcare data are reliable.

question

Data currency

answer

The extent to which data are up-to-date.

question

Data definition

answer

The specific meaning of a healthcare-related data element.

question

Data granularity

answer

The level of detail at which the attributes and values of healthcare data are described.

question

Data precision

answer

The extent to which data have the values they are expected to have.

question

Data quality management

answer

A managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection

question

Data relevancy

answer

The extent to which healthcare-related data are useful for the purpose for which they were collected

question

Data timeliness

answer

Refers to data being recorded at or near the time of the event or observation.

question

Diagnostic codes

answer

Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries.

question

Electronic health record (EHR)

answer

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

question

Health Record

answer

A paper- or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting.

question

Health Record Format

answer

refers to the organization format of electronic information or paper forms within the individual health record.

question

Information

answer

Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form tha can be used for a specific purpose.

question

Integrated health record format

answer

A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments. Commonly used in paper-based record systems.

question

Interoperability

answer

The ability, generally by adoption of standards, of systems to work together.

question

Personal health record (PHR)

answer

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual

question

Privacy

answer

The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information.

question

Problem-oriented health record format

answer

Patient record in which clinical problems are defined and documented individually. Organized into 4 components: the database, the problem list, initial plans, and progress notes. Commonly used in paper-based record systems.

question

Procedural codes

answer

The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients.

question

Quality improvement organizations (QIO)

answer

An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and non-emergent use of the emergency room; until 2002, called peer review organization.

question

Reimbursement

answer

Compensation or repayment for healthcare services

question

Security

answer

1) The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss. 2) The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems.

question

Source-oriented health record format

answer

A system of health record organization in which information is arranged according to the patient care department that provided the care; mostly used by acute care hospitals. Commonly used in paper-based record systems.

question

Third-party payers

answer

An insurance company (for example, Blue Cross/BlueShield) or healthcare program (for example, Medicare) that reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services.

question

Transcriptionist

answer

A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports.

question

DELETE Utilization Management organization

answer

An organization that reviews the appropriateness of the care setting and resources used to treat a patient.

question

Primary Purposes of the Health Record

answer

Patient care delivery; Patient care management; Patient care support processes; Financial & other administrative processes; Patient self management

question

Secondary Purposes of the Health Record

answer

These purposes of the health record: Education; Regulation; Research; Public Health and Homeland Security; Policy Making and Support; Industry; are considered: -secondary -primary.

question

Data

answer

Chapter Question: We had 324 Medicare patients last month. This statement represents which of the following: Information / Data / Content of the PHR / Patient-Specific information

question

PHR

answer

Chapter Question: 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: Health Record / EHR / PHR / Data

question

Patient Care Management

answer

Chapter Question:Which of the following is an example of a primary purpose of the medical record? Education / Policy making / Research / Patient Care Management

question

Getting patients involved in their own care

answer

Chapter Question: Examples of patient care delivery usage of the medical record include which of the following uses? -Developing of practice guidelines -Communication between caregivers -Reimbursement for patient care - Getting patients involved in their own care

question

This is a false statement as the PHR is controlled by the patient and the EHR is controlled by the caregiver.

answer

Chapter Question: Critique this statment: The PHR and EHR are synonyms

question

True

answer

True or False: the health record is the principal repository for data and information about the healthcare services provided to individual patients

question

False - it is "data"

answer

True or False: The lab test "hemoglobin: 14.6 gm/110 ml" is considered information.

question

True

answer

T/F The primary purposes of the health record are associated directly with the provision of patient care services, as well as the documentation of the patient's health status.

question

False - it is a primary purpose

answer

T/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.

question

False - it is a secondary purpose

answer

Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.

question

Third-party payer

answer

Chapter Question:Which of the following users of the health record is an example of an institutional user? -Third-party payer- Patient- Physician- Employer

question

Patient care managers and support staff

answer

Chapter Question:Which of the following users would utilize aggregate data?- Patient care providers- Coding and billing staff- Law enforcement officers- Patient care managers and support staff

question

Research

answer

Chapter Question: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?

question

This is a false statement as the information is used for other purposes such as analysis.

answer

Chapter Question: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. t/f

question

Make decision on healthcare reimbursement.

answer

Chapter Question:I work for CMS; how would I use the health record?-Make decision on healthcare reimbursement.-Medical research- Issuing hospital and medical staff licenses-Accrediting healthcare organizations

question

Results management

answer

Results retrieval technology that permits the view of data by type and manipulation of several different types of data.

question

Order-entry / Order Management (CPOE)

answer

provides physicians and other providers the ability to place orders via the computer from any number of locations and add decisions support capability to enhance patient safety.

question

Clinical Decision Support

answer

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts (such as abnormal lab results).

question

False - Individual

answer

Chapter Question: True or False A physical therapist documenting in the health record is an institutional health record user.

question

False - Institutional

answer

Chapter Question: True or False An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.

question

False - CMS is not an accrediting body

answer

Chapter Question: True or False CMS uses data to accredit hospitals

question

True

answer

Chapter Question: True or False A researcher uses data to determine the recommended treatment.

question

False

answer

Chapter Question: True or False Patients do not have the right to add missing information to the health record

question

Clinical Decision Support

answer

Chapter Question: 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?-Electronic records management -Clinical decision support-Results management-Order-entry/Order management

question

Confidentiality

answer

Chapter Question:I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called:-Data relevancy-Security-Confidentiality-Privacy

question

Relevancy

answer

Chapter Question: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?-Relevancy-Granularity-Consistency-Accuracy

question

Consistency

answer

Chapter Question:It was suggested that we enter the patient's age manually in all of our information systems rather than entering it once in one system and interfaced to the other systems. What quality characteristic would be the justification for not doing this?-Accuracy-Consistency-Granularity-Relevancy

question

Data Analysis

answer

Chapter Question:According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?-Data warehousing-Data analysis-Data collection-Data applications

Chapters 1-6 Health Information Management Technology An Applied Approach – Flashcards

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