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The common function of the health information management department is to:

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Provide availability, accuracy, and protection of clinical info

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Health records are more commonly completely:

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Electronic; but can be scanned and stored as computerized images.

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Miniature form

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Microfilm

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Clinical decision making and financial reimbursement depend on the:

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Information contained in the health record

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Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information

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Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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Coding involves converting diagnoses and procedure into a:

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numeric classification system

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System for Medicare patients by which a predetermined level of reimbursement is established before services are provided

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Prospective Payment System (PPS)

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System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

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Diagnosis-Related Groups (DRGs)

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Codes are reported to:

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Medicare & other third-party payers, such as Insurance companies

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__ __ __ __ must communicate needed data to departments

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Health information management practitioners

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Health records and radiology records are retained by a facility for a specific amount of time according to the:

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Code of Federal Regulations, state law, and accreditation requirements

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Health records are to be retained for a minimum of __ years from the date the patient was last seen

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5 years

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According to the MAMMOGRAPHY QUALITY STANDARDS ACT, a facility must keep a mammogram in the permanent medical record for __ years, or no less than __ years if a patient has had no other mammograms at that facility, or longer is mandated by state law.

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no less than 5 years, or no less than 10 years

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Standards for the maintenance and the documentation within health records have been established by accrediting agencies such as:

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The Joint Commission (TJC), and the American Osteopathic Association via its Healthcare Facilities Accreditation Program (HFAP)

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Documenting in the patient's record

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Charting

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Charting should be done by whom when a patient receives either diagnostic or therapeutic radiologic services?

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Radiologists or Radiographers

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The health record, per TJC, must contain sufficient information such as:

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1. Identify the patient 2 Support the diagnoses 3. Justify the treatment 4. Document the course and results 5. Facilitate continuity of care

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A computerized system tracks film and folders with a:

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Bar code system

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The term __ __ implies that the patient has been informed of the procedure or operation to be performed, the risks involved, and the possible consequences.

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Informed consent

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__ __ contains information relative to patient incidences or event occurrenes

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Incident report

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Before a radiologic procedure is performed, a __ is completed

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Radiology order for service

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A Radiology order for service includes:

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1. Patient demographic information 2. Specific procedure being requested 3. Physician order the procedure

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If Medicare does not cover the procedure,, the patient is notified and is required to sign:

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an advance beneficiary notice (ABN)

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The results of the procedure are documented on a:

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Radiology report

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A __ __ must be completed for every service for which a medical claim will be filed.

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Written report

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Radiology reports must be included in the patient record to describe:

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the radiologic services the patient received

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Where do original copies of documents go?

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In the patient's record

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__ documentation is not legal in any state.

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Pencil

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In a paper record, who is responsible for correcting an error in the documentation?

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The person who makes the error

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The concept of the DRG is that patients fall into statistically similar, __ __ groups.

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Diagnostically related

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The health information professional uses the __ __ provided by the __ to code the patient's information into the classification system.

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Diagnosis terminology Physician

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The __ is used for procedural classification of inpatient procedures

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International Classification of Diseases (ICD-10-CM), Procedure Classification System (ICD-10-PCS)

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Using a computer programer called a __, the health information practitioner computes the patient's DRG.

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Grouper

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__ codes are used to code procedures for outpatient encounters and coding for ancillary services such as radiology and laboratory.

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Current Procedural Terminology, 4th Edition (CPT-4)

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A criticism of DRGs has been that:

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the system does not take into account the severity of a patient's disease.

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The __ and __ classification systems are used for inpatient reporting.

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ICD-10-CM and PCS (effective 10-1-15)

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For outpatients, hospitals must report the diagnosis using the __ or __ codes and __ codes for the procedures.

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ICD-10-CM ICD-9-CM CPT-4

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The physician's offices uses the __ codes for the DIAGNOSIS, and the __ coding system for the PROCEDURES.

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ICD (International Classification of Diseases) CPT (Current Procedural Terminology)

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Radiology codes in CPT include:

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1. Diagnostic and Therapeutic radiology 2. Nuclear Medicine 3. Diagnostic ultrasonography 4. Radiation oncology

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Code number range from: Chest radiograph, single view, frontal, would be coded as: MRI of the cervical spine with contrast media is coded to:

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70010-79999 71010 72142

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List the 4 data tables in the IRD database:

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1. Anatomical 2. Sub-anatomical 3. Pathological 4. Sub pathological

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__ __ is a process by which the quality of the care and services provided to patients within a health care facility are monitored and elevated.

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Performance improvement

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The terms __ __, __ __, and __ __ are all used to encompass activities related to performance improvement

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quality assurance, quality assessment, and performance improvement

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List the dimensions of performance:

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1. Efficacy 2. Appropriateness 3. Availability 4. Timeliness 5. Effectiveness 6. Continuity 7. Safety 8. Efficiency 9. Respect & caring

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The __ __ is an important legal document that the health care institution uses to define what was or was not done to the patient.

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Patient record

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What is the proper method for correcting an error that an author makes in a health record?

answer

Draw a single line through the error, write "ERROR", record the correct info., date & sign.

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Which of the following is not a function of a hospital health information management department? 1. Coding of diagnoses and operative procedures and diagnosis-related group assignment 2. Documenting relevant patient information in the medical record 3. Quality management and performance improvement activities 4. Appropriate release of medical information

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Documenting relevant patient information in the medical record

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The prospective payment system is a payment system based on?

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the diagnosis-related group (DRG) or the ambulatory patient classification (APC)

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Which of the following is an example of an organization that accredits hospitals and other health care institutions in the US?

answer

The Joint Commission

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The chief complaint, included in a patient's history, is a statement made by the:

answer

Patient

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation affects radiology and other hospital departments by its focus on:

answer

Patient record confidentiality

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Which of the following is not required to be included in a patient's health record? 1. Medical history 2. Radiology reports 3. Patient's telephone number 4. Physical examination report

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Patient's telephone number

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Criteria used in performance improvement activities must be all of the following EXCEPT: 1. Clinically valid 2. Diagnosis or procedure oriented 3. Generally acceptable to department staffs 4. Written

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Diagnosis or procedure oriented

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Assessment of problems in performance improvement activities must be:

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ongoing

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In making a correction to an entry in the paper health record, the documenter should:

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line out the error, authenticate, and insert correct information

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The organization (chart orders, forms) of a hospital patient record is determined by:

answer

the hospital's own preference

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