question

the attending physician's assessment of the patient's current health status?

answer

physical examination

question

Which of the following is true of computer-based records?

answer

can be accessed by multiple end users simutaneously

question

True or False, AHIMA has developed Standards of Ethical Coding.

answer

True

question

what ICD-9-CM codes are always alphanumeric?

answer

V codes

question

At which level of the classification system are the most specific ICD-9-CM codes found?

answer

subclassification levels

question

Which type of standard is required of hospitals by states prior to providing any healthcare?

answer

Licensure

question

specialized patient assessment tools must be used by Medicare-certified home care providers?

answer

Outcomes and Assessment Information Set

question

"The patient indicates that she is dizzy, nauseous, and feels her throat tightening." This entry would be recorded in which section of a SOAP note?

answer

Subjective

question

I need to code an ambulatory record but the procedure code I need is not in the CPT manual. How do I code it?

answer

HCPCS level II codes

question

in which setting may treatment records travel with the patient between treatment centers?

answer

Correctional facility care

question

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?

answer

Accreditation

question

Nosology can be defined as the branch of medical science that deals with

answer

Classification systems

question

what organization drafted more than 130 functional standards for electronic health records?

answer

Health Level Seven (HL7)

question

what term refers to the incideces of death?

answer

Mortality

question

Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

answer

Commission on Accredition of Rehabilitation Facilities

question

True or False, V codes and E codes are referred to as supplementary classifications in ICD-9-CM

answer

True

question

i work at a substance abuse center. What system should i use to code diagnoses?

answer

DSM-IV-TR

question

The patients address is an example of

answer

Administrative information

question

what organization is responsible for updating the diagnosis classification of ICD-9-CM?

answer

National Centers for Health Statistics

question

in a medical history what is a detailed chronological description of the development of the patient's illness?

answer

Present Illness

question

Which type of patient care record includes documentation of a family bereavement period?

answer

Hospice record

question

not true of the process that should be followed in making corrections in paper-based health record entries?

answer

The incorrect information should be obliterated.

question

Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews?

answer

Joint Commission

question

would not be considered clinical data?

answer

name of insurance company

question

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?

answer

Laboratory findings

question

what group is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

answer

Commission on Accreditation of Rehabilitation Facilities

question

what is not a traditional health record format?

answer

Process-oriented health record

question

what is not usually a component of acute care patient records?

answer

Problem list

question

what term refers to the incidence of disease?

answer

Morbidity

question

"Acute allergic reaction" would be documented in which part of a SOAP note?

answer

Assessment

question

ICD-10-CM

answer

Diseases for morbidity

question

ICD-10-PCS

answer

Inpatient procedures

question

ICF

answer

States of functioning

question

ICD-O-3

answer

Diseases for Oncology

question

DSM--5

answer

Mental Disorders

question

AHIMA (American Health Information Management Association)

answer

Professional membership organization for managers of Health record services and healthcare info systems. As well as coding services.

question

The formal approval process for academic programs in health information management is called: The formal approval process for academic programs in health information management is called: A ) Accreditation B ) Certification C ) Registration D ) Standardization

answer

A ) Accreditation

question

The primary goal of the Hospital Standardization Program was: A ) Raise the standards of surgical practice B ) Train physicians and nurses for American hospitals C ) Standardize the educational curricula of American medical schools D ) Force substandard hospitals to close

answer

A ) Raise the standards of surgical practice

question

Data definition refers to the: A ) Meaning of data B ) Completeness of data C ) Consistency of data D ) Detail of data

answer

A ) Meaning of data

question

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

answer

D ) To determine whether standards of care are being met

question

Who are the primary users of the health record? A ) Clinical professionals who provide direct patient care B ) Insurance companies that cover healthcare expenses C ) Billers in the healthcare facility's business office D ) Patients and their families

answer

A ) Clinical professionals who provide direct patient care

question

Which organization's goal is centered on health information technology? A ) HIMSS B ) AHDI C ) AHIMA D ) AAPC

answer

A ) HIMSS

question

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

answer

C ) AHIMA Foundation

question

The paper-based health record format that organizes all forms in chronological order is known as the: A ) Problem-oriented health record B ) Integrated health record C ) Patient-oriented health record D ) Source-oriented health record

answer

B ) Integrated health record

question

The ____was established in 1847 to represent the interests of physicians across the United States. A ) AHA B ) AMA C ) ACS D ) AHIMA

answer

B ) AMA

question

The first professional association for health information managers was established in: A ) 1900 B ) 1905 C ) 1928 D ) 1970

answer

C ) 1928

question

Which of the following is true about the AHIMA certification program? A ) The eligibility requirements for all credentials are the same. B ) Candidates must pass an examination before obtaining any of the credentials. C ) Candidates must be college graduates before they can obtain any of the credentials. D ) Candidates must have work experience and pass a certification exam before they can obtain any of the credentials.

answer

B ) Candidates must pass an examination before obtaining any of the credentials.

question

The term used to describe expected data values is A ) Data definition B ) Data currency C ) Data precision D ) Data relevancy

answer

C ) Data precision

question

I have been asked to list institutional users of the health record. Which one of the following would I include in my list? A ) Blue Cross and Blue Shield B ) The patient C ) FBI agent D ) AHIMA

answer

A ) Blue Cross and Blue Shield

question

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

answer

D ) Data comprehensiveness

question

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.

answer

A ) They have a built-in access control mechanism.

question

Healthcare information systems need to exchange information. This linkage between systems is referred to as: A ) Connectivity B ) Efficiency C ) Flexibility D ) Security

answer

A ) Connectivity

question

Which of the following elements is not a component of most patient records? A ) Patient identification B ) Clinical history C ) Financial information D ) Test results

answer

C ) Financial information

question

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

answer

A ) They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature.

question

What is the defining characteristic of an integrated health record format? A ) Each section of the record is maintained by the patient care department that provided the care. B ) Integrated health records are intended to be used in ambulatory settings. C ) Integrated health records include both paper forms and computer printouts. D ) Integrated health record components are arranged in strict chronological order.

answer

D ) Integrated health record components are arranged in strict chronological order.

question

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

answer

C ) AHIMA House of Delegates

question

The accreditation program of AHIMA is concerned with: A ) Establishing standards for the content of college programs in HIT and HIM B ) Making sure that AHIMA has good certification examinations C ) Ensuring that AHIMA manages its property and affairs appropriately D ) Establishing policies and procedures to be followed by the Communities of Practice

answer

A ) Establishing standards for the content of college programs in HIT and HIM

question

The new opportunity for HIM professionals that deals with data repositories and data warehouses is: A ) Health information manager B ) Clinical data specialist C ) Enterprise content and information manager D ) Data resource administrator

answer

D ) Data resource administrator

question

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

answer

D ) All of the above

question

Critique this statement: Electronic health record systems have the same access control requirements as paper-based record systems. A ) This is a true statement. B ) This is a false statement as the requirements for the electronic health record are less stringent. C ) This is a false statement as the requirements for the electronic health record are more stringent. D ) Electronic health records are inherently less secure.

answer

A ) This is a true statement.

question

The hospital standardization program was started by the American College of Surgeons in: A ) 1900 B ) 1905 C ) 1918 D ) 1928

answer

C ) 1918

question

How do patient care managers and support staff use the data documented in the health record? A ) Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided B ) Communicate vital information among departments and across disciplines and settings C ) Generate patient bills and/or third-party payer claims for reimbursement D ) Determine the extent and effects of occupational hazards

answer

A ) Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided

question

In the Middles Ages plagues and epidemics killed millions and were spread by A ) rodents and travelers carrying the diseases B ) contaiminated food C ) unclean water supply D ) evil witch doctors bent on destroying the world

answer

A ) rodents and travelers carrying the diseases

question

Use of the health record to monitor bioterrorism activity is considere: A ) Primary purpose of the health record B ) Secondary purpose of the health record C ) Patient use of the health record D ) Healthcare licensing agency function

answer

B ) Secondary purpose of the health record

question

The admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? A ) Data completeness B ) Data consistency C ) Data accessibility D ) Data comprehensiveness

answer

B ) Data consistency

question

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

answer

C ) AHIMA Communities of Practice

question

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

answer

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

question

Which of the following best describes data completeness? A ) Data are correct. B ) Data are easy to obtain. C ) Data include all required elements. D ) Data are reliable.

answer

C ) Data include all required elements.

question

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

answer

A ) A primary purpose of the health record

question

The _______makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA. A ) Board of Directors B ) Communities of Practice C ) Commission on Certification for Health Informatics and Information Management D ) House of Delegates

answer

B ) Communities of Practice

question

When a patient is being treated in long term care facilities, we normally refer to them as a ________ rather than as a patient because they actually live there. A ) client B ) resident C ) outpatient D ) recipient

answer

B ) resident

question

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.

answer

C ) This is a false statement as data is raw facts and figures and information is data converted into a meaningful format.

question

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. Test Bank with Key Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

answer

A ) This is a true statement.

question

The primary function of the American Health Information Management Association is to: A ) Ensure that accurate and complete medical records are written for every hospital patient B ) Standardize the content and format of the health records maintained by acute and emergency care facilities C ) Promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting D ) Provide support for two- and four-year health information management educational programs

answer

C ) Promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting

question

Protection of healthcare information from damage, loss, and unauthorized alteration is also known as: A ) Privacy B ) Results management C ) Security D ) Data accuracy

answer

C ) Security

question

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. D ) Clinicians use computer keyboards when documenting in the EHR.

answer

B ) EHRs are filed in paper folders.

question

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

answer

C ) Support for research

question

Which of the following best describes data accessibility? A ) Data are correct. B ) Data are easy to obtain. C ) Data include all required elements. D ) Data are reliable.

answer

B ) Data are easy to obtain.

question

Which of the following represents an example of data granularity? A ) A progress note recorded at or near the time of the observation B ) An acceptable range of values defined for a clinical characteristic C ) A numerical measurement carried out to the appropriate decimal place D ) A health record that includes all of the required components

answer

C ) A numerical measurement carried out to the appropriate decimal place

question

Which of the following is a secondary purpose of the health record? A ) Document patient care delivery B ) Assist caregivers in patient care management C ) Aid in billing and reimbursement functions D ) Generate a report to be used in performance improvement

answer

D ) Generate a report to be used in performance improvement

question

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? A ) Data completeness B ) Data relevancy C ) Data currency D ) Data precision

answer

C ) Data currency

question

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 healthcare providers C ) Plan and market services D ) Locate missing persons

answer

B ) Protect the legal interests of the facility and its healthcare providers

question

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

answer

D ) Government policy maker

question

The only requirements for professional certification through the AHIMA are graduating from an accredited two-year or four-year educational program. A ) Yes B ) No

answer

B ) No

question

A study done by Abraham Flexner in the early 1900's found which of the following? A ) Excellent training being provided in medical colleges B ) A significant improvement in training being provided in medical colleges C ) Poor quality of the training being provided in medical colleges D ) None of the above

answer

C ) Poor quality of the training being provided in medical colleges

question

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

answer

C ) Privacy

question

Who is responsible for final approval of the AHIMA Code of Ethics? A ) AHIMA Board of Directors B ) AHIMA Commission on Certification for Health Informatics and Information Management C ) AHIMA Ethics Committee D ) AHIMA House of Delegates

answer

D ) AHIMA House of Delegates

question

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.

answer

D ) This is a false statement as the health record documents the care provided by healthcare professionals.

question

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

answer

D ) All of the above

question

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

answer

A ) Computerized physician/provider order entry

question

Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA? A ) House of Delegates B ) Board of Directors C ) Communities of Practice D ) Component state associations

answer

B ) Board of Directors

question

Which of the following accredits academic programs in health information management? A ) AHIMA Board of Directors B ) CAHIIM C ) CCHIIM D ) House of Delegates

answer

B ) CAHIIM

question

Which of the following best describes data accuracy? A ) Data are correct. B ) Data are easy to obtain. C ) Data include all required elements. D ) Data are reliable.

answer

A ) Data are correct.

question

Which professional organization sponsors the CTR certification? A ) AHIMA B ) NCRA C ) AAPC D ) Community College Consortia Test Bank with Key Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

answer

B ) NCRA

question

Which of the following actively promotes education and research in health information management? A ) Commission on Certification for Health Informatics and Information Management B ) CAHIIM C ) AHIMA Foundation D ) House of Delegates

answer

C ) AHIMA Foundation

question

Our record has all of the lab filed together, all of the progress notes filed 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

answer

A ) Source-oriented health record

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