question

The primary function of the American Health Information Management Association is

answer

To promote the accuracy, confidentialtiy, and accessibility of health records in every healthcare setting.

question

The primary goal of the Hospital Standardization Program was

answer

To raise the standards of surgical practice

question

Which of the following activities is not a traditional medical recoerds function?

answer

Data Administration

question

The only requirements for professional certification therough the AHIMA are graduating from an accredited two-year or four-year educational program.

answer

False

question

Which of the following is true about AHIMA certification program?

answer

Candidates must pass an examination before obtaining any of the credentials

question

Which of the foloowing classes of AHIMA membership requires that individuals hold an AHIMA credential?

answer

Active membership

question

Which of the following entities are at the head of the AHIMA volunteer structure?

answer

Board of Directors

question

The accreditation program of AHIMA is concerned with

answer

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

answer

Data resource administrator

question

HIM has been recognized as an allied health professional since

answer

1928

question

The ____________ makes up a virtual network of A?HIMA members who communicate via a Web based program managed by AHIMA

answer

Communities of Practice

question

Which of the following accredits academic programs in health information?

answer

CAHIM

question

Members of the AHIMA House of Delegates are

answer

Elected by members in state component organizations

question

Who is responsible for final approval of the AHIMA Code of Ethics?

answer

AHIMA Housse of Delegates

question

Which of the following actively promotes education and research in health information managment?

answer

AHIMA Foundation

question

Which of the following best describes the most important function of the health record?

answer

storing patient care documentation

question

Who are the primary users of the health record?

answer

the clinical professionals who provide direct patient care

question

Which of the following elements is not a component of most patient records?

answer

financial information

question

Healthcare information systems need to exchange information. This linkage between systems is referred to as:

answer

Connectivity

question

Which of the following is not a characteristic of high- quality healthcare data?

answer

data accountability

question

Which of the following represents an example of data granularity?

answer

a numerical measurement carried out to the appropriate decimal place

question

What is the defining characteristic of an integrated health record format?

answer

Integrated health record components are arranged in strict chronological order.

question

Critique this statement: Electronic health record systems have the same access control requirements as paper-based record systems.

answer

This is a true statement

question

Critique this statement: Paper-based record systems are not flexible enough to meet all of the needs of every health record user.

answer

This is a true statement

question

the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

answer

Confidentiality`

question

the right of individuals to control access to their personal health information

answer

Privacy

question

the protection of the privacy of individuals and the confidentiality of health records

answer

Security

question

Which of the following best describes data accuracy?

answer

Data are correct

question

Which of the following best describes data completeness?

answer

Data include all required elements

question

Which of the following best describes data accessibility?

answer

Data are easy to obtain

question

Data definition refers to ___________

answer

the meaning of data

question

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patrient. Which quality element is missing from the progress note?

answer

data currency

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?

answer

data consistency

question

I need an information system that will provide assist physicians in diagnosing and treating patients. The system that I need is

answer

clinical decision support

question

I have been asked to list institutional users of the health record. Which one of the following would I include in my list?

answer

Blue Cross Blue Shield

question

Which of the following is not usually a component of acute care patient records?

answer

problem list

question

The attending physician is responsible for which of the following types of acute care documentation?

answer

discharge summary

question

A nurse is rwesponsible for which of the following types of acute care documentation?

answer

medication report

question

Which of the following is an example of clinical data?

answer

admitting diagnosis

question

The number of ligatures, sutures, packs, drains and sponges used and specimens removed would be found in the ______________

answer

operative report

question

Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?

answer

emergency care report

question

Documentation standards and guidelines are published by a variety of private and public organizations, including the _______________

answer

all of the above, Joint Commission, American HEalth Information Management Association and National Committee for Quality Assurance

question

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

answer

can be accessed by multiple end users simultaneously

question

which of the following represents documentation of the patient's current and past health?

answer

medical history

question

Which of the following contains the physician's findings based on an examination of the patient?

answer

physical exam

question

What is the function of a consultation report?

answer

documents opinions about the patient's condition from the persepective of a physician not previously involved in the patient's care

question

What is the function of physician's orders?

answer

to document the physician's instructions to other parties involved in providing care to a patient

question

Which of the following is an example of an advance directive?

answer

living will

question

In a medical history, which of the following is a detailed chronological description of the development of the paitent's illness?

answer

pressent illness

question

Patient history questionnaires are most often used in:

answer

ambulatory care

question

Which of the following represents the attending physician's assessment of the patient's current health stratus?

answer

physical examination

question

Which of the following is not an example of a long-term care setting?

answer

community mental health centers

question

An RAI/MDS and care plan are found in records of patients in ___________

answer

long-term care

question

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

answer

correctional facility care

question

Documentation of genetic information, immunizations, hopspitalizations, surgeries, medications, and personal, family occupational and environmental histories are maintained over a lifetime in what type of record?

answer

personal health record

question

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

answer

hospice record

question

When correcting erroneous information in a health record, which of the following is not appropriate?

answer

Use black ink to obliterate the entry

question

Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?

answer

Joint Commission

question

documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleanings would be found in which type of specialty record?

answer

home health

question

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

answer

Commission on Accreditation of Rehabilitation Facilities

question

Which of the following is an advantage of paper based records?

answer

standardized familiar format

question

Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

answer

electronic record

question

Which of the following is an example pf data capture technology?

answer

document imaging

question

What is the general name for Medicare standards impacting healthcare organizations?

answer

Conditions of Participation

question

Which of the following organizations recently drafted functional standards for electronic health records?

answer

Health Level 7 (HL7)

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