EHR: Chapter 7 & 8 Study Guide – Flashcards

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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
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Encoder
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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
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Productivity
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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
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chart deficiency
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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
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dictation system
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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
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disclosure management system
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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
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letter notifying individual that the authorization was invalid
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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
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trauma registry
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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
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dictation system
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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
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tumor registry
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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
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quality indicator
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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
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birth certificate
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12. The data element principal diagnosis is found in: A. transcription system B. encoder/grouper C. data quality indicator D. tumor registry
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encoder/grouper
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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
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chart locator
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14. Where would you find a field entitled document type? A. transcription system B. encoder/grouper C. data quality indicator D. tumor registry
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transcription system
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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
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master patient index
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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.
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The release of information system's letters communicates with the requester.
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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.
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Encoders assign the code for both diagnoses and procedures.
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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
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rules-based
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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
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requester table
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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
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track status of request
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21. Reports designed specifically for one time use is called what type of report? A. standing B. routine C. ad hoc D. temporary
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ad hoc
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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
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checking social security death index
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23. The chart location system would help the healthcare facility with which of the following? A. security B. privacy C. accessibility D. documentation
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accessibility
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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
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cancer registry software
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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
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productivity reporting
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26. True or False: A registry tracks multiple diseases and conditions rather than specialize.
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FALSE
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27. True or False: The dictation system has implications for physicians and HIM staff
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TRUE
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28. True or False: The transcription system should collect the date of transcription.
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TRUE
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29. True or False: The grouper should only be able to utilize the current Medicare grouper.
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FALSE
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30. True or False: Quality indicator systems collect voice from the dictation system to capture data.
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FALSE
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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
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Conduct a functional needs assessment
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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)
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The Joint Commission (Comprehensive Accreditation Manual for Hospitals)
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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
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Patient care management
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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
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Regulations
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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
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Results management
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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
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Direct Care
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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
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Information Infrastructure
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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
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Direct Care
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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
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Supportive
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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
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Information Infrastructure
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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
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Accelerate the adoption of robust, interoperable HIT throughout the U.S.
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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
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2006 for ambulatory
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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
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Vendors can claim they are certified to specific criteria when they are not
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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
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Aids in educating users about functionality
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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
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Describes an EHR's behavior in response to a user process
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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
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Request for proposal could be D not sure
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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
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Inventory current functional capabilities
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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
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Has necessary source systems to supply data to the EHR
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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
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Data requirements for decision making
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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
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Specific products that support a process Could be C not sure
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 51. Medication reconciliation
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 52. Order set templates
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 53. Medication administration
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Inpatient
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 54. Access control
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 55. Alerts for disease management
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 56. Pharmacy communication
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Ambulatory
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 57. Clinical task management/assignment and routing
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Ambulatory
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 58. Capture patient-originated data
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 59. Receive and store laboratory results
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Both
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For each criterion, identify whether it pertains to an EHR for: A = Ambulatory B = Both C = Inpatient 60. Legal business record
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Both
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