Final Exam HIM – Flashcards
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HIM has been recognized as an allied Health profession since:
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1928
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The hospital standardization movement was inaugurated by the :
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American College of Surgeons
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Throughout the years, HIM roles have:
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Broadened in scope
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The traditional model of HIM practice was:
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Department based
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The new model of HIM practice is:
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Information based
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What evolving role oversees the process that begins at the time of documentation through billing?
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Revenue cycle management
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The organization that accredits HIM programs is:
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CAHIIM:
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What evolving role assesses quality in health record banking?
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Health record reviewer
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The primary focus of AHIMA is to:
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Foster professional development of its members
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Active members of AHIMA include those who:
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Are senior members
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Which of the following functions as the legislative body of AHIMA?
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House of Delegates
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Which of the following promotes education and research?
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AHIMA foundation
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The virtual network used by AHIMA members is:
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Communities of Practice
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We have 324 Medicare patients last month. This statement represents which of the following:
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Data
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I am a patient. My medical history including information from myself and my physicians in stored on the Internet. This is an example of which of the following:
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PHR: Personal Health Record
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Which of the following is an example of a primary purpose of the medical record?
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Patient care management
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Examples of patient care delivery usage if the medical record include which of the following uses?
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Communication of practice guidelines
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Critique this statement: The PHR and EHR are synonyms.
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This is a false statement as the PHR is controlled by the patient and the EHR is controlled by the care providers
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Which of the following users of the health record is an example of an institutional user?
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Third-party payer
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Which of the following users would utilize aggregate data?
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Patient care managers and support staff
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I wok for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
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Research
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Critique the following statement: A user of health records includes only care providers who document in the health record of refer to it for patient care.
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This is a false statement as the information is used for other purposes such as analysis
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I work for CMS; how would I use the health record?
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Make decisions on healthcare reimbursement
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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?
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Clinical decision support
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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:
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Confidentiality
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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?
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Relevancy
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It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this, but rather sharing information between the systems?
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Consistency
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According to the AHIMA sate quality model, what is the term that is used to describe how data is translated into information?
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Data analysis
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Which two major types of data are contained inn the health record?
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Administrative and clinical
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Which of the following terms refers to state or county regulation that healthcare facilities must meet to be permitted to provide care?
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Licensure
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Which of the following would not be found in a medical history?
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Vital signs
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An attending physician requests the advice of a second physician who than reviews the health record and examines the patient. The second physician records impressions in what type of report?
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Consultation
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Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
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Care plan
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Written or spoken permission to proceed with care is classified as:
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Expressed consent
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Which of the following reports provides information on tissue removed during a procedure?
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Pathology report
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Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
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Newborn
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Which of the following is not considered patient demographic information?
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Admitting diagnosis
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Which of the following administrative documents name s the patient's choice of legal representative for healthcare purposes?
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Advance directive
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Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided o stabilize the patient
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Emergency care
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patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?
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Ambulatory care
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The ambulatory surgery record contains information most similar to:
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Hospital operative records
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Which standardized tool is used to assess Medicare-certified rehabilitation facilities?
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Patient assessment instrument PAI
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Interdisciplinary care plans are an important part of which type of health record?
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Hospice care
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Portions of a treatment record may be maintained in a patient's home in which two types of settings?
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Home health and end-stage renal disease
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A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?
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Rehabilitative care
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Paper records may require thinning in which two settings?
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Long-term care and correctional services
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A growth and development record may be found in what type of record?
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Pediatric
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The document that indicates current and past medical conditions is :
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Problem list
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Which of the following is an accrediting organization?
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DNV (Det Norske Veritas)
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An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation under its guidelines do not need to:
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Undergo Medicare certification surveys
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Which group focuses on accreditation of managed care and preferred provider organizations?
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National Committee for Quality assurance
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Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient's record?
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Facility rules and regulations
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Which of the following groups has instituted a health record-prohibited abbreviation list?
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Joint Commission on Accreditation of Healthcare Organizations
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Which type of health record includes both paper and computerized components?
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Hybrid
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Which of the following is a disadvantage of an EHR over a paper-based record?
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Requires privacy and security measures
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In an integrated health record, documentation by health professionals is organized:
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Intermixed in date sequence
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The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
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Subjective
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Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?
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Image processing
