question

The first professional association for health information managers was established in:

answer

1928

question

The hospital standardization program was started by the American College of Surgeons in:

answer

1918

question

The formal approval process for academic programs in health information management is called:

answer

Accreditation

question

The formal process for conferring a health information management credential is called:

answer

Certification

question

RHIT

answer

Registered Health Information Technicians

question

AHIMA

answer

American Health Information Managment Association

question

Make up a virtual network of AHIMA members who communicate via a web based program managed by AHIMA.

answer

Communities of Practice

question

functions as the legislative body of AHIMA

answer

AHIMA House of Delegates

question

Must graduate from approved program to sit for RHIT or RHIA exam

answer

Credentialing

question

AHIMA foundation was founded in

answer

1962

question

Principal repository for data and information about health care, who, what, when, where, why and how

answer

Health Records

question

Basic facts

answer

Data

question

Data that has been collected and analyzed, has meaning

answer

Information

question

Who is responsible for management of health records

answer

HIM Professionals

question

PHR

answer

Personal Health record, maintained by an individual.

question

What is the primary purpose of a health record?

answer

Make informed decisions about diagnoses and treatment

question

What is the secondary purpose of a health record?

answer

Related to environment, education, research,regulations, policy making and support.

question

EHR

answer

Electronic Health Record

question

Primary users of the health records are

answer

Patient care providers, dentists, dietitians, nurses, physicians,etc

question

Individual users of health records are

answer

Coding & billing staff, patients, employers, lawyers, law enforcement officials, researchers

question

IOM

answer

Institute of medicine

question

Functions of the Health Record

answer

Store patient care documentation

question

The purposes for which data is collected

answer

Data Application

question

The processes by which data is collected

answer

Data Collection

question

The processes by which data is archived, saved for future use

answer

Data warehousing

question

Processes by which data is translated into information that can be used for designated application

answer

Data Analysis

question

Right of individuals to control access to their personal health information

answer

Privacy

question

Expectation that information will be shared only for the intended purpose

answer

Confidentiality

question

Protection of privacy of individuals and confidentiality of health records

answer

Security

question

CPOE

answer

CPOE - Computerized physician/provider order entry

question

Documents medical condition, diagnoses, procedures and treatment

answer

Clinical Data

question

Demographic and Financial Information Consents and Authorizations - Patients full name, address, phone #, birth date, place of birth, gender, etc.

answer

Administrative Data

question

Medicare may identify them as a medicare recognized accreditation organization

answer

Deemed Status

question

accredits a number of different settings, unannounced surveys, standards for documentation, prohibited abbreviation list

answer

Joint Commission

question

An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by:

answer

American Osteopathic Association Accreditation Association for Ambulatory Healthcare National Committee for Quality Assurance

question

Accredits Rehabilitation programs CARF

answer

Commission on Accreditation of Rehabilitation Facilities (CARF)

question

Addresses uniformity in the content of records

answer

Acute Care Health Record Documentation

question

Documents demographic information on a patient

answer

Registration Record

question

Documents patients current and past Health status

answer

Medical History

question

Contains providers findings based on exam of patient

answer

Physical Exam

question

What is happening with a patient on a day to day basis

answer

Progress Notes

question

rules and regulations of the hospital of who can enter info into these notes

answer

Physician Notes

question

Is assumed when a patient voluntarily submits to treatment

answer

Implied consent

question

either spoken or written

answer

Expressed Consent

question

What organization requires authorization granted by patient or representative to release information

answer

Health Insurance Portability and Accountability Act (HIPAA) HIPAA

question

is used when the permission is for treatment, payment, or healthcare operations tied in with the TPO - treatment, payment & healthcare operations

answer

Consent

question

written document that provides directions about a patients desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not able to communicate.

answer

Advance Directives

question

2 Different Types of Advance Directives

answer

Living Will and Durable Power of Attorney for healthcare

question

Documents presenting problems Diagnostic and therapeutic services

answer

Emergency Care Documentation

question

Physician offices, group practices, clinics, hospital outpatient, etc.

answer

Ambulatory Care Documentation

question

Obstetric/Gynecologic Care Documentation Pediatric Care Documentation

answer

Specialized Health Record Documentation

question

Nursing homes, assisted living

answer

Long Term Care Documentation

question

RAI

answer

Resident Assessment Instrument - RAI

question

care plan is based on the minimum data set for long term care. Critical component of the health record in long term care.

answer

Resident Assessment Instrument - RAI

question

provide medical and non-medical services inpatients home

answer

Home Healthcare Documentation

question

OASIS

answer

Outcomes and Assessment Information Set - OASIS

question

used for Home Health

answer

Outcomes and Assessment Information Set - OASIS

question

care provided in patients home, hospitals, long term care facilities, free standing facilities - terminally ill - provide care focuses on symptom management

answer

Hospice Care Documentation

question

mental health issues

answer

Behavioral Healthcare Documentation

question

Increase a patients ability to function

answer

Rehabilitation Services Documentation

question

PAI

answer

Patient assessment instrument - PAI

question

completed after admission and upon discharge

answer

Patient assessment instrument - PAI

question

often provide health services to those incarcerated and thus must maintain health records. Prisons, jails, and juvenile detention centers are all examples of correctional facilities.

answer

Correctional Facilities Documentation

question

Individuals with severe kidney disease requiring renal dialysis may be treated in outpatient settings of healthcare facilities, in independent dialysis centers, while residents of long-term care settings, or even in their own homes (self-dialysis).

answer

End-State Renal Disease Service Documentation

question

uniformity, who can document, who can receive verbal orders

answer

Basic Documentation Principles

question

Errors in Paper Records are corrected by? 3 things

answer

1. Draw a single line in ink through incorrect entry 2. Printing the word "error" at top of entry along with signature (or initials). 3. Document date, time, reason for change

question

CDI

answer

Clinical Documentation Improvement - CDI

question

Usually nurses review the day after a patient is admitted and continues until discharged

answer

Clinical Documentation Improvement - CDI

question

Draws attentions to missing information

answer

Query

question

Formats of the Health Record

answer

Paper or electronic

question

3 Health records formats

answer

Source Oriented Problem Oriented Integrated

question

grouping together of items. ex - lab records, radiology records

answer

Source Oriented

question

patients past and present social, psychological and medical problems

answer

Problem Oriented

question

SOAP Format

answer

subjective, objective, assessment, plan

question

information in patients words

answer

Subjective

question

data from lab findings

answer

Objective

question

made up of the subjective & objective

answer

Assessment

question

comments and changes

answer

Plan

question

In chronological order of date. 3rd major paper based health record

answer

Integrated Health Records

question

single fact or measurement. ex. age, gender, insurance company

answer

Data Element

question

list of data elements collected in individual health records, definition of the data elements, etc

answer

Data Dictionary

question

list of recommended data elements with uniform definitions that are relevant for a particular use.

answer

Data Sets

question

Data Sets are used for -

answer

Research, clinical trials, quality, safety improvement, reimbursement accreditation, exchanging clinical information

question

Two purposes of Data sets

answer

1. Identify the data elements that should be collected for each patient. 2. to provide uniform definitions for common terms

question

UHDDS

answer

Uniform Hospital Discharge Data Set

question

list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases.

answer

The purpose of the UHDDS

question

UHDDS was adopted when?

answer

In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs.

question

Who elects the following: 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

answer

They are elected to their positions by AHIMA members

question

makes up a virtual network of AHIMA members

answer

AHIMA Communities of Practice

question

is an arm of AHIMA that promotes education and research in health information management?

answer

AHIMA Foundation

question

best describes the mission of AHIMA

answer

Community of professionals providing support to members and strengthening the industry and profession

question

Which professional organization sponsors the CTR certification?

answer

NCRA

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

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

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

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 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

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

d. All of the above

question

The hospital where I work is transitioning to an EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as: a. Integrated health record format b. A hybrid record c. A resident record d. Integrated health record format

answer

b. A hybrid record

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

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

Use of the health record by a clinician to facilitate quality patient care is considered: a. Primary purpose of the health record b. Patient care support c. Secondary purpose of the health record d. Patient care effectiveness

answer

a. Primary purpose of the health record

question

Use of the health record to monitor bioterrorism activity is considered: 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

How do accreditation organizations use the health record? a. Serve as a source for case study information b. Determine whether the documentation supports the provider's claim for reimbursement c. Provide healthcare services d. Determine whether standards of care are being met

answer

d. Determine whether standards of care are being met

question

How do research organizations use the health record? a. To examine results of experimental protocols b. For reporting of communicable diseases c. To investigate domestic violence d. To manage disability insurance benefits

answer

a. To examine results of experimental protocols

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

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

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

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

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

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

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

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

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

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

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.

answer

a. This is a true statement.

question

Which type of standard is required of hospitals by states prior to providing any healthcare? a. Accreditation b. Certification c. Licensure d. Medical staff bylaws

answer

c. Licensure

question

Which of the following clinical data elements is not usually documented in the acute-care health record? a. Clinical observations b. Discharge information c. Medical history d. Records of immunizations

answer

d. Records of immunizations

question

Which of the following is not a function of the discharge summary? a. Providing information about the patient's insurance coverage b. Ensuring the continuity of future care c. Providing information to support the activities of the medical staff review committee d. Providing concise information that can be used to answer information requests

answer

a. Providing information about the patient's insurance coverage

question

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? a. Autopsy report b. Laboratory findings c. Pathology report d. Surgical report

answer

b. Laboratory findings

question

Which of the following would not be considered clinical data? a. Progress notes b. Physician orders c. Admission diagnosis d. Name of insurance company

answer

d. Name of insurance company

question

Which of the following federal laws resulted in the new privacy regulations for healthcare organizations? a. The Health Information Access and Disclosure Act b. The Health Insurance Portability and Accountability Act c. The Patient Self-Determination Act d. The Social Security Act

answer

b. The Health Insurance Portability and Accountability Act

question

Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Operative report b. Anesthesia report c. Pathology report d. Laboratory report

answer

a. Operative report

question

Which of the following materials is not documented in an emergency care record? a. Patient's instructions at discharge b. Time and means of the patient's arrival c. Patient's complete medical history d. Emergency care administered before arrival at the facility

answer

c. Patient's complete medical history

question

Which of the following types of facility is not generally governed by long-term care documentation standards? a. Subacute care facilities b. Assisted living facilities c. Skilled nursing facilities d. Nursing facilities

answer

b. Assisted living facilities

question

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Patient assessment instrument b. Minimum data set for long term care c. Resident Assessment Protocol d. Outcomes and Assessment Information Set

answer

d. Outcomes and Assessment Information Set

question

Which regulations are most commonly applied in end-stage renal disease treatment? a. Medicare Conditions for Coverage b. Commission on Accreditation of Rehabilitation Facilities c. Accreditation Association for Ambulatory Healthcare d. Joint Commission

answer

a. Medicare Conditions for Coverage

question

Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries? a. The correction should be dated and signed or initialed. b. The reason for the change should be noted. c. The incorrect information should be obliterated. d. The word error should be noted on the entry.

answer

c. The incorrect information should be obliterated.

question

Which of the following types of healthcare facilities may seek accreditation from the Joint Commission? a. Acute care hospitals b. Psychiatric hospitals c. Home care providers d. Ambulatory care organizations e. All of the above

answer

e. All of the above

question

The federal Conditions of Participation apply to which type of healthcare organization? a. Organizations that are accredited b. Organizations that treat Medicare or Medicaid patients c. Organizations that provide acute care services d. Organizations that are subject to the Health Insurance Portability and Accountability Act

answer

b. Organizations that treat Medicare or Medicaid patients

question

Which of the following is not a traditional health record format? a. Integrated health record b. Problem-oriented health record c. Source-oriented health record d. Process-oriented health record

answer

d. Process-oriented health record

question

Which health record format is most commonly used by healthcare settings as they transition to electronic records? a. Integrated records b. Problem-oriented records c. Hybrid records d. Paper records

answer

c. Hybrid records

question

Which of the following is an example of administrative information? a. An admitting diagnosis b. Blood pressure records c. Medication records d. The patient's address

answer

d. The patient's address

question

The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is: a. Subjective b. Objective c. Assessment d. Plan

answer

d. Plan

question

"Acute allergic reaction" would be documented in which part of a SOAP note? a. Subjective b. Objective c. Assessment d. Plan

answer

c. Assessment

question

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization? a. Certification b. Licensure c. Accreditation d. Deemed status

answer

c. Accreditation

question

Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) _________ paper record. a. Integrated b. Source-oriented c. Problem-oriented d. Hybrid

answer

a. Integrated

question

22. Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words? a. Present illness b. Social and personal history c. Past medical history d. Chief complaint

answer

d. Chief complaint

question

Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay? a. Physical examination b. Physician order c. Progress notes d. Medical history

answer

c. Progress notes

question

Which of the following determines who can receive and transcribe verbal orders? a. Accreditation standards b. Certification regulations c. Medical staff bylaws d. Licensure standards

answer

c. Medical staff bylaws

question

The name of the government agency that has led the development of basic data sets for health records and computer databases is the: a. Centers for Medicare and Medicaid Services b. Johns Hopkins University c. American National Standards Institute d. National Committee on Vital and Health Statistics

answer

d. National Committee on Vital and Health Statistics

question

Minimum data set in healthcare are developed to: a. Recommend common data elements to be collected in health records b. Mandate all data that must be contained in a health record c. Define reportable data for federally funded programs d. Standardize medical vocabulary

answer

a. Recommend common data elements to be collected in health records

question

Data that are collected from individual records and then combined are referred to as: a. Statistics b. Information c. Aggregate data d. Standards

answer

c. Aggregate data

question

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-Term Care d. Health Plan Employer Data and Information Set

answer

b. Uniform Hospital Discharge Data Set

question

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for: a. Performance improvement programs b. Billing and claims data processing c. Developing hospital discharge abstracting systems d. Developing individual care plans for residents

answer

a. Performance improvement programs

question

Critique this statement: The continuity care record contains only current clinical information. a. This is a true statement. b. This is a false statement as the CCR contains both current and future plans. c. This is a false statement as the CCR contains both past information. d. This is a false statement as the CCR contains both future and past clinical information.

answer

d. This is a false statement as the CCR contains both future and past clinical information.

question

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of: a. Transaction standards b. Content and structure standards c. Vocabulary standards d. Security standards

answer

c. Vocabulary standards

question

The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the: a. Medicare Act b. Prospective Payment Act c. Health Insurance Portability and Accountability Act of 1996 d. American Recovery and Reinvestment Act

answer

c. Health Insurance Portability and Accountability Act of 1996

question

A key technology tool for enabling data is: a. Content standard b. Vocabulary standard c. Extensible markup language d. Metadata standards

answer

c. Extensible markup language

question

Most healthcare informatics standards have been implemented by: a. Federal mandate b. Consensus c. State regulation d. Trade association requirement

answer

b. Consensus

question

A critical early step in designing an EHR is to develop a ______ in which the characteristics of each data element are defined. a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary

answer

d. Data dictionary

question

According to the UHDDS definition, ethnicity should be recorded on a patient record as: a. Race of mother b. Race of father c. Hispanic, non-Hispanic, unknown d. Free text descriptor as reported by patient

answer

c. Hispanic, non-Hispanic, unknown

question

Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry? a. DEEDS b. UACDS c. MDS Version 3.0 d. OASIS

answer

a. DEEDS

question

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Reason for encounter c. Discharge diagnosis d. Activities of daily living

answer

b. Reason for encounter

question

In long term care, the resident's care plan is based on data collected in the: a. UHDDS b. OASIS c. MDS Version 3.0 d. HEDIS

answer

c. MDS Version 3.0

question

Reimbursement for home health services in dependent of data collected from: a. HEDIS b. UHDDS c. OASIS d. MDS Version 3.0

answer

c. OASIS

question

A consumer interested in comparing the performance of health plans should review data from: a. HEDIS b. OASIS c. ORYX d. UHDDS

answer

a. HEDIS

question

HEDIS is designed to collect: a. Administrative data b. Claims data c. Health record review data d. Administrative, claims, and health record review data

answer

d. Administrative, claims, and health record review data

question

Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for: a. Government regulations b. Core data elements c. Privacy controls d. Technology requirements

answer

b. Core data elements

question

A statewide cancer surveillance system is an example of which of the NHII dimensions? a. Personal b. Provider c. Community d. Payer

answer

c. Community

question

Providers and health plans need to share information. What standard must they use? a. X12N b. LOINC c. IEEE 1073 d. DICOM

answer

c. IEEE 1073

question

A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is: a. X12N b. LOINC c. IEEE 1073 d. DICOM

answer

d. DICOM

question

I work for an outpatient surgery center. What data set should I use? a. Continuity of Care Record b. Minimum Data Set c. Uniform Ambulatory Care Data Set d. Uniform Hospital Discharge Data Set

answer

c. Uniform Ambulatory Care Data Set

question

Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? a. X12N b. LOINC c. RxNorm d. DICOM

answer

d. DICOM

question

As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for: a. Developing unique provider identifiers b. Finalizing the extensible markup language c. Harmonization of standards from multiple sources d. Building software systems to support EHR development

answer

b. Finalizing the extensible markup language

question

ICD-10 is used in the United States for morbidity reporting. True or False

answer

True

question

The International Classification of Diseases for Oncology Third Edition is a system used for classifying incidences of benign disease. True or False

answer

False

question

CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services. True or False

answer

True

question

HCPCS codes are made up of CPT and Level II (national) codes. True or False

answer

True

question

The APA developed the Diagnostic and Statistical Manual of Mental Disorders as a tool for standardizing the diagnostic process for patients with psychiatric disorders. True or False

answer

True

question

AHIMA has developed Standards of Ethical Coding. True or False

answer

True

question

An encoder is a tool that aids coders in assigning diagnostic and procedure codes. True or False

answer

True

question

I need to confirm the patient's principal diagnosis for the chart I am coding. How should I do this? a. Call attending physician b. Review documents such as the discharge summary c. Have attending physician certify diagnoses d. Refer it to a physician advisor

answer

b. Review documents such as the discharge summary

question

The degree to which codes accurately reflect the patient's diagnoses and procedures is: a. Timeliness b. Completeness c. Validity d. Reliability

answer

c. Validity

question

Standardized vocabulary is needed to: a. Facilitate the indexing, storage, and destruction of patient information in a EHR b. Facilitate the indexing, storage, and retrieval of patient information in a EHR c. Group like diseases together for the purpose of reimbursement d. Record care provided by nurses

answer

b. Facilitate the indexing, storage, and retrieval of patient information in a EHR

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? a. ICD-10-CM codes b. HCPCS level II codes c. ICD-10-PCS codes d. ICD-9-CM procedure codes

answer

b. HCPCS level II codes

question

Which of the following would be an argument for the transition to ICD-10-CM/PCS? a. Coders have to be retrained b. MS-DRGS would have to be updated to accommodate the new codes c. More detail in the code d. ICD-10-CM contains diagnosis and procedure codes unlike ICD-9-CM

answer

c. More detail in the code

question

Which of the following is a goal of ICD-10-PCS? a. Reduce inconsistency due to overlapping of terms b. Eliminate need to communicate with physicians c. Assign diagnosis codes d. Assign diagnosis and procedure codes

answer

a. Reduce inconsistency due to overlapping of terms

question

Commission for Health Informatics and Information Management - AHIMA Certification Programs

answer

CCHIIM

question

AHIMA Membership

answer

Active Membership who are credentialed or Student Membership who does not have AHIMA credentials.

question

Leads the volunteer structure. Responsible for managing the property, affairs and operations of AHIMA.

answer

AHIMA Board of Directors

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Strives to be the premiere source for HIM professionals and the leader in advancing the field for the betterment of the HIM profession

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AHIMA Foundation

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Standard Guide on Content and Structure of Electronic Health Records

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E1384

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Branch of medical science that deals with classification systems

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Nosology

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System that lists preferred medical terminology

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Nomenclature

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World Health Organization

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WHO

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Mortality

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loss of life, death

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Morbidity

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diseased state or symptom

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History & Physical

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H&P

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Data Elements for Emergency Department Systems - collects data in hospital based emergency departments

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DEEDS

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Digital Imaging and Communication in Medicine

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DICOM

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Essential Medical Data Set

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EMDS

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Uniform Ambulatory Care Data Set

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UACDS

Health Information Management Chapters 1 – 5 Flashcards

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