question

Which of the following carries out the operational tasks necessary to support the organization's mission and goals?

answer

Staff

question

Our transcription is performed by a company outside of our organization. What is this called?

answer

Outsourcing

question

The services provided by HIM department is acute care hospitals usually include all the following except:

answer

Medical Billing

question

The patient registration department assists the HIM department in what way?

answer

Assigning the health record number

question

Which of the following professional is not mentioned in this text as requiring licensing by all 50 states?

answer

Health Information Management

question

Which of the following confers scholarships?

answer

AHIMA Foundation

question

A member of the AHIMA Board of Directors is which of the following?

answer

Elected

question

Patients in hospice care are expected to live a maximum of ______ days.

answer

180 days

question

Which of the following elements is typically found in the paper health record?

answer

Patient Identification

question

Which of the following is a secondary purpose of the health record?

answer

Support for research

question

What is the name given to the privileges assigned to physicians to provide clinical services in a hospital?

answer

Clinical

question

Which of the following is an example of information?

answer

The number of patients discharged has increased 175% over the past year.

question

In which department or unit does the health record typically begin?

answer

Patient Registration

question

An RHIT is going back to earn her bachelor degree so that she can sit for the RHIA exam. What membership category is she qualified for?

answer

Active

question

Who is responsible for communicating information relevant to national issues and keeping members informed of regional affairs that affect HIM?

answer

AHIMA component state associations

question

What committee oversees the development and approval of new forms for the health record?

answer

Health information management committee

question

How many linear filing inches can a shelving unit hold based on the following data? Shelving unit shelf width=36 in Number of shelves per unit=9 shelves Average record thickness=1/2 in

answer

324

question

Which of the following is true about the AHIMA House of Delegates?

answer

They meet virtually throughout the year

question

Long term care in mainly rehabilitative and supportive rather than curative.

answer

True

question

What percentage of hospitals offers emergency services?

answer

More than 90%

question

Sustained professional achievement is required by which of the following?

answer

Fellowship

question

Which of the following should be taken into consideration when designing a health record form?

answer

Including original and revised dates

question

Which organization's goal is centered on health information technology?

answer

HIMSS

question

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

answer

AHIMA House of Delegates

question

Two types of practitioners can hold the degree of Doctor of Medicine. They are:

answer

Physician and Surgeon

question

Which of the following makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA?

answer

Engage

question

Calculate the number of shelving units required for 35,000 linear filing inches of record if the shelving units has 7 shelves and is 36 inches wide.

answer

139

question

Which of the following is a surgical specialty?

answer

Anesthesiology

question

Dr.Smith wants to use a lot of free text in his EHR. What should be your response?

answer

Dr.Smith, we recommend that you use little, if any, free text in the EHR.

question

How can the healthcare facility determine which physician has the best patient outcomes?

answer

Data mining

question

Which of the following filing method is considered the most efficient?

answer

Terminal digit filing

question

The Social Security Act of 1935 has a healthcare component added by the Republican president, Franklin D. Roosevelt.

answer

False

question

Which of the following classes of AHIMA membership requires that individuals have interest in HIM and will abide by the AHIMA code of ethics?

answer

Active membership

question

Critique this statement: Version control is not an issue in the EHR.

answer

There are issues related to versions of documents, such as there must be a flag to indicate a previous version

question

AHIMA fellowship is conffered for:

answer

Life

question

Which one of the following are included in a list of institutional users of the health record?

answer

Blue Cross and Blue Shield

question

Which of the following is true about the AHIMA certification program?

answer

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

question

The board of directors can also be called the board of trustees.

answer

True

question

Which of the following statements describes alphabetical filing?

answer

File the record alphabetically by the last name, following by the first name, and then the middle initial.

question

Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record number of three records filed together within the filing system? 36-45-99 37-45-99 38-45-99

answer

Terminal digit

question

The release of information function requires the HIM professional to:

answer

Disclose patient identifiable information to a third party

question

Why should the copy and paste function should not be used in the electronic health record?

answer

The content may contain outdated inforamtion

question

Which of the following HIM tasks is eliminated by the electronic health record system?

answer

Assembly

question

Which of the following is a request from a clinical area to change out a health record?

answer

Requisition

question

Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public's health?

answer

Surgeon General of the United States

question

What is the software that is used for voice recognition known as?

answer

Natural Language Processing

question

Which of the following is a disadvantage of alphabetic filing?

answer

Uneven expansion in file shelves or cabinets

question

Which step comes first in the accreditation process?

answer

Self-assessment

question

A health record with deficiencies that is not complete within the time-frame specified in the medical staff rules and regulations is called a(n) _________ record.

answer

Delinquent

question

Who are the primary users of the health record?

answer

Clinical professionals who provide direct patient care

question

The term used to describe controlling information is _______.

answer

Information governance

question

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

answer

Storing patient care documentation

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?

answer

Board of Directors

question

The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:

answer

Purged

question

Which of the following lists of names is in correct order for alphabetical filing?

answer

Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas

question

The difference in health insurance coverage between medical and psychiatric care is

answer

Non-parity

question

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a ____________ review.

answer

Concurrent

question

In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintained that identifier for all subsequent encounters?

answer

Unit numbering system

question

Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis?

answer

Quantitative

question

This type of facility is more homelike and less institutional than in the past

answer

Residential Care Facilities

question

The role of the AHIMA chief executive officer is to:

answer

Manage the day-to-day operations

question

Which one of the following is in terminal digit order?

answer

12-56-36,13-58-39,14-75-87,15-85-98

question

The average length of stay (LOS) for acute care hospitals is:

answer

25 days or less

question

The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged what type of review?

answer

Retrospective

question

Which of the following indexes is key to locating a health record?

answer

Master Patient Index

question

Members of the AHIMA House of Delegates are:

answer

Elected by members in component state organizations

question

With the implementation of the Affordable Care Act, U.S. states were given the opportunity to expand Medicaid, though not all have done so.

answer

True

question

Cell-based technologies include

answer

Stem cells for transplant

question

Where should new graduates begin their volunteer experience?

answer

CSA

question

Which organization should be contacted regarding the certified healthcare documentation specialist exam?

answer

Association for Healthcare Documentation Integrity

question

True or False? Auto-authentication is not in compliance with CMS Interpretive Guidelines for Hospitals

answer

True

question

The data characteristics that refers to promptly entering up-to-date information into the patient's medical record is which of the following?

answer

Timeliness

question

An example of a standard for forms development is to mandate that the title of the form appear on the rip center of the page

answer

True

question

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

answer

Physical Examination

question

Patient history questionnaires are most often used in what setting?

answer

Ambulatory care

question

The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module and released of information module with the electronic health record. This is an example of what data strategy method?

answer

Data Ownership

question

Which of the following is true of many electronic health records?

answer

They are interoperable

question

The Uniform Hospital Discharge Data Set's core data elements are collected by

answer

Acute care, short-term stay hospitals

question

When correcting erroneous information in a paper health record, which of the following is appropriate?

answer

Add the reason for the change

question

CPT is a terminology and also a

answer

Code system

question

True or False? Healthcare provider organizations normally do not have patients sign an acknowledgement addressing the fact that the healthcare provider organization is not responsible for the loss or damage of the patient's valuables

answer

False

question

The ambulatory surgery record contains information most similar to which records?

answer

Hospital operative records

question

AHIMA has created 8 principles to help organizations create ________________ within their organization?

answer

Information governance

question

True or False? The term ambulatory is the same as the term outpatient.

answer

True

question

In what part of the health record would the social and personal history be found?

answer

Medical History

question

The ______________ established the Common Clinical Data Set

answer

ONC

question

Create a clear and open documentation process for the information governance strategy and activities within an organization, instruments and clinical information systems

answer

Transparency

question

Which of the following is usually a component of acute care patient records?

answer

Progress Notes

question

Authorship validation is one part of _____________________________?

answer

Data integrity

question

True or False? Analysis of patient registration information can promote population health management.

answer

True

question

_____________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations?

answer

Information Assets

question

Nursing terminologies are

answer

Used to direct patient care given by nursing staff

question

Patient Account Information includes

answer

Insurance

question

Who drives which clinical terminology, classification, and code system in selected as the standard?

answer

Government regulation

question

A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a health attack. The combined data is referred to as?

answer

Information

question

If you were coding a patient with the diagnosis of congestive heart failure, which classification would you use?

answer

ICD-10-CM

question

Which of the following procedure classifications include definitions?

answer

ICD-10-PCS

question

Which of the following creates a visual process to understand the data being collected in two different systems and how it is linked to one another?

answer

Data Mapping

question

When defining the legal health record, what must the healthcare provider do?

answer

Assess the legal environment

question

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

answer

Medical History

question

Which specialized type of progress note provided healthcare professionals impressions of patient problems with detailed treatment action steps?

answer

Care plan

question

Which of the following is the standard for healthcare equipment under HIPAA?

answer

HCPCS Level II

question

What is a system of terms that follows pre-established naming conventions

answer

Nomenclature

question

A patient's birth data and gender documented in the health record are examples of a data?

answer

Element

question

Create a process for proper preservation of information based on requirements from regulations. accrediting organizations, and company policy

answer

Retention

question

A healthcare organization must ensure that data is presented in a way that is appropriate for the purpose of the data

answer

True

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

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

answer

Conditions of Participation

question

The Healthcare Effectiveness Data and Information Set contains standard

answer

Performance measures

question

When writing a query for clinical documentation questions, the requester should specifically state what diagnosis they are evaluating.

answer

False

question

Which system would be used to classify a state of disability?

answer

ICF

question

An example of clinical documentation improvement tool is computer-assisted coding (CAC)

answer

True

question

Category II CPT is used for

answer

Performance measurement

question

True or False? An increase of healthcare-related identity theft has had no influence on a healthcare provider organization's decision not to collect Social Security Numbers from patients.

answer

False

question

Interoperability is the capability of two or more systems and software applications to communicate electronically and exchange information

answer

True

question

Data warehousing is the process of extracting information stored in structured data formats within a database.

answer

False

question

A single or individual fact that represents a patient in healthcare is known as a/n

answer

data element

question

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

answer

Physical Exam

question

True or False? The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance.

answer

True

question

True or False? An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance

answer

True

question

The overall goal of documentation standards is to

answer

Ensure what is documented in the health record is complete and accurately reflects the treatment

question

True or False? Nursing documentation should only be subjective

answer

False

question

Which of the following is a clinical terminology?

answer

CPT

question

One of the required descriptions for a SNOMED CT is

answer

Preferred term

question

According to CMS, who is qualified to collect the OASIS data?

answer

Registered nurses

question

what is the function of a consultation report?

answer

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

question

Which of the following is an example of a long-term care setting?

answer

Community mental health center

question

Safeguards established to support the data is available when and where is it needed under the data quality model is called which of the following?

answer

Accessibility

question

True or False? CMS does not require healthcare providers to inform their patients about general patient rights afforded to them

answer

False

question

A list of recommended data elements with uniform definitions is a

answer

Data Set

question

Which of the following is an example of an external user utilizing secondary data?

answer

Federal agencies

question

A notice of privacy practices should include a statement explaining that individuals may complain to the Secretary of the Department of Health and Human Services if they believe that their privacy rights have been violated.

answer

True

question

Law that involves the government and its relationships with individuals or organizations

answer

Public law

question

Process by which a lawsuit is initiated

answer

complaint

question

Which of the following statements about the directory of patients maintained by a covered entity is true?

answer

Individuals must be given an opportunity ti deny permission to place information about them in the directory

question

List of the operations and procedures performed in a facility, sequenced according to classification code numbers

answer

operation index

question

Proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system

answer

Arbitration

question

Registry that includes information from more than one facility in a geopolitical region

answer

population-based registry

question

Spoken or written agreement; may be given by a patient to a healthcare provider to permit treatment

answer

Express contract

question

The main goal of Healthy People 2020 is to focus on promoting vaccine safety in public and private provider settings

answer

False

question

Central collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery

answer

disease registry

question

What is the biggest threat to the security of healthcare data?

answer

Employees

question

A level I trauma center provides care from initial evaluation through stabilization

answer

False

question

Sworn testimony usually collected before a trial

answer

deposition

question

A record is considered a primary data source when it

answer

contains information about the patient that has been documented by the professionals who provided care to the pateint

question

Permission inferred when a patient voluntarily submits the healthcare treatment

answer

Implied consent

question

A nurse cannot practice without

answer

Licensure

question

Critique this statement: Case definition for trauma registries is determined by individual facilities

answer

This is a true statement

question

Mary's PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the physicians office's required action?

answer

It must report the breach to HHR within 60 days after the end of the calendar year in which the breach occurred

question

Though the HIPAA Security Rule does not specify audit frequency, how often should an organization's security policies and procedures be reviewed

answer

Once a year

question

Which of the following is required by HIPAA standards?

answer

A written contingency plan

question

Law enacted by a legislative body

answer

Statute

question

Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity

answer

Can deny access to psychotherapy notes

question

Explain what the accession number 16-214 means

answer

The year that the patient was entered in the registry is 2016 and this was the 214th patient entered in the registry during 2016

question

Written document directing an individual to furnish documents and other records to a court

answer

Subpoena Duces Tecum

question

A risk analysis is useful to

answer

Identify security threats

question

Which of the following is an organization's planned response to protect its information in the case of a natural disaster?

answer

Business Continuity Plan

question

Information about the patient that is documented by the clinicians who provide services to the patient

answer

Primary Data

question

Registry that includes only cases for a specific facility

answer

Facility-based registry

question

An accession number is a number assigned to cases as it is entered in a cancer registry

answer

True

question

Written permission to use or disclose patient-identifiable health information

answer

authorization

question

Failure to meet the conditions specified under a legal agreement

answer

breach of contract

question

The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of the

answer

Healthcare Integrity and Protection Data Bank

question

Which of the following is a software program that tracks every access to data in the computer system?

answer

Audit Trail

question

What type of health records are subject to the HIPAA Privacy Rule

answer

Health records in any format

question

In all cases, covered entity may deny an individual's request to restrict the use or disclosure of his or her PHI.

answer

False

question

Which of the following situations is considered a breach of PHI

answer

A patient's attorney is sent records not requested by the patient

question

Data extracted from individual patient records and combined to form information about groups of patients

answer

Aggregate data

question

Security controls built into a computer software program to protect information security and integrity are which of the following

answer

Application controls

question

Secondary data is generally used

answer

by external users

question

individuals or party who is the object of a lawsuit

answer

defendant

question

Who prohibits specific abbreviations from being used in the health record

answer

Joint Commission

question

In two computer systems the same data element is different. This is what type of issue?

answer

Data Consistency

question

What does the acronym PHI stand for?

answer

Protected health information

question

Rules developed by administrative bodies empowered by law to regulate specific activities

answer

Administrative law

question

Disclosure of pertinent facts or documents to the opposing parties in a legal case

answer

Discovery

question

Which of the following is an example of a physical safeguard that should be provided for in a data security program?

answer

Locking computer rooms

question

The health cost and utilization project is a major initiative of which organization within the federal government?

answer

The agency of Healthcare Research and Quality

question

Which of the following statements is true in responding to request from individuals who wish to access their PHI?

answer

A cost-based fee may be charged for making a copy of the PHI

question

The HIPAA data integrity standard requires that organization do which of the following?

answer

Keep documented logs of system access and access attempts

question

How many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHi is stored off-site?

answer

60

question

What does the term access control mean?

answer

Identifying which data employees should have a right to use

question

The Joint Commission sets the official record retention standards for hospital and other healthcare facilities

answer

False

question

List of cases in a cancer registry arranged in the order in which the cases were entered

answer

Accession registry

question

HIPAA administrative requirements include which of the following?

answer

Designating a privacy officer

question

This type of control is designed to prevent damage cause by computer hackers

answer

Network Control

question

A valid Authorization requires which of the following?

answer

AN expiration date or event

question

Rules and principles that define rights and duties among individuals or organizations

answer

Private law

question

An audit identified that an employee accessed a patient whose last name is the same as the employee. This is known as a/an

answer

Trigger

question

List of patients by physician, usually arranged by physician code numbers

answer

Physician index

question

Information such as age and data of birth

answer

Demographic data

question

Professional liability of healthcare providers in the delivery of care to patients

answer

medical malpractive

question

Identify the true statement about the health record

answer

the health record is a primary data source

question

To identify cases to be entered into the trauma registry, where should someone look?

answer

Disease index

question

Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?

answer

Notice of privacy practices

question

The services that a physician is allowed to perform in a healthcare facility is known as which of the following?

answer

Clinical privileges

question

Amber files a medical malpractice lawsuit against Dr.Mason, who performed her surgery. She names no other defendant in the lawsuit. Dr. Mason files a complaint against Amber. By doing this, Dr. Mason has completed which legal action?

answer

Counterclaim

question

List of patients with severe injuries

answer

trauma registry

question

PHR vendors that are nor part of a covered entity or business associate must report PHI breaches to

answer

The Federal Trade Commision

question

Civil wrong doing

answer

tort

question

Secondary data source consists of

answer

registries

question

Individual who bring a lawsuit

answer

plaintiff

question

AHIMA's record retention guidelines recommend that the master patient index be maintained for what length of time

answer

Permanently

question

The creation of hte National Practitioner Data Bank was mandated by teh

answer

Health Care Quality Improvement Act

question

The physical health record is usually considered the property of which entity?

answer

The organization or provider

question

Which of the following is a covered entity under the HIPAA Privacy Rule

answer

Pharmacy

question

Which of the following is one of the causes of action

answer

Breach of Contract

question

AHIMA's record retention guidelines recommend that diagnostic images such as x-rays be maintained for what length of time?

answer

at least 5 years

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