HIMT 1150 Introduction Chapter 7 – Flashcards
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Automated codebook encoder
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Computerized codebook that mimics the structure of the coding books.
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Birth certificate information system
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State-approved software that reports births occurring in the healthcare facility to the state health agency.
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Cancer registry information system
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Tracks very detailed information regarding diagnosis and treatment about the patient's cancer from time of diagnosis to the patient's death.
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Chart deficiency system
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Records and tracks when a medical record comes to an HIM department with a documentation omission-can be in paper, imaged, or electronic records depending on the system used.
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Chart locator system
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Tracks the paper medical record.
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Clinical documentation improvement software
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Assists in identifying ways to improve clinical documentation in the health record.
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Computer-assisted coding (CAC)
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The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-10-CM and CPT evaluation and management codes for billing and coding purposes.
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Dictation system
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Used by physicians and transcription staff to dictate various medical reports such as the operative report, history and physical, and the discharge summary.
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Disclosure management system
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Tracks the disclosures made throughout the healthcare organization for reporting purposes, required by HIPAA.
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Encoder
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Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.
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Expander
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Allow transcriptionist to type an acronym and the full phrase will automatically be spelled out, thus saving keystrokes and time.
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Grouper
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(1) computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes. (2) computer software program that automatically assigns prospective payment groups on the basis of clinical codes.
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Healthcare quality indicator system
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An abstracting system that records information about the patient and the care provided to the patient.
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Natural language processing (NLP)
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A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence.
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Release of information system
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Designed to manage the processing of request for protected health information received and processed by the HIM department.
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Rules-based encoder
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Requires the user to type in the name of portion of the name of the diagnosis or procedure. This entry into the encoder generates a list of suggestions from which the coder selects.
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Trauma registry software
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Tracks patients with traumatic injuries from the initial trauma treatment to death.
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Transcription system
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Used by the transcriptionist to type the various documents dictated by the physicians.
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Which of the following systems should one use to assign the diagnosis and procedure codes
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Grouper
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Which of the following is the type of encoder that mimics a codebook
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Automated codebook encoder
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A computerized system designed to help assign the proper code is a(n)
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Encoder
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The system used to notify requesters of invalid authorization is called a(n)
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Release of information
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Which system would you use to print out a report of people who have not paid for the copies of records sent to them
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Release of information
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The term used to describe where you enter the locations that a record can be checked out to is called a(n)
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Table
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Which type of software tracks patients who meet criteria for inclusion such as a specific disease or treatment
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Registry
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Which system tracks the location of the paper medical record
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Chart locator
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Which system collects the TNM stage
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Cancer registry software
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Life expectancy is information that would come from the
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Cancer registry software
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Which system would tell a physician that they need to sign an operation report
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Chart deficiency
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A physician speaks into a phone and gives a summary of the patient's care, which is later transcribed. What type of system is the physician using
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Dictation
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To enter the number of units of blood that a patient received during a recent hospitalization, one would use the
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Healthcare quality indicator
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What system would one use to enter data required by the NCHS
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Birth certificate software
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Which system would one be using if one typed out the abbreviation EGD and the term esophagogastroduodenoscopy was spelled out
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Expander
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The information system that assigns an ICD-10-CM code is called a(n)
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Encoder
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Which of the functionalities below is more likely to be found in a birth certificate system designed by a vendor than the state
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Productivity
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Which product would identify that Dr. Smith needs to sign a discharge summary
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chart deficiency
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Which of the following systems would be used primarily by physicians, rather than HIM Department staff
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dictation system
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Which of the letters listed below would be part of the release of information system
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letter notifying individual that the authorization was invalid
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Which of the following systems would track follow-up rates
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Trauma registry
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Which of the following systems could have voice recognition as a feature
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dictation system
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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
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quality indicator
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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
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birth certificate
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The data element principal diagnosis is found in
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encoder/grouper
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Where would you find a field entitled document type
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transcription system
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As a general rule, which of the following systems would be utilized by departments other than HIM
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master patient index
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Which of the following statements is true
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The release of information system's letters communicates with the requester.
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Which of the following statements is true about the encoder
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Encoders assign the code for both diagnoses and procedures.
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Which of the following is a term used to describe a type of encoder
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rules-based
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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
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requester table
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Which of the following is a function of the release of information software
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track status of request
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Reports designed specifically for one time use is called what type of report
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ad hoc
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Which of the following is an example of a function of the cancer registry software
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checking social security death index
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The chart location system would help the healthcare facility with which of the following
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accessibility
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Patient follow-up is a key part of which HIM system
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cancer registry software
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True or False: A registry tracks multiple diseases and conditions rather than specialize
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False
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True or False: The dictation system has implications for physicians and HIM staff
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True
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True or False: The transcription system should collect the date of transcription
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True
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True or False: The grouper should only be able to utilize the current Medicare grouper.
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False
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True or False: Quality indicator systems collect voice from the dictation system to capture data.
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False
