question

BUN

answer

blood urea nitrogen

question

CK-MB

answer

creatine kinase, MB function

question

CPK

answer

creatine phosphokinase

question

CrCl

answer

creatine clearance

question

C & S

answer

culture and sensitivity

question

ESR

answer

erythrocyte sedimentation rate

question

Gluc

answer

glucose

question

FBS

answer

fasting blood sugar

question

CHOL

answer

cholesterol

question

HDL

answer

high density lipoprotein

question

LDL

answer

low density lipoprotein

question

LDH

answer

lactic dehydrogenase

question

Trig

answer

triglycerides

question

INR

answer

international normalized ratio

question

DB

answer

direct bilirubin

question

TB

answer

total bilirubin

question

TP

answer

total protein

question

OGTT

answer

oral glucose tolerance test

question

PSA

answer

prostate specific antigen

question

UA

answer

urinalysis

question

Diff

answer

differential

question

Eos

answer

eosinophils

question

Fe

answer

iron

question

Hct

answer

hematocrit

question

Hgb

answer

hemoglobin

question

Plt

answer

platelets

question

MCV

answer

mean corpuscular volume

question

Segs

answer

segmented neutrophils

question

ABG

answer

arterial blood gas

question

WNL

answer

within normal limits

question

ECG

answer

electrocardiogram

question

EEG

answer

electroencephalogram

question

FEV1

answer

forced expiratory volume in one second

question

IPPB

answer

intermittent positive pressure breathing

question

PEEP

answer

positive end expiratory pressure

question

MUGA

answer

multigated radionuclude angiogram

question

CT

answer

computerized tomography

question

IVP

answer

intravenous pyelogram

question

MRI

answer

magnetic resonance imagin

question

PET

answer

positron emission tomography

question

US

answer

ultrasound

question

PCTA

answer

percutaneous coronary transluminal angioplasty

question

D&C

answer

dilation and curettage

question

OOB

answer

out of bed

question

BRP

answer

bathroom privileges

question

DAW

answer

dispense as written

question

I/O

answer

intake and output

question

LD

answer

loading dose

question

PICC

answer

percutaneous indwelling central catheter

question

IVPB

answer

intravenous piggyback

question

NGT

answer

nasogastric tube

question

An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the __ __.

answer

provisional diagnosis

question

How do research organizations use the health record?

answer

examine results of experimental protocols

question

How do accreditation organizations use the health record?

answer

to determine whether standards of care are being met

question

Use of the health record by a clinician to facilitate quality patient care is considered a..

answer

primary purpose of the health record

question

Between 1996 and 206, the number of ambulatory care visits in the US has ___.

answer

increased

question

The Joint Commission requires patient records be completed ___ days after a patient has discharged.

answer

30

question

What would provide information that can be used by the HIM department to monitor electronic record transactions?

answer

audit trail

question

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion.

answer

Objective

question

To calculate the delinquent record rate, divide the total number of delinquent records by...

answer

total number of discharges in the period

question

When all required data elements are included in the health record, the quality characteristic for ______ _______ is met

answer

data comprehensiveness

question

An individual's right to control access to his or her personal information is known as

answer

privacy

question

URI

answer

upper respiratory infection

question

The term used to describe expected data values

answer

data precision

question

The AHA recommends that patient records be retained for..

answer

5 years

question

Which filing order saves time in processing discharged records?

answer

universal chart order

question

AMI

answer

acute myocardial infarction

question

APR-DRG CMI

answer

all patient refined diagnostic related group case mix index

question

ASN

answer

associate of science nursing degree

question

b.

answer

born

question

BOD

answer

board of directors

question

CABG

answer

coronary artery bypass graft

question

CABSI

answer

catheter associated bloodstream infection

question

CV

answer

cardiovascular

question

DRG

answer

diagnostic related group

question

NH3

answer

ammonia

question

AT III

answer

antithrombin III

question

C/O

answer

complains of

question

CC

answer

chief complaint

question

CTA

answer

clear to auscultation

question

Dx

answer

diagnosis

question

F/U

answer

follow up

question

FH

answer

family hisotry

question

H/O

answer

history of

question

HPI

answer

history of present illness

question

Hx

answer

history

question

PE

answer

physical exaination

question

PH/SH

answer

personal and social history

question

PI

answer

present illness

question

PMH

answer

past medical history

question

ROS

answer

review of systems

question

SH

answer

social history

question

GI

answer

gastrointestinal

question

GU

answer

genitourinary

question

UCD

answer

usual childhood diseases

question

A&P

answer

auscultation and percussion

question

ADL

answer

activities of daily living

question

CN III

answer

third cranial nerve

question

RCM

answer

right costal margin

question

TM

answer

tympanic membrane

question

AAOX 3

answer

alert, awake and oriented to person, place and time

question

BM

answer

bowel movement

question

True or False: Lab System is an example of an ancillary system

answer

True

question

Discrete data are generally entered into EHR via ____.

answer

templates

question

The ability to electronically put tasks into a queue for someone to perform is called __ __.

answer

work flow

question

What technology is used to manage data from different source systems, including discrete data, scanned images, and digital forms of data.

answer

CDR

question

In a regional health information organization (RHIO), patients would most likely be identified using ____ ____ ____.

answer

record locator service

question

A special web page that offers secure access to data is a ___.

answer

portal

question

To run an analysis on a large set of data from many patients, the best tool is a ____.

answer

CDW

question

A program to exchange data is called a(n) ____.

answer

interface

question

Standards from which organization would be used for enabling exchange of clinical images is ____.

answer

DICOM

question

Refers to the meaning of a clinical concept

answer

semantics

question

What vocabularies is likely to be used to describe drugs in clinically relevant form:

answer

rxnorm

question

When some computers are used primarily to enter data and others to process data the architectures is called:

answer

client/server

question

Form of wireless technology that is used to beam data between devices in close proximity to one another

answer

bluetooth

question

What can a healthcare organization implement to help significantly reduce downtime?

answer

mirrored processing on redundant servers

question

Data that describes the data to be entered into an EHR is called:

answer

metadata

question

When a hospital uses many different vendors to support its information system needs, the IT strategy being used is called:

answer

best of breed

question

A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as

answer

implementation plan

question

What form of system testing ensures that each data element is captured correctly:

answer

unit testing

question

What describes the step during implementation when data from an old system are able to be incorporated into the new system is called ____ ____.

answer

data conversion

question

How are health plans incentivizing providers to use EHR's:

answer

paying for performance

question

Of a judge asks a record custodian to attest to the performance of an EHR, the custodian should describe ____ ____.

answer

contingency plans

question

An example of how security of an EHR is afforded is via ____ ___.

answer

access controls

question

A high level overview of when EHR components will be implemented is ___ ___.

answer

migration path

question

A means to reduce the data entry burden for providers but still capture discrete data is ___ ___ ___.

answer

patient data entry

question

Ensure accurate and timely data entry is ___ ___.

answer

data quality

question

The name of the government agency that has led the development of basic data sets for health records and computer data bases is the...

answer

national committee on vital health and statistics

question

The primary purpose of a minimum data set in health care is to recommend ___ ____ ___ to be collected in ___ ___

answer

common data elements, health records

question

Data that are collected on large populations of individuals and stored in databases are referred to as ___ ___.

answer

aggregate data

question

Both HEDIS and JCAHO's ORYX program are designed to collect data to be used for ____ ____ ____.

answer

performance improvement programs

question

ASTM standard E1384 provides guidance to healthcare organizations in developing ___ __ ___ of health records

answer

content and structure

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 ___ ___.

answer

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 ___.

answer

HIPAA

question

The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the ___ ___ __.

answer

social security number

question

Most healthcare informatics standards have been implemented by ___.

answer

consensus

question

A critical early step in designing an EHR is to develop a ___ ___in which the characteristics of each data element are defined.

answer

data dictionary

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?

answer

DEEDS

question

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on ___ ___ ___.

answer

reason for encoutner

question

In long term care, the resident's care plan is based on data collected in the ____ ___ ___.

answer

MDS version 2.0

question

Reimbursement for home health services in dependent data collected from ____.

answer

OASIS

question

A consumer interested in comparing the performance of health plans should review data from ____.

answer

HEDIS

question

To be successful, a regional health information network is dependent on ____ ____ on ____ regional needs.

answer

stakeholder consensus, local

question

Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for___ ___ ___.

answer

core data elements

question

A statewide cancer surveillance system is an example of which of the NHII dimensions?

answer

community

question

In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?

answer

X12N

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 ___.

answer

DICOM

question

A core data set developed by ASTM to communicate a patient's past and currenthealth information as the patient's transitions from one care setting to another is ___ ___ ___ ___

answer

Continuity of care record

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?

answer

LOINC

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 ___ of standards from ___ sources.

answer

harmonization, multiple

question

True or False: The first medical nomenclature to be universally accepted in the United States was the Standard Nomenclature of Disease and Operations

answer

true

question

True or False: CPT is the most widely recognized classification system in use today

answer

false

question

True or False: A consulting physician may take over a patient's care

answer

true

question

The Medicare Prospective Payment System was implemented in the year ____

answer

1983

question

True or False: The UHDDS is the minimum core data collected on ambulatory patients

answer

false

question

An assumed name is also known as a(n) ____.

answer

alias

question

A living will is a(n) ____ ___.

answer

advance directive

question

The report used to record items a patient brought to the hospital is called a(n) ____ ____ ___.

answer

patient property form

question

The Patient's own description of his or her medical condition is called the ____.

answer

cc

question

Which of the following indicates that several possible diagnoses are being considered?

answer

differential diagnosis

question

"Time and means of arrival" are documented in the ____ department record

answer

emergency

question

Identification and financial information is entered onto the face sheet by what department?

answer

admissions

question

The form used in a physician's office that consists of a single page listing common services provided in the office is called a(n) _____.

answer

superbill

question

True or False: A new progress note sheet should not be generated until the previous form is filled.

answer

true

question

A patient's smoking and alcohol drinking habits are collected as part of the ____ ___.

answer

social history

question

True or False: A nursing care assessment can be documented instead of a H&P

answer

false

question

True or False: Physicians are usually responsible for documenting vital signs

answer

false

question

Signing a medical record entry is known as ______.

answer

authentication

question

Vital signs are often recorded on a(n) ____ sheet.

answer

graphic

question

The initials T.O. after an entry refer to _____ ___.

answer

telephone order

question

Which report describes the gross findings, organs examined, and techniques associated with the performance of surgery?

answer

operative report

question

True or False: A durable power of attorney is the same as a health care proxy

answer

true

question

Preprinted orders, preapproved by the medical staff, are known as ____ ____.

answer

routine orders

question

The _____ ___ is documented in the newborn record and measures 1 minute and 5 minutes after birth.

answer

APGAR score

question

APGAR stands for

answer

appearance, pulse, grimace, activity, respirations

question

True or False: A postdated entry in a medical record can be made instead of an addendum

answer

false

question

A pregnant woman's obstetrical record begins with the _____ record at the physicians office

answer

prenatal

question

Which two filing systems are used to file medical records?

answer

alphabetic and numeric

question

Chart tracking, audits, and file guides are examples of filing _____.

answer

controls

question

The most common circulation method is using a(n) _____.

answer

messenger

question

The Veterans Affairs medical centers use the ___ ___ numbering system

answer

social security

question

A computer record tracking system uses ___ ___ for locating medical records

answer

bar codes

question

True or False: a pseudonumber is assigned to patients without their social security number, the pseduonumber is in the 000-00-0000 format.

answer

true

question

A patient was seen in the ED on January 31 for a persistent cough and chest congestion. She is sent for a chest x ray before being discharged from the ED room. In February, she is admitted to the hospital for pneumonia. How many medical record folders would result if a serial numbering system were used?

answer

2

question

True or False: Some patients have more than one social security number

answer

true

question

A STAT record requisition is also known as a(n) ____ requisition

answer

emergency

question

True or False: Tertiary digits in a terminal digit filing system can be of unlimited length

answer

true

question

True or False: When medical records are filed in the department in which they are generated, the facility is using a centralized filing system.

answer

false

question

If two patients have identical names and date of birth, the next data element selected for alphabetic filing is the _____ ____.

answer

city name

question

A small elevator that transports records from one floor to another is called a(n) _____.

answer

dumbwaiter

question

True or False: Straight numeric filing provides more record security than terminal digit filing.

answer

false

question

The US Census Bureau uses the ____ indexing system

answer

soundex

question

In which numbering system do outguides or previous folders remain in the files as new numbers are assigned and the medical records are moved?

answer

serial unit

question

An information security policy should be drafted by a _____ committee

answer

confidentiality

question

To prevent records from being crushed during fling, ____ is done to the side and top tabs of record folders

answer

rounding

question

The federal legislation that requires that patient information systems be analyzed to determine the potential for breaches of patient privacy is called ____.

answer

HIPAA

question

True or False: A popular filing system is the unit medical record

answer

false

question

In a family numbering system, modifier ____ is assigned to the first born child.

answer

03

question

The year a patient was seen is indicated on a(n) ____ ___, which can be embossed on a folder

answer

activity legend

question

True or False: A benefit of the alphabetic filing system is that the file clerks can be quickly trained.

answer

true

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