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Comp Aps
all quiz questions
| Question | Answer |
|---|---|
| What is the term used for the official business record used for evidentiary purposes created by or for the healthcare organization | Legal health record |
| The push for hospital reform was initiated by | American College of Surgeons |
| What term describes a group of healthcare organizations that collectively provides a full range of coordinated health-related services? | Integrated healthcare network |
| The retention and destruction processes of health information are subject to specific regulations in many states as well as guidelines found in federal regulations and _________ standards. | HIPAA |
| The ______________ accelerated the adoption of and use of information technology in healthcare through economic incentives and planned future financial penalties. | American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) |
| Which of the following is a method of grouping patients according to a predefined set of characteristics? | Case-mix analysis |
| A hybrid health record may be a combination of paper-based, electronic-based, and which other format? | Mobile technology-based |
| Copies of personal health records (PHRs) are considered part of the legal health record when: | Used by the organization to provide treatment |
| Who owns the health records of patients treated in a healthcare facility? | The facility |
| What type of service is used when the professional nursing care and related medical, therapeutic, psychosocial, and personal services is provided in a residential setting to individuals recovering from injuries or illnesses or the residual effects of inju | Rehabilitative care |
| The process of accreditation of a healthcare organization is mandatory. | False |
| The purpose and value of documenting in the patient’s health record is effective communication to other caregivers for continuity of customer care. | True |
| Which organization developed standards for interoperability of health information technology? | Health Level Seven (HL7) International |
| The concept of the continuum of care has which three levels of care? | Primary, secondary and tertiary |
| When should entries in the health record be documented? | As soon as possible after the service is performed |
| What is the name of the clinical document that is a concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instr | Discharge Summary |
| What is hospital licensure? | The mandatory process whereby state governments grant individual hospitals permission to operate within a specific geopolitical area |
| Health Insurance Portability and Accountability Act (HIPAA)’s Privacy Rule states that ___________ used for the purposes of treatment, payment, or healthcare operations does not require patient authorization to allow providers access, use, or disclosure. | Protected health information; minimum necessary |
| What factor is medical necessity based on? | The beneficial effects of a service on the patient’s physical needs and quality of life |
| What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard? | Comply with both the state law and the HIPAA standard |
| The ________ collects information on medical malpractice settlements, clinical privilege actions, and medical society actions taken against licensed healthcare providers. | National Practitioner Data Bank |
| What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients? | Derived |
| What type of data relates to the patient’s condition and course of treatment? | Clinical |
| What is the outcome of analyzing data for a specific purpose? | Information |
| Which of the following is not a benefit of the electronic health information exchange (eHIE)? | Increase efficiency by eliminating necessary paperwork |
| Which of the following represents paper and electronic documentation? | Hybrid records |
| Which of these are known as common type of fraud in healthcare? | Providing unnecessary services to patients to increase payment |
| When queries are performed during the patient’s stay at the facility or organization, it is done _______. | concurrently |
| What type of index is used to determine if a healthcare organization can meet their individual, specific needs for customer care or other reporting requirements? | Facility-specific index |
| What is a descriptive list of names (also called representations or displays), definitions, and attributes of data elements to be collected in an information system or database? | Data dictionary |
| Which form was required by Health Insurance Portability and Accountability Act of 1996 (HIPAA)? | Notice of Privacy Practices |
| What are initiatives that rewards acute-care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries? | Value-based purchasing (VBP) |
| What refers to the relative levels of loss of function and mortality that may be experienced by patients with a particular disease? | Severity of Illness (SOI) |
| Specialty providers are identified as _________ under Meaningful use. | Eligible professionals |
| Which of the following is not included in the collection of vital statistics? | Hospital acquired conditions (HAC) |
| This organization is known for developing messaging or data exchange standards? | HL7 |
| Which agency compiles the nation's statistical information to guide actions and policies to improve health? | NCHS |
| Authentication is the process of providing proof of the authorship of documentation in the health record in electronic format only. | False |
| Which type of data includes compiled information on groups of people or patient that does not identify any particular patient? | Aggregate data |
| What term reflects the expected intensity of resources needed to care for patients? | Case Mix Index (CMI) |
| Which of the following involves allowing more than one clinician to add documentation while conserving the authorship of another clinician? | Authorship Integrity |
| What is a unique personal identifier that is entered by the author of EHR documentation electronically? | Electronic signature |
| How long are master patient indexes (MPI) retained? | Permanently |
| Larger healthcare organizations that include numerous hospitals experience an enhanced level of importance for the correct patient mapping in a(n) _____________________ . | Enterprise Master Patient Index |
| Which of these has the ability to pull data from different sources; they are designed to receive very large amounts of data and perform analytical processes on the data? | Data warehouse |
| Which of these processes supports the auxiliary utilization of patient information for registries, public reporting, research, and various purposes? | Abstracting |
| The purpose of the data dictionary is to __________ definitions and ensure consistency of use. | standardize |
| Which of the following is NOT a criteria for high-quality documentation? | Relative |
| Registry | Considered a secondary data source and is a chronological listing of patient with a common characteristic. |
| Operation index | This index is arranged by procedural codes and facilitates the study of patients with the same treatments. |
| Disease index | This index is arranged by diagnosis codes to monitor the quality of care with patient with similar conditions. |
| Physician index | This index is used for providing comparative information when reviewing quality of care, standards of practice and other specialized studies that may be customized at the facility level. |
| Queries performed _______ are developed during the patient's stay at the facility or organization. | concurrently |
| The process of identifying common elements in two or more data sets is known as ________. | data mapping |
| When applying the principle of data relevancy, which of the following data would apply? | Eye color |
| Before a physician will be permitted to provide patient services in a specific facility, he or she must first go through which of the following processes? | Credentialing |
| AHRQ’s quality indicators (QI) are _________________________ | measures of healthcare quality that make use of readily available hospital inpatient administrative data |
| A physician is reviewing the lab results of a patient in his office. The EHR screen displays one set of results in red with a flashing asterisk and also shows that this result is three times higher than the expected value. This is an example of a(n) ___ | alert |
| The most important outcome of a CDI program is: | Documentation that describes the patient's condition and treatment as accurately as possible. |
| The IG levels of maturity are a(n) ____________ platform divided into five different levels. | scalable |
| A pre-existing condition that affects the treatment received and/or prolongs the length of stay | Comorbidity |
| Which one of the following documents contains information about pertinent laboratory, radiology, therapy and consultations? | Discharge Summary |
| What are the four Vs in big data? | Volume, velocity, veracity, value |
| Which of these organizations mandates accreditation standards for discharge summaries? | The Joint Commission |
| What type of data are consents and authorizations? | Administrative |
| The concept of data oversight is most effectively administered through a strategic _________ program. | Data governance |
| When the physician enters orders in the EHR, the software automatically confirms the authentication to ensure that the individual who entered the data is authorized to do so (that is, that the authentication is correct). This is an example of a computer b | Validity |
| The process of storing health information is called: | Retention |
| Between 2009 and 2015, the number of healthcare records compromised for all reported breaches affecting 500 individuals or more has risen. | True |
| The PHR is maintained by whom? | The patient |
| Defining the legal record becomes __________ as organizations with EHRs. | Complex |
| The number of individuals who have health insurance continues to rise each year. | False |
| Which of the following processes would investigate a medical error that resulted in the death of a patient? | Risk Management |
| Which of the following is an example of unstructured data? | Provider notes |
| The admissions intake form asked patients if their health insurance plan was sponsored by someone else and, if so, to provide the sponsor’s date of birth. For the month of June 20XX, out of the 320 admissions who were sponsored by someone else, only 43% p | data consistency |
| The term "data" and "information" may be used interchangeably. | False |
| AHIMA defines a query as a ______ tool used to clarify documentation in the health record for accurate code assignment. | communication |
| The purpose of CDI is to increase reimbursement. | False |
| Tiffany is coding for reposition of the scapula. Although the report does not indicate any comorbidities, she did notice that the lab results indicate the patient may have diabetes. What should Tiffany do? | Query the physician to have the documentation clarified and updated, including the review of the lab results, to include the comorbidity. |
| What are used to sort data in a variety of ways to assist study of certain data elements? | Indexes |
| As an HIM professional working on IG initiatives, it is important to find out how the data in the organization is collected, stored and analyzed because: | It needs to be able to be trustworthy and have the highest integrity and quality. |
| What type of service is used when the professional nursing care and related medical, therapeutic, psychosocial, and personal services is provided in a residential setting to individuals recovering from injuries or illnesses or the residual eff | Skilled nursing care |
| The effective ongoing management of data assets is critical to maintaining the __________ of data in organizations: | Integrity |
| A valuable tool for clinical research that relates to the EHR includes the use of the secured __________ to reach potential research and study subjects as part of clinical trials. | Patient portal |
| The _________ is the driving force behind movement toward the universal adoption of EHR systems. | Health Insurance Portability and Accountability Act (HIPAA) |
| Data becomes __________________ when something is done to that data to make it meaningful | Information |
| Who is responsible for the collection of vital statistics? | State |
| The push for hospital reform was initiated by _____________________. | American College of Surgeons |
| Which of the following HIPAA offenses are considered criminal offenses? | Willful neglect but the violation corrected within required time period |
| Copies of personal health records (PHRs) are considered part of the legal health record when: | Used by the organization to provide treatment |
| Which of the following dictates the maximum period of time that may elapse between an event and any consequent legal action in a specific geopolitical area? | Statute of limitations |
| Unstructured data are stored in nondiscrete formats. Examples include: | Text reports and summaries |
| What Federal agency is charged with improving the safety and quality of America's healthcare system? | Agency for Healthcare Research and Quality |
| Essential patient information, such as patient allergies, needs to be highlighted to each member of the healthcare team. Which of the following EHR feature best highlights this? | Bright color alert on the EHR dashboard |
| Which of the following documents is a clinical document? | Physical examination |
| CLIA is focused to which service line? | Laboratory |
| The e-discovery amendments may be found in which of the following documents? | Federal Rules of Civil Procedure |
| Which of the following provide secondary care? | Specialty care offices |
| An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: | Granularity |
| Quantitative analysis is based on the regulatory, accrediting, licensing and reimbursement requirements that apply to the facility or organization. | True |
| What does the abbreviation OCR stand for? | Office for Civil Rights |
| CDI is an accurate description of a patient’s clinical status into coded data, which is then translated into: | a quality report |
| When dealing with a healthcare organization, the data may be: | Structured, semi-structured and unstructured |
| What is the name of the current performance measures used by The Joint Commission? | ORYX Performance Measures |
| What type of service is used for the medical–surgical care is provided to individuals whose injuries or illnesses require urgent care to address conditions that could be life threatening or disabling if not treated immediately; it is provided through a ne | Emergency and trauma care |
| Reflects the expected intensity of resources needed to care for the patient? | Severity of Illness (SOI) |
| How are amendments handled in the EHR? | The amendment must have separate authentication, data and time. |
| The patient owns the information documented within the EHR. | True |
| Which of the following is the biggest challenge of using a regional health information exchange? | Identifying the correct patient |
| The medical offices of Patrick Hall, MD, would like to participate in the Lower Salt Lake City Health Information Exchange (HIE). The patient name data element from Dr. Hall’s office looks like LNAME_MI_FNAME; however, the patient name data element in the | Data currency |
| The primary purpose of healthcare documentation is ________. | To chronicle patients' health over time |
| Which of the following technologies has been demonstrated to significantly reduce medication administrative errors? | Computer physician order entry (CPOE) |
| When healthcare facilities use a hybrid health record, what is the best strategy for discharge analysis? | The healthcare facility should identify the minimum discharge data elements both in the EHR and the hybrid records to develop a process to incorporate analysis of both types of records. |
| The physician monitored Stacey’s fluid input and output over several days to ensure she was hydrated. The use of the collected data is an example of: | primary data |
| Data elements included in the MPI should: | Accurately match patients being registered for care with their MPI records. |
| Before a hospital is permitted to provide medical services in a particular state, the organization must first go through which of the following processes? | Licensure |
| What is the general name for Medicare standards impacting healthcare organizations? | Conditions of Participation |
| Ambulatory care facilities must obtain state licensure and should adopt a method to address credential verification and monitor compliance with continuing education requirements for all licensed and credentialed personnel. | True |
| What best describes the principal diagnosis assigned at the LTCH? | Reason for admission to the LTCH |
| All these items except ___ can be found in the LTCH health record. | Medical bill |
| What is not an example of an ADL that would be assessed in a long-term care setting? | Shopping for food |
| What is one example of relevant data to include in a Transfer of Care Summary? | Medication list |
| What is one example of relevant data to include in a Transfer of Care Summary? | Medication list |
| What is it called when accrediting bodies such as the Joint Commission or AOA can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government? | Deemed status |
| CMS guidelines require a resident assessment to be performed on each resident. The assessment must be completed no later than ____ after the date of admission. | 24 hours |
| The ____ is a snapshot of a patient’s status and includes everything from social issues to disease processes, as well as critical paths and clinical pathways that focused on a specific disease process or pathway. | Care Plan |
| Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? | Tracer methodology |
| What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or are otherwise dying and unable to speak for themselves? | Advance directive |
| Sharing of patient information upon transfer | MU |
| Composed of board certified pathologists | CAP |
| First to offer accreditation to home and community-based healthcare programs | CHAP |
| Continuous quality improvement | TJC |
| Offer international accreditation to speech, physician and rural health centers | AAAASF |
| The oldest anti-fraud law, which is to be addressed in a healthcare corporate compliance program, is the _________. | False Claims Act |
| Under the Centers for Medicare and Medicaid Services Comprehensive (CERT) program which of the following is a not common documentation error in the Ambulatory Care? | History and physical within 30 days |
| Patients that require specialized care, including intensive therapies and nursing care are known as _____________ . | Medically complex patients |
| Within what period of time after admission to a LTCH must the history and physical be completed and placed in the health record? | 24 hours |
| A problem list is used to capture what information? | Relevant and current problems |
| Which type of facility does not use the test results to determine the course of the patient’s treatment? | Diagnostic Imaging Center |
| CMS reimburses the office physician on a _______________ payment system. | Fee-for-service |
| A history and physical completed within 60 days prior to admission may be used as long as it summarizes the patient’s condition and care prior to admission and describes their current physical/psychosocial status. | False |
| Which organization developed the Healthcare Effectiveness Data and Information Set? | National Committee for Quality Assurance |
| What does The Joint Commission call a patient safety event that reaches a patient, but is not primarily related to the natural course of the patient’s illness or underlying condition, and results in death, permanent harm, or severe temporary harm that req | Sentinel event |
| Ambulatory surgical centers only provide emergency surgery services | False |
| Residents must be seen by a physician at least once every ___ days for the first ___ days after admission, and at least once every ___ days thereafter. | 30, 90, 60 |
| What is used to collect information on a nursing home patient? | Resident assessment instrument |
| what is the resonsible leading agency for scientific research on complinetary and intergrative health approaches | National Center and Intergrative Health |
| Medicare pays for hospice services provided to the family and signifcant others after the death of a patient? | ture |
| in 2016, what percentage of physicians are utilziing a certificed EHR? | 77.9 percent |
| which of the following statements is correct regarding by Medicare Contractors? | The lack of a physcian signature can result in a denial of the entire episode |
| which of the following is a quality measure collected by CMS for dialysis patients? | anemia |
| medicare is the major payer of home health, Which of the following is the INCORRECT statement regarding MEdicares impact on documenation? | Government programs typically decrease the documentation burden because eligiblity is straightforward |
| The abbreviations AAAHC stands for: | Accrecidation Association for Ambulatory Health Care |
| What is the term for advanced nurses who provide healthcare services similar to a physician and diagnose and treat health problems focusing on caring and curing? | Nurse practitinoers |
| ___ is the use of medical information transmitted from one site to another via eletronic communication to improve a patients health status? | Telemedicine |
| What did congress enact to protect the privacy of student educational records? | FERPA |
| The goal of any quanatiative medical reveiw should be to find the problems prior to a surveyor and or medical review so ducmenatiosn inadequacies can be fixed? | false |
| what medical philosophy and practice focuses on imporoving ealth treating disease chiefly by assisting the bodys intrisnics ability to recuperoate from illinios and injurty? | naturopathy |
| which setting is described as any distinced entitty that operates esclusivly for the purpose of providing surgical services to patients not requiring hopsilization? | ambluatroy surgery center |
| which of the following is a correct statemtn regarding a DNR order? | The record should be clearly marked to indicate the presence of a DNR order |
| Which of the following staements is correct regarding home health HIM audits? | a 100% review of all records should be completed on a quartley basiss |
| There is an increasing trend in the US for drs to be direcly emplywed by the hospital? | true |
| which of the following is considered a condition of coverage for ASC health records? | documenation of unsigned consent form |
| the five critera for establishing a life expentancy of six months or less for hopsice patinents include which of the following? | subjective and objective medical findings |
| continious home care day | predominatley nursing for the brief periods of time |
| inpatient respite care day | provided for the family or cargiviers |
| routine home care day | usual payment per diem |
| general inpatient care day | provided for symptom managment or pain control |
| which type of dentist focuses on injuries and defects of the neck, head and jaw? | orl and maxio facial surgeons |
| which of the following is an unture statmen t? | the Utliziaion outcome is the patiemtn improvemont in the ablilty to ambulate independtaly? |
| the goal of any quanatiative medical review should be to find the promblems prior to a surveyro and or medical review so docmuenatiions inadquacies can be fixed | false |
| what is one of the greatest compianc risks in hopsice, according to OIG | providign or billing for general inpaitnt services |
| what facilites provide walk in extended hour access for acute illness and injury care that is beyond the scope of availablity of the typica primary care or practice | urgent care |
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