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HIT242 Final Review
| Question | Answer |
|---|---|
| What is designed to minimize the facility's potential risks and when an incident occurs, its losses? | risk management program |
| According to Federated Ambulatory Surgery Association, what percentage of all surgeries in America are outpatient? | 70 percent |
| 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 |
| Coordination of care is dependent upon the quality of _________ provided by each of the healthcare providers involved in the patient's treatment. | documentation |
| Health problems or conditions, present in the patient before admission, that affected the patient's care are called? | comorbidities |
| How are patients using ambulatory surgical centers for elective surgical procedures classified? | Outpatient |
| Leaving a sponge or foreign body such as a sponge in a patient after surgery is an example of a(n) ______________________. | sentinel event |
| True or false? Records that are involved in open investigations, audits or litigation should not be destroyed. | True |
| Responsibility for the collection of vital statistics rests with the _________. | state |
| Secondary data sources provide information that is _____ available by looking at individual health records. | not easily |
| Specific instructions for patient care after discharge are called: | discharge instructions |
| What is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for long-term care (MDS 3.0)? | RAI |
| True or false? The health record is considered a primary source because it contains-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient. | True |
| Under what circumstances would an outpatient become an inpatient? | The patient was admitted to an acute-care unit after receiving emergency room services. |
| What is hospital licensure? | The mandatory process whereby state governments grant individual hospitals permission to operate within a specific geopolitical area. |
| What is the main difference between primary, secondary, and tertiary care? | the degree specialization |
| What kind of facility offers comprehensive, primary healthcare services to patients who otherwise would have limited access to healthcare? | Community health centers |
| What organization is responsible for setting standards for cancer treatments? | The Commission on Cancer |
| What type of data are consents and authorizations? | Administrative |
| What type of data was the first to be subject to data standardization efforts? | Hospital discharge |
| When a patient collapses upon arrival at the entrance to an emergency department, what type of treatment authorization is in effect? | Implied consent |
| Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? | Tracer methodology |
| Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers? | Healthcare Integrity and Protection Data Bank (HIPDB) |
| Which of the following is NOT required for physician's orders? | The orders must be typed |
| Which of the following specialized patient assessment tools must be used by Medicare certified home care providers? | Patient assessment instrument |
| Who oversees the operational functions related to collecting, protecting, and archiving the legal health record? | HIM professionals |
| 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 |
| What are used to sort data in a variety of ways to assist study of certain data elements? | Indexes |
| What is the term used for the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business or payment purposes? | Legal health record |
| How do healthcare providers use the administrative data they collect? | For regulatory, operational, and financial purposes |
| Which of the following processes would investigate a medical error that resulted in the death of a patient? | Utilization management review |
| What process involves overseeing the hospital's internal medical, legal and administrative operations with the goal of minimizing the hospital's exposure to liability? | Risk management |
| Data taken from the health record and entered into registries and databases are considered a(n): | Secondary data source |
| Which inpatient services does CARF offer accreditation programs for? | Rehabilitation |
| Instructions on the use of restraints or seclusion are considered what type of documentation? | Special orders |
| When a patient collapses upon arrival at the entrance to an emergency department, what type of treatment authorization is in effect? | Implied consent |
| Who is responsible for writing and signing discharge summaries and discharge instructions? | Attending physician |
| What is a unique personal identifier that is entered by the author of EHR documentation? | Electronic signature |
| Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of: | Documentation integrity |
| When is the timeframe for an unannounced survey after a full survey? | 18-36 months |
| Written instructions that describe how functions and processes must be carried out are: | Procedures |
| Determination of ___________ is considered to be one of the most difficult documentation issues facing the long-term care environment including the LTCH. | principal diagnosis or reason for admission |
| What is the definitional length of stay for long-term acute-care hospitals? | 25 days or greater |
| 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. | 14 days |
| Documentation that supports that skilled services are medically reasonable and necessary is called: | Medical necessity |
| Home care organizations that choose to be accredited by the Joint Commission must meet its ______ standards. | Management of Information (IM) |
| In data quality management, what term is the processes by which data elements are accumulated? | Collection |
| For Medicare patients, how often must the home health agency's assessment and care plan be updated? | At least every 60 days or as often as the severity of the patient's condition requires |
| To prevent denials for hospice claims, coding personnel are advised to use the most specific diagnosis codes and to ensure the ________ is always listed as the principal diagnosis. | terminal diagnosis |
| What are instruments patients can use to clarify treatment choices in the event that they are no longer capable of doing so? | Advance directives |
| What is the most common diagnosis of patients needing inpatient mental health care? | Schizophrenia |
| Schools and universities may provide outpatient mental health assistance to students through: | Crisis therapy or counseling, clinics and guidance therapy |
| Someone may be considered recommended for conservatorship if they | are gravely disabled and unwilling or incapable of accepting voluntary treatment |
| A non-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework for the electronic health record. | Health Level 7 (HL7) |
| A group of federal and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims and improve public health through interoperable health information exchange. | Nationwide Health Information Network(NHIN) |
| Creates and promotes data interchange standards for the pharmacy services sector of the healthcare industry. | National Council for Prescription Drug Programs(NCPDP) |
| Established by Congress to serve as an advisory body to HHS on health data , statistics and national health information policy | national Committee on Vital and Health Statistics(NCVHS) |
| An organization that was founded in 2004 to help certify EHRs | Certification Commission for Healthcare Information Technology(CCHIT) |
| The effective ongoing management of data assets is critical to maintaining the __________ of data in organizations: | Integrity |
| What are the four Vs in big data? | Volume, velocity, veracity, value |
| AHRQ’s quality indicators (QI) are _________________________ | measures of healthcare quality that make use of readily available hospital inpatient administrative data |
| CDI is an accurate description of a patient’s clinical status into coded data, which is then translated into: | a quality report |
| A pre-existing condition that affects the treatment received and/or prolongs the length of stay | comorbidity |
| Reflects the expected intensity of resources needed to care for the patient? | Severity of Illness (SOI) |
| 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. |
| What are used to sort data in a variety of ways to assist study of certain data elements? | Indexes |
Created by:
Prof Clark