Intro Final Exam
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| What does IDS stand for? | Integrated Delivery System
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| According to AMA's definition of allied health- it incorporates the healthcare-related professions that function to assist, facilitate, and/or compliment the work of physicians and other clinical specialists. True or false? | True
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| Which aspect(s) of managed care has had the greatest impact on healthcare organizations during the past twenty-five years? | Cost control and Access control
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| Medical staff classification refers to the organization of physicians according to clinical assignment. True or false? | True
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| What is the primary goal of integrated healthcare delivery systems? | To ensure that patients receive high-quality, cost-effective care in the most appropriate setting
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| The federal government reimburses healthcare providers for all of the healthcare services supplied to elderly and low-income Americans. True or False? | False
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| The role of ___ has changed rapidly in healthcare organizations, just as it has in many service organizations. | Computers
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| What factors may be considered in classifying the various types of hospitals? | 1. Type of services provided 2. For-profit or not-for-profit status 3. Type of ownership
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| Medical staff bylaws are considered legally binding, and any changes must be approved by a vote of the medical staff and employees of the hospital. True or False? | False
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| Which is the fastest growing sector of Medicare? | Home Care services
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| What was the main result of the publication of the Flexner report? | Medical school standards were established
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| Which organization developed the first hospital standardization program? | The American College of Surgeons
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| What is defined as a voluntary system of institutional review in which a quasi independent body periodically evaluates the quality of the services provided by healthcare organizations against written criteria? | Accreditation
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| Which federal legislation enacted the Medicare and Medicaid programs? | Public Law 89-97 of 1965
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| What statement best describes Medicare? | A federal program that finances healthcare services for the elderly
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| What statement best describes Medicaid? | A federal/state program that finances healthcar4e services for low-income families
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| Which governmental entities administer the Medicaid program? | State governments
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| Which type of healthcare organization is privately owned; that is, which one pays out their excess revenues in teh form of bonuses and dividends to managers, owners, and investors? | For-profit hospitals
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| Who is primarily responsible for setting the overall direction of an acute care hospital? | The board of directors
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| What refers to the organization of physicians according to clinical assignment? | Medical staff classification
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| What dictates how the medical staff operates? | Medical staff bylaws
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| Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective exuctive management team? | Chief Executive Officer
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| Most comnmercial health insurance is provided in the form of group policies offered by employers as part of their fringe-benefit packages for employees. True or false? | True
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| The federal government became involved in the quality-of-care/malpractice issue through the establishment of the National Practitioner Data Bank. True or false? | True
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| What statement describes the most important function of the health record? | Storing patient care information
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| All of the primary purposes of the health record are associated directly with the provision of patient care services. True or false? | True
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| Name 3 of the primary purposes of the health record. | 1. Patient care delivery 2. Patient care management 3. Patient care support
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| Name a secondary purpose of the health record. | Research and education
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| Who are the primary users of the health record? | The clinical professionals who provide direct patient care.
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| Direct patient care providers do not document their services directly in the patient's record. True or false? | False
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| What is the difference between data and information? | Data represent basic facts, while information represents meaning.
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| Name 3 users that can use a health record. | 1. Dieticians 2. Lab techs 3. Patients
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| Name 3 characteristics of high-quality healthcare data. | 1. Data relevency 2. Data currency 3. Data consistency
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| What scenario would represent data granularity? | A numerical measurement carried out to the appropriate decimal place
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| Computer-based patient record systems have the same access control requirements as paper-based record systems. True or false? | True
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| What is the primary characteristic of the integrated health record format? | Components are arranged in strict chronological order.
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| Paper-based record systems are not flexible enough to meet all of teh needs of every health record user. True or false? | True
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| _______ is the right of individuals to control access to their personal health information. | Privacy
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| _______ is the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose. | Confidentiality
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| _______ is the protection of the privacy of individuals and the confidentiality of health records. | Security
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| What would best describe data accuracy? | Data are correct
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| What would best describe data completeness? | Data include all required elements.
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| What would best describe data accessibility? | Data are easy to obtain.
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| Data definition refers to the ____. | Meaning of data.
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| Suppose that Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. From this description, which quality element would be missing from the note? | Data currency.
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| Suppose that the admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birthdate was recorded as July 21, 1948. Which element is missing from her health record? | Data consistency
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| The terms data and informatino mean the same thing. True or false? | False
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| Healthcare reimbursement is based directly on the documentation contained in the record. True or false? | True
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| For providers, the health record serves as a device for communication of information among disciplines. True or false? | True
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| The main function of the health record is to store patient care data and information. True or false? | True
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| In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? | Unit numbering
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| Which numerical filing system results in an even distributin of records and ensures activity throughout the filing area? | Terminal-digit filing system
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| What is an advantage of the unit filing system? | All records for a specific patient, both inpatient and outpatient, are filed together
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| What describes a unit record system? | All records, both inpatient and outpatient, for a specific patient are in one file
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| When records are received in the HIM department after discharge or conclusion of the visit, what is the first thing that should be done? | Someone should check to ensure that all records have been received
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| What type of record review is conducted while the patient is in the facility to ensure that items are completed and signatures are present? | concurrent review
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| A patient gets a new number for every visit to the health care facility best describes: | Serial numbering
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| A patient receives a new number at every visit but all records are placed in one file best describes: | Serial-unit numbering
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| The most common tyupe of tracking system used for paper based records is: | Outguides
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| An automated record tracking system will include bar codes. The bar code is usually going to be found on te file folder and it's going to represent the medical record number. True or false? | True
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| REcords that are missing from the chart are going to be found during a : | Quantitative analysis
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| You should always monitor the incomplete record filing area whether you have an electronic record system or a paper based record system. True or false? | False
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| In ROI, the medical infomration is released to a 3rd party requesting the information. True or false? | True
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| _____ is a prediction of how much money the organization is going to spend e.g. salaries. | Expense budget
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| _____ is a projection of what the organization is going to spend on long-lived assets such as equipment. | Capital budget
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| _____ is the anticipated flow of money into and out of the organization | Cash Budget
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| Data quality begins at the source of the data. What or where is the first point of data collection in a data facility? | Patient registration
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| Coding in the HIM department is accomplished using ______ and _____ codes. | ICD-9 and CPT
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| When you are putting the chart together in a pre-established order after the patient is discharged, you are ___ the record or chart. | Assembling
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| When you are looking at a record to make sure that there are no missing reports, forms or signatures, and you are making sure that each document has the patients name and record number, you are ___ the record. | Analyzing
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| The ___ is a report that tells whawt reports are missing and what signatures are missing. | Deficiency slip
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| ____ are request forms used to request a specific health record. They can be either paper or electronic. | Requisition slips
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| In a large facility where a numeric filing system is used- an index file has to be checked in order for the user to identify a patient. What is the name of the index file. | Master patient index
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| Name 2 typical HIM functions. | 1. coding 2. transcription
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| A statement or guideline that directs decision making or behavior is called a: | Policy
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| What entities have established documentation standards? | 1. JCAHO 2. Medicare 3. AOA
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| If the vice president of marketing requested information regarding the number of cardiac catheterizations performed in 2007, what index would you consult? | Operations/procecures index
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| What best describes alphabetic filing? | File the record alphabetically by last name, first name, then middle initial
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| The right of individual patients to determine what healthcare services they do or do not undergo. | Autonomy
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| Given the competing interests and limited resources of the parties involved, the consideration of fairness to those affected by decisions | Justice
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| The principle that requires that one party must do no harm to another, as in the physician's Hippocratic oath | Nonmaleficence
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| The prmotion of good for others or the provision of helpful services for others. | Beneficence
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| The application of ethical principles to decisions that affect human lives. | Bioethics
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| What is an example of nonmaleficence? | HITs must ensure that patient-identifiable information is not released to unauthorized parties.
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| Security involves physical and electronic mechanisms that protect health information from accidental or intentional damage, loss, or unauthoriized access. True or false? | True
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| Which organization issues and maintains ethical standards for the health information management profession? | AHIMA
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| In making job-related decisions, HITs must consider a number of ethical factors, including (3)__________. | 1. the rights and interests of healthcare patients and providers2. their employer's policies, rules, and regulations as well as cost and technological feasibility3. federal and state laws, medical staff bylaws, and accreditation &licensing standards
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| The ethical decision-making process includes consideration of steps to ensure that teh same issue does not come up again. True or false? | True
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| HITs have ethical obligations to their employers and the people who receive and provide services in their organizations, but generally they have no real obligations to the public at large. True or false? | False
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| What is a core ethical obligation of HITs? | Protecting patient's privacy and confidential communications
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| Which term means "promoting good"? | Beneficence
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| Which term means "treating others fairly"? | Justice
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| What ethical principle is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it and will benefit the patient? | Beneficence
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| What ethical principle is being followed when an HIT professional applies rules fairly to all? | Justice
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| What ethical principle is being followed when an HIT refuses to participate in a fraudulent act? | Nonmaleficence
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| What is an example of unethical practice? | Backdating progress notes
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| The right of someone to be left alone. | Privacy
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| The limitation of the use and disclosure of private information. | Confidentiality
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| Established privacy and security standards are part of _____. | HIPAA
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