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eHIM Final Study Guide
The accreditation program of AHIMA is concerned with: A. Establishing standards for the content of college programs in HIT and HIM B. Making sure that AHIMA has good certification examinations C. Ensuring that AHIMA manages its property and affairs appropriately D. Establishing policies and procedures to be followed by the Communities of Practice - correct answer A. Establishing standards for the content of college programs in HIT and HIM All of the following are AHIMA credentials except A. RHIT B. CCS-P C. CPC-P D. CCS - correct answer C. CPC-P Which of the following make up a virtual network of AHIMA members? A. AHIMA Board of Directors B. AHIMA Council on Certification C. AHIMA Communities of Practice D. AHIMA House of Delegates - correct answer C. AHIMA Communities of Practice Which of the following functions as the legislative body of AHIMA? A. AHIMA Board of Directors B. AHIMA Commission on Certification for Health Informatics and Information Management C. AHIMA House of Delegates D. AHIMA Foundation - correct answer C. AHIMA House of Delegates
What evolving role assesses quality in health record banking? A. physician group consultant B. health record reviewer C. health data analyst D. terminology manager - correct answer B. health record reviewer The primary function of the American Health Information Management Association is to: A. Ensure that accurate and complete medical records are written for every hospital patient B. Standardize the content and format of the health records maintained by acute and emergency care facilities C. Promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting D. Provide support for two- and four-year health information management educational programs - correct answer C. Promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting Which of the following is an arm of AHIMA that promotes education and research in health information management? A. AHIMA Board of Directors B. AHIMA CAHIIM C. AHIMA Foundation D. AHIMA Commission on Certification for Health Informatics and Information Management - correct answer C. AHIMA Foundation Which of the following classes of AHIMA membership requires that individuals hold an AHIMA credential? A. Active membership B. Associate membership C. Student membership D. Honorary membership - correct answer A. Active membership
A. Health information manager B. Clinical data specialist C. Enterprise content and information manager D. Data resource administrator - correct answer D. Data resource administrator The traditional model of HIM practice was: A. department based B. information based C. electronically based D. analytically based - correct answer A. department based The hospital standardization program was started by the American College of Surgeons in: A. 1900 B. 1905 C. 1918 D. 1928 - correct answer C. 1918 Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA? A. House of Delegates B. Board of Directors C. Communities of Practice D. Component state associations - correct answer B. Board of Directors Who is responsible for final approval of the AHIMA Code of Ethics? A. AHIMA Board of Directors B. AHIMA Commission on Certification for Health Informatics and Information Management C. AHIMA Ethics Committee D. AHIMA House of Delegates - correct answer D. AHIMA House of Delegates
Which of the following best describes the mission of the AHIMA? A. Community of professionals providing support to members and strengthening the industry and profession B. Community of professionals whose major purpose is lobbying Congress to change laws C. Community of credentialed members who monitor the credentialing process D. Community of credentialed members whose purpose is to ensure jobs for their members - correct answer A. Community of professionals providing support to members and strengthening the industry and profession Which of the following activities is not a traditional medical records function? A. Forms control B. Quantitative analysis C. Productivity monitoring D. Data administration - correct answer D. Data administration The virtual network used by AHIMA members is: A. certification B. fellowship C. house of delegates D. communities of practice - correct answer D. communities of practice The only requirements for professional certification through the AHIMA are graduating from an accredited two-year or four-year educational program. A. Yes B. No - correct answer B. No The formal process for conferring a health information management credential is called: A. Accreditation B. Certification
What is the defining characteristic of an integrated health record format? A. Each section of the record is maintained by the patient care department that provided the care. B. Integrated health records are intended to be used in ambulatory settings. C. Integrated health records include both paper forms and computer printouts. D. Integrated health record components are arranged in strict chronological order. - correct answer D. Integrated health record components are arranged in strict chronological order. How do research organizations use the health record? A. To examine results of experimental protocols B. For reporting of communicable diseases C. To investigate domestic violence D. To manage disability insurance benefits - correct answer A. To examine results of experimental protocols Which of the following best describes data accessibility? A. Data are correct. B. Data are easy to obtain. C. Data include all required elements. D. Data are reliable. - correct answer B. Data are easy to obtain. The paper-based health record format that organizes all forms in chronological order is known as the: A. Problem-oriented health record B. Integrated health record C. Patient-oriented health record D. Source-oriented health record - correct answer B. Integrated health record Which of the following best describes data accuracy?
A. Data are correct. B. Data are easy to obtain. C. Data include all required elements. D. Data are reliable. - correct answer A. Data are correct. Use of the health record by a clinician to facilitate quality patient care is considered: A. A primary purpose of the health record B. Patient care support C. A secondary purpose of the health record D. Patient care effectiveness - correct answer A. A primary purpose of the health record Protection of healthcare information from damage, loss, and unauthorized alteration is also known as: A. Privacy B. Results management C. Security D. Data accuracy - correct answer C. Security Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using? A. Computerized physician/provider order entry B. Electronic health record C. Results management D. Clinical decision support - correct answer A. Computerized physician/provider order entry 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 birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? A. Data completeness B. Data consistency
D. Generate a report to be used in performance improvement - correct answer D. Generate a report to be used in performance improvement Use of the health record to monitor bioterrorism activity is considered: A. Primary purpose of the health record B. Secondary purpose of the health record C. Patient use of the health record D. Healthcare licensing agency function - correct answer B. Secondary purpose of the health record How do patient care managers and support staff use the data documented in the health record? A. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided B. Communicate vital information among departments and across disciplines and settings C. Generate patient bills and/or third-party payer claims for reimbursement D. Determine the extent and effects of occupational hazards - correct answer A. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided Which of the following elements is not a component of most patient records? A. Patient identification B. Clinical history C. Financial information D. Test results - correct answer C. Financial information The hospital where I work is transitioning to an EHR. In the meantime, we have part of the health record electronic and part is still paper. This concept is known as: A. Integrated health record format B. A hybrid record C. A resident record D. Integrated health record format - correct answer B. A hybrid record
I need an information system that will provide assistance to physicians in diagnosing and treating patients. The system that I need is: A. Results management B. Order-entry/order management C. Clinical decision support D. Electronic health record - correct answer C. Clinical decision support How do accreditation organizations use the health record? A. To serve as a source for case study information B. To determine whether the documentation supports the provider's claim for reimbursement C. To provide healthcare services D. To determine whether standards of care are being met - correct answer D. To determine whether standards of care are being met Critique this statement: Patient care managers are individual users of health records. A. This is a true statement. B. This is a false statement as they do not require patient information to do their job. C. This is a false statement as they require patient information to do their job. D. This is a false statement as patient care managers are institutional users. - correct answer A. This is a true statement. Which of the following best describes the most important function of the health record? A. Communicating instructions between physicians and nurses B. Providing information to support reimbursement claims C. Storing patient care documentation D. Providing information to support managed care - correct answer C. Storing patient care documentation
B. Data are easy to obtain. C. Data include all required elements. D. Data are reliable. - correct answer C. Data include all required elements. Which of the following is an institutional user of the health record? A. Patient care provider B. Third-party payer C. Coding and billing staff D. Government policy maker - correct answer B. Third-party payer Which of the following statements does not pertain to paper-based health records? A. They have a built-in access control mechanism. B. They are kept in locked storage areas that are accessible only to authorized staff. C. They are logged out according to the organization's prescribed procedure. D. They are forwarded to the appropriate service area when needed for patient care purposes. - correct answer A. They have a built-in access control mechanism Which of the following is not a characteristic of high-quality healthcare data? A. Data relevancy B. Data currency C. Data consistency D. Data accountability - correct answer D. Data accountability Critique this statement: Paper-based record systems are not flexible enough to meet all of the needs of every health record user. A. This is a true statement. B. This is a false statement as paper-based record systems are more flexible than electronic systems. C. This is not an issue as flexibility of the health record is not important to the quality of the patient care and administrative needs of the organization.
D. This is a false statement as paper-based systems may not be flexible but they still meet all of the needs of every health record user. - correct answer A. This is a true statement. Our record has all of the labs filed together, all of the progress notes filed together, and so on. What format are we using? A. Source-oriented health record B. Integrated health record C. Patient-oriented health record D. Problem-oriented health record - correct answer A. Source-oriented health record Attorneys for healthcare organizations use the health record to A. Support claims for medical malpractice B. Protect the legal interests of the facility and its healthcare providers C. Plan and market services D. Locate missing persons - correct answer B. Protect the legal interests of the facility and its healthcare providers Critique this statement: The health record documents services provided by allied health professionals and a patient's family. A. This is a true statement. B. This is a false statement as the health record only document's physician's care. C. This is a false statement as the health record only documents care provided by patient families. D. This is a false statement as the health record documents the care provided by healthcare professionals. - correct answer D. This is a false statement as the health record documents the care provided by healthcare professionals. An individual's right to control access to his or her personal information is known as: A. Security B. Confidentiality C. Privacy D. All of the above - correct answer C. Privacy
B. International Standards Organization C. American Health Information Management Association D. National Library of Medicine - correct answer A. Health Level Seven (HL7) Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) ________ paper record. A. Integrated B. Source-oriented C. Problem-oriented D. Hybrid - correct answer A. Integrated Which of the following is not a function of the discharge summary? A. Providing information about the patient's insurance coverage B. Ensuring the continuity of future care C. Providing information to support the activities of the medical staff review committee D. Providing concise information that can be used to answer information requests - correct answer A. Providing information about the patient's insurance coverage Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews? A. Accreditation Association for Ambulatory Healthcare B. Commission on Accreditation of Rehabilitation Facilities C. American Osteopathic Association D. Joint Commission - correct answer D. Joint Commission In a medical history, which of the following is a detailed chronological description of the development of the patient's illness? A. Chief complaint B. Present illness C. Past medical history
D. Review of systems - correct answer B. Present illness What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization? A. Certification B. Licensure C. Accreditation D. Deemed status - correct answer C. Accreditation Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? A. Patient assessment instrument B. Minimum data set for long term care C. Resident Assessment Protocol D. Outcomes and Assessment Information Set - correct answer D. Outcomes and Assessment Information Set Which of the following federal laws resulted in the new privacy regulations for healthcare organizations? A. Health Information Access and Disclosure Act B. Health Insurance Portability and Accountability Act C. Patient Self-Determination Act D. Social Security Act - correct answer B. Health Insurance Portability and Accountability Act Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record? A. Correctional facility health record B. End-stage renal disease record C. Long-term care record D. Personal health record - correct answer D. Personal health record
Which of the following types of healthcare facilities may seek accreditation from the Joint Commission? A. Acute-care hospitals B. Psychiatric hospitals C. Home care providers D. Ambulatory care organizations E. All of the above - correct answer E. All of the above The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the: A. Anesthesia report B. Progress notes C. Operative report D. Recovery room report - correct answer C. Operative report "The patient indicates that she is dizzy, nauseous, and feels her throat tightening." This entry would be recorded in which section of a SOAP note? A. Subjective B. Objective C. Assessment D. Plan - correct answer A. Subjective Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words? A. Present illness B. Social and personal history C. Past medical history D. Chief complaint - correct answer D. Chief complaint What is the function of a consultation report?
A. Provides a chronological summary of the patient's medical history and illness B. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care C. Concisely summarizes the patient's treatment and stay in the hospital. D. Documents the physician's instructions to other parties involved in providing care to a patient - correct answer B. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care Which of the following is not an example of a long-term care setting? A. Assisted living facilities B. Nursing homes C. Community mental health centers D. Subacute care organizations - correct answer C. Community mental health centers Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? A. Autopsy report B. Laboratory findings C. Pathology report D. Surgical report - correct answer B. Laboratory findings Documentation standards and guidelines are published by a variety of private and public organizations, including the: A. Joint Commission B. American Health Information Management Association C. National Committee for Quality Assurance D. All of the above - correct answer D. All of the above Which of the following is a standard terminology used to code medical procedures and services? A. CPT
