Health Information Management: Key Concepts and Practices, Exams of Nursing

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Health Information Management Technology

Which organization's goal is centered on health information technology? - HIMSS Which of the following is a traditional HIM role? - Tracking record completion Critique this statement: Once someone has earned the registered health information technician (RHIT) credential, it is a lifetime certification. - This is incorrect as RHITs have to become recertified by reporting CEUs The primary focus of AHIMA is to: - Foster professional development of its members Which of the following best describes the mission of AHIMA? - Community of professionals providing support to members and strengthening the industry and profession The first professional association for health information managers was established in what year? - 1928 The new model of HIM practice was - Information focused The formal approval process for academic programs in health information management is called which of the following? - Accreditation

The requirement for an HIM professional to comply with all laws, regulations, and standards governing the practice of HIM is in the AHIMA _________. - Code of ethics The accountability framework and decision rights to achieve enterprise information management is known as: - Information Governance What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-establised objective screening criteria at time frames specified - Utilization Review To "create social and physical enviroments that promote good health for all" is a goal of which of the following organizations? - Healthy People 2020 HITECH was a portion of which bill - American Recovery and Reinvestment Act of 2009 One of the most important health issues in the United States is Long-Term Care. List two principal reasons for this: - People are living longer today than they did in the past as a result of advances in medicine and healthcare practices. An increase in the birth rate after World War II, baby-boomer generation. The mission of the QIOs is to ensure________________ - quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries in its locale. Which of the following places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers -

Continuum of care Which of the following federal laws created Medicare and Medicaid? - Public Law 89-97 of 1965 Patients in hospice care are expected to live a maximum of ____ days. - 180 Two types of practioners can hold the degree of Doctor of Medicine. They are: - Physician and Surgeon Which of the following is part of qualitative analysis review? - Checking that only approved abbreviations are used Deficiencies in a health record include which of the following? - Missing document The specific number of days defined in the medical staff rules and regulations for a delinquent medical record varies between how many days? - 15-30 Days How many linear filing inches can a shelving unit hold based on the following data? Shelving unit shelf width: 36 inches Number of shelves per unit: 9 shelves Average record thickness: 1/2 inch - 324 Monitor bioterrorism activity - Public Health

Serve as evidence in litigation - Legal, accreditation, and policy development Prepare conferences and presentations - Education of healthcare professionals Develop new products - Research Which of the following lists of names is in correct order for alphabetical filing? - Smith, Carl J Smith, Mary A Smith, Paul M Smith, Thomas List three common problems of the MPI. - Duplicate health records Overlay Overlap Which of the following elements is typically found in the paper health record? - Patient Identification Once a document has been authenticated, the document should be locked in order to prevent any changes to the document. - True As a HIM Professional it is your responsbility to ___________________________________. -

ensure that the purposes of the health record are fulfilled. The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? - Laboratory What year did AHIMA House of Delegates vote to establish the independent accreditation commission (CAHIIM)? - 2004 Research is one of the secondary purposes of the health record. - True The HIM profession is continuing to evolve from the traditional HIM roles. List 4 reasons that the HIM role has changed.

4. Electronic Health Record Regulations New Technologies Engaged Consumers What is the ideal ratio of medical specialist to generalist? - 16: The expected turnaround time for transcribed reports are the same for all documents. -

False Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public's health? - Surgeon General of the United States List the five major ways hospitals are classified: - Numbers of beds Types of services provided Types of patients served For-profit and Not-for-profit status Type of ownership List the six typical medical staff classifications - active provisional honorary consulting courtesy medical resident assignments The average length of stay (LOS) for acute care hospitals is: - 25 days or less List AHIMA's four Core Values.

Quality Integrity Respect Leadership One of the reasons not to use the copy and paste function in a health record is the information may be outdated. - True not-for-profit organization that focuses on better health through information technology - HIMSS a professional organization dedicated to the capture of health data and documentation - AHDI educates and certifies medical coders - AAPC represents cancer registrar professionals - NCRA Assess workload - Patient Care Support Document services received - Patient Care Delivery (Patient) Manage Costs - Financial/Administrative Purposes

Document patient's risk factors - Patient Care Delivery (Provider) To formulate practice guidelines - Patient Care Management The clinical data portion of the acute-care record constitutes the largest portion of the health record. - True Documentation standards have become more detailed and have become focused on ________. - Patient care quality Auto-authentication is not in compliance with the CMS Interpretiave Guidelines for Hospitals. - True For the Electronic Health Record to be a legal health record certain requirements must be met. Certain concepts need to be considered. Give two examples listed in your text book of these concepts. - How documentation is actually created and signed off by the healthcare providers How the documentation is managed and preserved How the documentation impacts and interacts with the revenue cycle functions of billing and claims submission How the documentation is displayed both electronically to the user as well as in hard copy form, should the data be printed. What prohibits healthcare providers from refusing to treat patients or delaying treatment due to the ability to pay? - EMTALA - Emergency Medical Treatment and Active Labor Act

Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? - Operative Report Identify the report where the following information would be found: "HEENT: Reveals the tympanic membrane, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." - Physical examination CMS does not require healthcare providers to inform their patients about general patient rights afforded to them. - False Ambulatory Surgery Centers - Accreditation Association for Ambulatory Health Care (AAAHC) Rural Health Clinics - The Compliance Team Critical Access Hospitals, Hospitals - DNV GL Healthcare Ambulatory surgery centers, critical access hospitals, hospitals, home health, hospice, psychiatric hospitals - Joint Commission Hospital - Center for improvement in healthcare quality

Home Health, Hospice - Accreditation Commission for Health Care Which of the following is an example of administrative information - Patient's address Which of the following statement is true of the process that should be followed in making corrections in paper-based health record entries? - The reason for the change should be noted The Uniform Hospital Discharge Data Set's core data elements are collected by__________. - Acute care, short term stay hospital The purpose of ICD-10-PCS is to provide a system for classifying procedures performed on _________________________. - Hospital inpatients deidentified information to compare and analyze - Classficiations Goal is detail in the information - Clinical Terminologies A patient was seen in the emergency department for chest pain. It was suspected that he patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD". The correct ICD- 10-CM diagnosis code is: - R07.9 Chest pain, unspecified RxNorm was not chosen as the standard for medications for the entry of structured data in certified EHR systems under the Meaningful Use program -

False Clinical diagnosis of a DSM-5 mental disorder does not necessarily meet legal criteria for the presence of a mental disorder - True One barrier to the interoperable health IT enviroment is not all healthcare intentities are eligible for the incentive payment for adopting an EHR - True According to CMS, who is qualified to collect the OASIS data? - Registered Nurse Coding accuracy is best determined by - A predefined audit process What is the "comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting - SNOMED CT In SNOMED CT descriptions are human-readable representations of concepts. - True List one key action to an interoperable Health IT enviroment. - Supporting EHR adoption among health care providers across the health care system. Increasing the number of health IT workforce professionals that can facilitate the implementation and support of an electronic health care system.

Sharing studies and recommendations with providers, payers and patients on how health IT improves health care quality and patient safety. Empowering individuals to access and use their health information to stay informed and improve their health and well-being. Messaging standards for electronic data interchange in healthcare have been developed by: - HL AHIMA has created 8 principles to help organizations create _______________ _____________ within their organization. - Information Governance Which of the following is one of the principles of data stewardship as defined by the National Committee on Vital and Health Statistics (NCVHS)? - Individual Rights Emergency Care Setting - EMDS Hospital Inpatient - UHDDS Home Healthcare Setting - OASIS Long-term Care Setting - MDS Hospital-based Emergency Room -

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Ambulary Care Setting - UACDS Within AHIMA's data quality model what is the characteristic of quality data that refers to promptly entering up-to-date information into the patient's medical record? - Timeliness What is the purpose of computer databases? - Store and retrieve data Data governance manages the information ___________________ the different systems used in healthcare and information governance manages the information _________________ the different systems - Put into; output from Dynamic data is data that ________________________ and static data is data that __________________________. - Can be changed; is view only Which one of the following is an example of clinical data? - Admitting diagnosis To evaluate a new line of service a hospital may profile the community in which the clinic exists to understand the population - True This document defines how records and documentation are assembled and authenticated within the hospital. - Medical Staff bylaws

List three (3) reasons in healthcare for the need of information governance:

3. 1. The risk of privacy and security breaches that become more costly each day

4. The need for a massive update of systems, processes, and education that must be undertaken to support ICD-10-CM/PCS implementation

5. Trying to get the workflows and information right to qualify for attestation to the "meaningful use" EHR Incentive Program

6. Changing payment models that make it impossible to survive without good quality clinical and financial information

7. Courts that are promulgating new rules on e-discovery that can prove to be extremely costly, even when the healthcare institution is not a litigant or party in a lawsuit Which of the following is made up of claims data form Medicare claims submitted by acute care hospitals and skilled nursing facilities - MEDPAR List two of the mandated data that must be collected by cancer registries - Demographic information about each case of cancer Information on the industrial or occupational history of the individuals with the cancers Administrative information, including date of diagnosis and source of information Pathological data characterizing the cancer, include site, stage of the neoplasm, incidence, and type of treatment List the four major purposes of collecting secondary data. - quality, performance, patient safety research

population health administrative Aggregate data includes data on groups of people or patients by identifying each patient individually. - False The most prevalant trend in the collection of secondary databases is: - Increased use of automated data entry Review of disease indexes, pathology reports, and radiation therapy reports are part of which function in the cancer registry? - Case Finding Accession registry - List of cases in a cancer registry arranged in the order in which the cases were entered Disease index - List of diseases and conditions of patients treated in a facility, sequenced according to classification code numbers Disease registry - Central collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery Population-based registry - Registry that includes information from more than one facility in a geopolitical region Facility-based registry - Registry that includes only cases for a specific facility

Operation Index - List of the operations and procedures performed in a facility, sequenced according to classification code numbers Physician Index - List of patients by physician, usually arranged by physician code numbers Trauma registry - . List of patients with severe inujuries Within the federal government, the organization most involved in health services research is the _________________________________________. - Agency for Healthcare Research and Quality (AHRQ) Issues related to the efficiency and effectiveness of the healthcare delivery system are addressed by the _____. - Agency for Healthcare Research and Quality SNOMED CT is used in: - Over 50 Countries Nursing terminologies are:____________________________. - Used to direct patient care given by nursing staff From Chapter 4, using the medical record for M2A1, code all the diagnosis for the patient. All diagnoses must be captured for extra credit to be given. Points Possible: 4 - I21. I I25.

F17.

Creates standards to support the exchange of clinical information - Health Level 7 Creates standards for the messaging of digital images - Digital Imaging and Communication in Medicine Creates standards regarding exchanging prescription information and payment information - National Council for Prescription Drug Programs Creates and develops different standards for hospital systems that need communication between bedside instruments and clinical information systems - Institute of Electrical and Electronics Engineers Data elements collected on large populations of individuals and stored in databases are referred to as: - Aggregate data Which of the following is considered the authoritative key in locating a health record? - Master patient index A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit withing a two-week period. What clinical report would be the best source to gather this information? - Vital signs record One of the ten characterictics of quality data within AHIMA's data quality model is Currency. Give an example of the quality data characteristic - Reviewing and updating a patient's medication each encounter with the facility. This would consist of removing medication no longer being taken or adding new medication

Written or spoken permission to proceed with care is classified as: - Expressed consent Which of the following is a function of the discharge summary? - Ensuring the other healthcare providers know what to do next An example of a clinical documentation improvement tool is computer assisted coding (CAC). - True As the EHR technology advances the traditional HIM job roles continue to be more focused on ________________________. - information technology (IT) A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute- care hospital? - UHDDS The ________________________ is a component of ICD-10-CM. - Index of External Causes List the 3 types of clinical documentation data queries discussed in your textbook.

3. further specificity of a diagnosis inconsistency in documentation missing clinical indicators

Which group focuses on accreditation of rehabilitation programs and services? - CARF Which of the following is true regarding the reporting of communicable diseases? - The disease to be reported are established by state law Which one of the following is an example of an external user utilizing secondary data? - Federal Agencies The federal Conditions of Participation apply to which type of healthcare organization? - Organizations that treat Medicare or Medicaid patients Identify the true statement about the health record. - The health record is a primary data source There is no book of SNOMED CT codes and no coding professional assigns a SNOMED CT identifier - True Patient-identifiable data - Information such as age and date of birth Demographic Data - Information such as age and date of birth Aggregate Data - Data extracted from individual patient records and combined to form information about groups of patients

Primary Data - Information about the patient that is documented by the clinicians who provide services to the patient Secondary Data - Data derived from the primary patient record. List the six ANA-recognized nursing terminologies:

6. NANDA International Nursing Interventions Classification (NIC) Nursiing Outcomes Classification (NOC) Clinical Care Classification (CCC) Omaha System International Classification for Nursing Practice (ICNP) Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay? - Progress Notes The Healthcare Cost and Utilization Project is a major intiative of which organization within the federal government? - The agency for Healthcare Research and Quality The legal health record: -

Will de disclosed upon request The physical health record is usually considered the property of which entity? - The organization or provider List at least one challenge in obtaining advance directives in a healthcare setting. - The facility must rely on the patient or family to provide documents Nursing homes do not typically send advance directive with patients Having the advance directive contiously available to entire healthcare team Most lawsuits against healthcare professionals fall within Tort Law. - True Which of the following is a true statement about the legal health record? - It includes PHI stored on any medium Sworn testimony usually collected before a trial - Deposition Professional liability of healthcare providers in the delivery of care to patients - Medical Malpractice Rules and principles that define rights and duties among individuals or organizations - Private Law Written permission to use or disclose patient-identifiable health information - Authorization Spoken or written agreement; may be given by a patient to a healthcare provider to permit treatment -

Express Contract Permission inferred when a patient voluntarily submits to healthcare treatment - Implied Consent Written document directing an individual to furnish documents and other records to a court - Subpoena duces tecum Law that involves the government and its relationship with individuals or organizations - Public Law Who prohibits specific abbreviations from being used in the health record? - Joint Commission AHIMA's record retention guidelines recommend that the master patient index be maintained permanently. - True An individual who brings a lawsuit is called the - Plaintiff A child's health record should be retained for how long? - The age of majority plus the status of limitations A pharmacist who submits Medicaid claims for reimbursement on brand name drugs when less expensive generic drugs were actually dispensed has committed the crime of: - Products Liability In which of the following situations must a covered entity provide an appeal process for

denials to requests from individuals to see their own health information? - When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual An authorization form is still considered valid if the expiration date is included but the expiration date has passed - False List two exceptions to the Business Associate standard under HIPAA. -

1. Disclosures by a covered entity to a health care provider for treatment of the individual. 2. 2. Disclosures to a health plan sponsor, such as an employer, by a group health plan, or by the health insurance issuer or HMO that provides the health insurance benefits or coverage for the group health plan, provided that the group health plan's documents have been amended to limit the disclosures or one of the exceptions at 45 CFR 164.504(f) have been met. On page 5 of your SoftChalk lesson an example was given regarding the notice of privacy of practices, what steps did the facility take to correct the HIPAA violation that was validated by OCR after the investigation? - They revised their intake assessment policy and procedures to specify that the notice will be provided and the clinician will attempt to obtain a signed acknowledgement of receipt of the notice prior to the intake assessment. The acknowledgement form is included in the intake package of forms. All policy changes were brought to the attention of the staff involved in the daughter's care and then disseminated to all staff affected by the policy change Breach is now defined as ___________________________________________________, which was published on January 25, 2013 in the Omnibus Final Rule. - the acquisition, access, use, or disclosure of protected health information in a manner [not permitted by the HIPAA Privacy Rule] which compromises the security or privacy of the protected health information The HIPAA Privacy Rule requires that covered entities limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this? - Minimum necessary

A subpoena differs from a court order because it can be issued by a court clerk or even an attorney - True ARRA and HITECH granted which of the following the ability to bring civil actions in federal district court on behalf of residents believed to have been affected by a HIPAA violation? - State Attorneys General The HIM Professional is responsible for intrepreting the information in the patient's medical records when presenting them in court. - False List three reasons that do not apply to the minimum necessary standard. - Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information. Uses or disclosures made pursuant to an individual's authorization. Uses or disclosures required for compliance with the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Rules. Disclosures to the Department of Health and Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes. Uses or disclosures that are required by other law. Which of the following statements is true: - State law preempts HIPAA A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? - No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient Yes, this is hospital policy for which HIPAA has no control

No.; the records from the previous hospital are not included in the designated record set but should be released anyway Yes: HIPAA only requires that current records be produced for the patient The right to an individual to keep personal health information from being disclosed to anyone is a definition of - Privacy Out of the three (3) key HIPAA Privacy Rule documents does HIPAA state is optional - Consent If an organization or person meets the definition of a BA but does not have an agreement in place with the covered entity they are not subject to HIPAA penalties, only the covered entity will be liable for any HIPAA violations committed by the BA. - False HIPAA standardization requirements include the electronic submission of billing data. - True List four elements a valid authorization must contain - Date of disclosure Name & Address of the entity or person who received the information Brief description of PHI disclosed Breif statement of the purpose of the disclosure or a copy of the individual's written authorization request Under the HIPAA Privacy Rule, which of the following is a covered entity category -