1-6 EXAM STUDY GUIDE

Question 1

One of the first medical schools in the United States?

Answer 1

1. College of Philadelphia (1756)
2. King’s College (1768)
3. Harvard University (1783)
4. Dartmouth College (1797)

Question 2

Center of Excellence & what are the requirements?

Answer 2

Center of Excellence (CoE)- is a team, shared facility or entity that provides LEADERSHIP, BEST PRACTICES, RESEARCH, SUPPORT AND/OR TRAINING for a FOCUS AREA.

Requirements

• Any health provider, facility, or organization that PARTICIPATES IN MANAGED CARE PLANS can qualify if it can prove (through data) that it has met certain quality of care goals and/or offered competitively priced services.
• BOARD CERTIFIED PHYSICIANS are a requirement, and CREDENTIALLING CRITERIA MUST BE MET by the facility and any support service, such as laboratory or pharmacy services, and its personnel.
• COMPLIENCE IS MONITORED through PERIODIC RE-EXAMINATIONS of the facility or provider (Managed Care Answer Guide.)

Question 3

CAHIM-& what health informatics includes & does not include?

Answer 3

CAHIM- Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)- an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality Accreditation Standards for Health informatics and Health Information Management (HIM,2014) educational programs (CAHIIM,2014)

Endorsed a health informatics curriculum at the graduate level, consisting of three parts:

1. Information systems
2. Informatic principles
3. Information technology

Health Informatics- the practice of information and knowledge management across clinical healthcare and public health domains

• Focuses on the processes of electronic exchange, digital storage, and the computerized manipulation of health data
• Built on top of this governed information and is focused on the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of clinical and related patient data.
• These tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.

Require technical expertise such as

• project management
• systems management
• programming
• database management

Other positions analyze and use the data created in an integrated computerized healthcare system.

• These include data analysts, reporting specialists, and biostatisticians.

Health Informatics does not include:

• Bioinformatics // Molecular and Cellular Processes
• Imaging Informatics // Tissues and Organs

Question 4

Be able to file a chart in terminal numbering sequence

Answer 4

Terminal Digit filing- breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then the first segment

Question 5

Be able to identify decentralized versus centralized registration.

Answer 5

Decentralized Registration - type of hospital registration in which there are multiple points of patient access, depending on the type of care being sought-inpatient admission, emergency department, outpatient diagnostics, ambulatory surgery, and so on

Centralized Registration – type of hospital registration in which all patients presenting for nay type of care are registered through one central area, regardless of the type of care being sought

Question 6

Master Patient Index & How often patient information is reviewed in the MPI

Answer 6

Master Patient Index- a permanent listing of all patients who have been admitted to or received care in a healthcare facility’ it is the key to locating patient records in a facility and is maintained permanently.

The information is reviewed during the registration process or on a patient’s subsequent visit.

Question 7

What does information governance (data governance department) do?

Answer 7

Information Governance - the specification of decision rights and an accountability framework to ensure appropriate behavior in the valuation, creation, storage, use, archiving, and deletion of information: it includes

the processes
role and policies
standards
metrics
they ensure the effective and efficient use of information enabling an organization achieve its goals

• Ensures that the data collected are accurate
• The processes and policies ensure the validity of the data collection and storage of it
• Technical ability to collect and maintain secure data
• Policies and procedures
• The selection of software systems that results in valid data
• The financial backing to provide for it

This is a joint effort of many departments, but key players include the health information management staff and the information technology (IT) department

Question 8

What is an interface and what does it do?

Answer 8

Interface- a program that allows two or more similar or different devices to communicate and be interoperable.

Custom interfaces and programing are often required when figuring out how to integrate legacy systems.

Question 9

What is included in Protected Health Information (PHI)?

Answer 9

PHI- any piece of data that identifies a patient as well as the clinical data tied to the patient

	Examples Include: 
name
address
date of birth
email
phone number
account numbers associated with the patient
medical record number
social security number
fingerprints
photographs
any piece of information that would automatically identify a patient.

PHI also includes clinical information tied to the patient

Question 10

What is accreditation, what does it typically include and require of the organization?

Answer 10

Accreditation- Voluntary assessment by an accrediting agency that proves a healthcare facility exceeds the minimum requirements set by licensing agencies

It Includes and requires organizations to –

• CONTINUEING EDUCATION OF THE FACILITY STAFF, which is helpful in recruiting new staff and retaining current staff
• ADVOCATE AN OFFICAL PERFORMANCE IMPROVEMENT PLAN // healthcare facilities should have a formal method of identifying areas where improvement is needed and should improve those areas through a multistep systematic approach.
• Depending on the accrediting agency, accreditation may also mean that the facility holds “deemed status” (by virtue of achieving accreditation status, a facility is also in compliance with CoP)
• Each accrediting agency has an APPLICATION PROCESS and ELIGABILITY REQUREMENTS/ because it is voluntary, there is a FEE INVOVED, which varies by agency

Question 11

Downfalls of paper records-

Answer 11

• Are available to only one person at a time
• Are easily misplaced or misfiled
• The security and confidentiality of paper records are questionable- there is no way to safeguard paper records within the facility
• Illegible handwriting is a safety concern, as errors in treatment or medication administration could result- in addition, illegible handwriting leads to wasted time on the part of healthcare professionals who are trying to find out what documentation actually says
• Require a lot of space to house
• Can easily go missing
• Communication with external users of the health information found in a paper record is difficult, takes valuable time to accomplish, and is more expensive
• Expensive to maintain

Question 12

What is a health insurance exchange?

Answer 12

Shopping for and purchasing health insurance that meets a person’s specific needs (for instance a 22-year-old may be different from the coverage a 50-year-old would need) at a cost they can afford.

Question 13

What skills does a data base manager need?

Answer 13

• Understanding computer operating systems
• Server administration
• SQL (a specialized programming language designed for databases)
• Understanding of standards, such as HL-7 and LOINC for health information exchange
• coding standards such as ICD-10
• healthcare terminology systems like SNOMED

Question 14

The difference between an active and inactive record and who decides the parameters for differentiating active and inactive records in an organization?

Answer 14

Active Record- records that are still being actively used in an office

Inactive Record- records become inactive due to the patient’s death or because a record was destroyed because the patient had not been readmitted or received any other type of treatment within a certain period of time.

The length of time a record is considered active is a decision to be made collectively by the HIM director, the medical staff leaders, the quality assessment department, and the administration.

This decision is based on a number of factors, including

• the amount of space available for filing or for a database
• the medical staff’s professional opinion of what is useful in terms of a patient care
• the use of health records for quality assessment and risk management activities
• the period of time within which records may be requested by third party payers and licensing or accrediting bodies

Question 15

What is charting by exception and be able to identify an example of charting by exception.

Answer 15

Charting by exception- documentation based on occurrences that are out of the norm or documentation of complaints voiced by the patient.

Examples include:
• patient stating that his pain is worse than it had been
• the fact that a patient was combative
• the fact that a patient walked to the bathroom without calling for assistance, even though he was to be non-ambulatory

Question 16

Conditions of Participation- What are they- are they treatment based; provider based? Who do they apply to?

Answer 16

Conditions of Participation- are rules governing the eligibility of someone or of an entity to be involved in a particular activity or organization. The conditions vary according to the activity or organization.

• The CoP regulations apply to the entire facility, not just the care, treatment, and resulting health records of that patient population. All records are subject to review, not just Medicare and Medicaid records. Formal complaints must be investigated, resulting in a survey. The survey team reviews the facility for compliance with all the regulations, not just those that pertain to the topic of the complaint.
• Appropriate hospital policies cannot contradict state or federal mandates// in the event that the CoP and state licensure regulations are contradictory, the more stringent of the two must be followed.
• the governing body (including that of the medical staff and chief executive officer)
• care of patients
• emergency services
• patient’s rights
• privacy and safety
• confidentiality of patient records
• restraint or seclusion
• death reporting requirements
• quality assessment and performance improvement (including scope, data, activities, and projects)
• composition of the medical staff
• medical staff organization and accountability
• medical staff by-laws
• nursing services (including organization, staffing, and delivery of care
• medical record services (including organization and staffing, form and retention of the medical record, and content of medical records)
• utilization review (including applicability, composition of the utilization review committee, scope and frequency of review and admissions, continued stay and extended stay review)
• discharge planning (including identification of patients in need of discharge planning, discharge planning evaluation, discharge plan, transfer or referral and reassessment)
• the organization, staffing, and delivery of services for medicine, emergency services, outpatient services, nuclear medicine, and respiratory services
• apply to all facilities that diagnose or treat Medicare and Medicaid patients and, in turn, expect payment from either.

Question 17

What is a pathologist, what do they do?

Answer 17

Pathologist- a physician whose specialty is dealing with the analysis of a tissue sample to establish a diagnosis.

The pathologist is responsible for providing documentation such as a description of the specimens received and examined and the pathological diagnosis for each.

Pathologist also perform autopsies and are responsible for documenting a summary of the events leading to the patient’s death, the gross and microscopic findings, and the diagnoses as well as cause of death.

Question 18

What is a physician extended- be able to identify examples?

Answer 18

Physician Extender- providers of healthcare who have advanced education and can diagnose as well as give orders- Include:

• physician’s assistant
• certified registered nurse anesthetist
• nurse midwives

All of whom work under the supervision of a medical doctor (MD) or doctor of osteopathy (DO)

Question 19

Under ACA what benefits are covered in full? (Elaborate)

Answer 19

• Preventative care
• inpatient and outpatient hospital care
• prescription drug coverage
• pregnancy and childbirth
• mental health services

Question 20

What is a wired health system and what must it have?

Answer 20

Wired Health System-information being shared safely in an integrated, wired system. In the health care industry this refers to sharing

•	hospital data
•	health plan data
•	ambulatory her data
•	community providers data.
Through 
•	health information exchange
•	secure communication
•	Analytics
•	Population management
•	patient engagement 
•	patient access

All hardware, software, and networks need to be maintained to keep them operating

Upkeep consists of cleaning, fixing, updating software, trouble shooting, and continually testing for performance

Question 21

If a patient wants to see her or his record, what does he or she need to do?

Answer 21

The following information must be reviewed, and documented that it was reviewed, before protected health information is disclosed:

• A patient or other designated/authorized individual requesting disclosure of the medical information has completed a Release of Information form. The Release of Information form must be completed or updated by the patient or other designated/authorized individual.
• The Release of Information should be reviewed to verify the signature (scanned or electronically signed) of the patient or legally authorized representative. Verbal or telephone authorization are not accepted.
• The date on the authorization must be no more than three-years-old or must not have expired.
• A healthcare provider can verbally disclose or fax medical information to a physician, hospital, or medical facility upon receipt of the required authorization or a statement in the record documenting that the patient is unable to authorize release of their information in an emergency.
• Medical information may be released and/or disclosed with another healthcare provider/healthcare organization without a signed authorization if the healthcare providers have a known patient in common or for continuity of care.