Ch. 25 Health Information And Information Management

Question 1

Current Procedural Terminology, 4th Edition (CPT-4)

Answer 1

Codes are used to code procedures for outpatient encounters and ancillary services such as radiology and laboratory.
(Exams)

Question 2

Electronic Health Record (EHR)

Answer 2

Electronic record of patient health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory date and radiology reports.

Question 3

Health Information Management (HIM)

Answer 3

Allied health profession, built around the management of the healthcare record in it physical form, as well as the management of date and information within the medical record.

Question 4

Medical Necessity

Answer 4

Healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease l, or its symptoms

Question 5

Master Patient Index (MPI)

Answer 5

Is an electronic file that identifies all patients who have been admitted or treated at a healthcare organization.

Question 6

Demographic Data , included in the MPI

Answer 6

Data that contains identifying information about the patient.
Examples; internal patient identification, persons name, date of birth, gender, race, ethnicity, address, phone #, SSN, facility identification, Universal patient identifier

• this information should be verified during registration for each visit and updated as needed.

Question 7

Visit Level

Answer 7

Information that changes with each encounter

Question 8

What are the two levels of data elements that should be included in a MPI? (Master Patient Index)

Answer 8

Demographic & Visit-Level

Question 9

What is Health insurance portability and accountability act of ___

Answer 9

1996

Question 10

Components of the History & Physical Illness: Chief Complaint (CC)

Answer 10

• Statement by the patient of signs and symptoms that caused them to seek medical care
• Example; Difficult Breathing

Question 11

Components of the History & Physical Illness:
History of present illness (HPI)

Answer 11

A chronological description of the development of the patients illness
Ex: two episodes of shaking chills lasting a few minutes, temp of 96. Second episode at 8. No fever

Question 12

History and physical

Answer 12

Provided a detailed information of why the patient is being seen for the current episode of care, there medical history, physical examination, a clinicians impression or diagnosis, and a plan of care.

Question 13

Past medical history (PMH)

Answer 13

Summary of patients past illnesses, surgeries, pregnancies, allergies, & current medication

Question 14

Family History

Answer 14

Illness and disease among past or current family members

Question 15

Ancillary Reports

Answer 15

Results of all ancillary studies are a part of patients health record. These studies include imaging studies, laboratory work, pathology reports, and any monitoring or tracing of body functions.

( this is us )

Question 16

Physician Orders

Answer 16

All treatments and procedures, or medications to be administered to a patient require a physician order for the purpose of diagnosing a patients illness or symptoms.

Question 17

In January of _____ , requirements for an appropriate use criteria (AUC) consulting prior to any advanced diagnostic imaging order was enacted for Medicare patients and AUC consults must be documented for reimbursement.

Answer 17

2020

Question 18

Revenue Cycle

Answer 18

Process of patient financial and health information moving into, through, and out of the healthcare organization, culminating with the healthcare organization receiving reimbursement for services provided.

Question 19

Medial necessity is the part of the _____ . Within the revenue cycle

Answer 19

Front-end process, if a patient presents for an exam and the physicians order is lacking a diagnosis or a diagnosis that does not meet medical necessity the provider should should be contacted immediately.

Question 20

The middle process pf the revenue cycle includes the process of clinical coding.

What is ICD-10-CM?

Answer 20

Code used for diagnostic coding.
- the diagnosis, symptom, or reason for visit is documented by the physician is translated into ICD-10-CM codes.

Question 21

CPT-4?

Answer 21

Codes are used to code procedures for outpatient encounters and ancillary services such as radiology and laboratory.
- Exams

Question 22

_____ are designed to manage healthcare data.

Answer 22

• Health information systems
• this allows for sharing or protected health information across the healthcare enterprise

Question 23

PACS

Answer 23

• Picture archiving and communication system
• refers to a networked group of computers, servers, and achieves to mange digital images.

Question 24

Define health informatics?

Answer 24

The interdisciplinary field that works to improve health and healthcare

Question 25

Which organization accredits hospitals and other health care institutions in the United States?

Answer 25

The joint review committee

Question 26

The chief complaint, included in a patient history is a statement made by the ?

Answer 26

Patient

Question 27

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) legislation affects radiology & other hospital departments by its focus on ?

Answer 27

Patient record confidentiality

Question 28

When a physician orders a diagnostic exam, what must be included on the order?

Answer 28

The diagnosis or symptoms

Question 29

What is used to assign codes for the diagnostic exam?

Answer 29

CPT-4

Question 30

Which part of the HIPAA privacy rule requires workforce training to ensure patient privacy?

Answer 30

Administrative Requirements

Question 31

Which system is designed to manage imaging orders?

Answer 31

RIS

Question 32

Which technology is used to identify and classify cancer?

Answer 32

Artificial Intelligence

Question 33

What is typically documented in a History & Physical?

Answer 33

Chief Complaint
History of present illness
Review of systems
Past medical history
Family history
Social history
Physical examination
Impression or diagnosis and treatment plan