Chapter 2 - Functions, Careers, and Credentials of the HI Professional

Question 1

Authentication

P. 42

Answer 1

Any paper record, the signature of the person who wrote an entry in a health record, the one authorship; in a digital environment, the security process of verifying an individual’s right to access a system or portion of it.

Question 2

Cancer registry

P. 48

Answer 2

A database of all patients diagnosed or treated for a malignant neoplasm (cancer) in a hospital; the hospital registry data are submitted to a state cancer registry, then reported to the Centers for Disease Control and Prevention (CDC).

Question 3

Care Provider

P. 33

Answer 3

A physician, physician’s assistant, dentist, psychologist, nurse practitioner, or midwife; these individuals can diagnose and give orders for diagnostic or therapeutic services.

Question 4

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

(P. 56)

Answer 4

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)

Question 5

Compliance officer

P. 47

Answer 5

A position responsible for monitoring activities that are susceptible to fraud, misuse, or overutilization.

Question 6

Computer-assisted coding (CAC)

P. 45

Answer 6

Computer software that improves the efficiency and quality of coding by assessing documentation and suggesting possible code choices, which are then verified by the coder.

Question 7

Current Procedural Terminology (CPT)

P. 45

Answer 7

The coding system used to convert narrative procedures and services performed in an outpatient setting to numeric form.

Question 8

Delinquent records

P. 42

Answer 8

Records that remain incomplete after 15 or 30 days post-discharge or encounter.

Question 9

Digitized health records

P. 37

Answer 9

Health records kept in an electronic binary format.

Question 10

Document Imaging/scanning

P. 43

Answer 10

The process of digitizing images of documents into computer-readable format.

Question 11

eHealth management

P. 47

Answer 11

The processes and policies that govern the digital collection, maintenance, and archival of data.

Question 12

Electronic health record (EHR)

P. 36

Answer 12

An EHR captures more information than in EMR and is designed to be exchanged and used at any point of care, following the patient. EHRs need to meet Meaningful Use standards.

Question 13

Electronic medical record (EMR)

P. 36

Answer 13

An EMR provides a digital record of the traditional chart used within one location. It does not meet the certification requirements of Meaningful Use because of its limited functionality.

Question 14

Encoder software

P. 45

Answer 14

Technology used to assign ICD for CPT codes based on the coder’s input of terms.

Question 15

Enterprise system

P. 47

Answer 15

A health system, made up of a hospital or Hospital, physicians’ practices, long-term care facilities, outpatient (ambulatory) diagnostic and therapeutic facilities, and the like.

Question 16

Grouper software

P. 45

Answer 16

Technology used to categorize an inpatient admission or an outpatient encounter into a payment classification.

Question 17

Healthcare professional

P. 33

Answer 17

Generally refers to a nurse, medical assistant, or other technician who directly cares for the patient.

Question 18

Information (data) governance

P. 47

Answer 18

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, rules and policies, standards, and metrics that ensure the effective and efficient use of information in enabling an organization to achieve its goals. (Gartner 2013)

Question 19

Information security

P. 48

Answer 19

Administrative, Technical, and physical safeguards put in place to ensure the validity and safety of digital data.

Question 20

International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM)

(P. 45)

Answer 20

A classification system used to convert narrative diagnoses and procedures to numeric form for statistical and reimbursement purposes.

Question 21

International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

(P. 45)

Answer 21

A more specific and scalable classification system for coding of diagnoses that, though approved for use in the United States, has not yet been implemented at the time of this writing.

Question 22

International Classification of Diseases, 9th revision, Procedural Coding System (ICD-10-PCS)

(P. 45)

Answer 22

A more specific and scalable classification system for coding of inpatient procedures that, though approved for use in the United States, has not yet been implemented at the time of this writing.

Question 23

Medical staff bylaws

P. 42

Answer 23

A set of policies that defined the code of conduct, categories of medical staff membership, rules and regulations related to individual departments with which they may be affiliated, and health information-related policies.

Question 24

Medical transcriptionist

P. 34

Answer 24

A healthcare professional who converts the recorded dictation of care providers into typed report form using word processing software.

Question 25

Outguides

P. 35

Answer 25

In a manual record-keeping system, these are cardboard or plastic folders that take the place of health records that have been removed from file. They include the date the files were removed and the locations to which the files were taken.

Question 26

Physician extenders

P. 38

Answer 26

Providers of healthcare who have advanced education and can diagnose as well as give orders includes physicians’ assistants, certified nurse practitioners, certified registered nurse anesthetists, and nurse midwives.

Question 27

Privacy officer

P. 44

Answer 27

A higher-level position dealing with compliance with privacy laws, investigation of potential breaches in confidentiality, and monitoring of the facility’s release of information practices.

Question 28

Quantitative analysis

P. 42

Answer 28

The review of a health record to ensure that required documentation is complete and a part of the record–for instance, a history and physical report or an operative report–but it does not include a review of the quality of the documentation.

Question 29

Recovery audit contractor (RAC)

P. 49

Answer 29

A position resulting from the Medicare Modernization Act of 2003, with a purpose of recovering improper Medicare payments.

Question 30

Revenue cycle managers

P. 47

Answer 30

Those responsible for the functions that lead to an efficient, effective revenue cycle from the time a patient is registered for care until the bill is paid in full.

Question 31

Third-party payer

P. 33

Answer 31

Often referred to as an insurance carrier or company includes Medicare, Medicaid, Blue Cross/Shield, Tricare, CHAMPVA, and any of the private health insurers.

Question 32

Uniform Hospital Discharge Data Set (UHDDS)

P. 46

Answer 32

Define data elements that are required to be collected on all hospital discharges.

Question 33

Unit record

P. 42

Answer 33

System in which all records for one person are filed together under one medical record number in one location.

Question 34

Voice recognition

P. 55

Answer 34

Software that recognizes the dictation of a care provider or other professional and converts the speech to text.