Chapter 25

Question 1

health information management

Answer 1

the allied health profession built around the management of the healthcare record in its physical form, as well as the management of data and information within the medical record

Question 2

health informatics

Answer 2

the interdisciplinary field that studies and pursues the effective uses of biomedical data, information and knowledge for scientific inquiry

Question 3

HIPAA

Answer 3

Health insurance portability and accountability act

Question 4

medical necessity

Answer 4

healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease

Question 5

revenue cycle

Answer 5

process of patient financial and health information moving into, through, and out of the healthcare organization

Question 6

clinical informatics is also referred to as:

Answer 6

applied clinical informatics
operational informatics

Question 7

which patients are listed individually in the MPI?

Answer 7

all patients registered to receive care as inpatient/outpatient

Question 8

what information is included in a visit level data in an MPI?

Answer 8

account/visit number
admission date
discharge date
encounter/service type
location
primary physician
patient disposition

Question 9

what information does the history and physical provide?

Answer 9

why patient is being seen, medical history, physical exam, physicians impression/diagnosis, plan of care

Question 10

what is the specific timeframe completion of the history and physical for inpatients?

Answer 10

24 hours

Question 11

what is an operative report?

Answer 11

descriptions of the details of a surgical procedure

Question 12

ancillary studies include what?

Answer 12

imaging studies, labs, pathology reports, monitoring/tracings

Question 13

what can physicians use to send orders directly to an ancillary department?

Answer 13

computerized physician order entry (CPOE)

Question 14

what is the code set used for diagnostic coding? example?

Answer 14

ICD-10-CM
international classification of diseases, 10th edition, clinical modification
R05-Cough; R06.02- SOB

Question 15

what is used to code procedures for outpatient encounters and ancillary services? example?

Answer 15

CPT-4
current procedural terminology 4th edition
71046 - radiologic exam, chest; 2 views

Question 16

what supports the need for timely access to health information, and the EHR remains secure and patient information remains private?

Answer 16

HIPAA

Question 17

what allows for the sharing of information between disparate information systems?

Answer 17

interoperability

Question 18

what does HIS stand for and what does it typically include?

Answer 18

health information systems
manage healthcare data

Question 19

what does RIS stand for and what is it responsible for?

Answer 19

radiology information system
management of imaging orders, scheduling, billing, tracking, reporting

Question 20

what does PACS stand for?

Answer 20

picture archiving and communication system