Final Exam HIM 110 Flashcards
The chief financial officer is responsible for the day to day operations of the facility.
False
A patient would visit a primary care physician for an annual exam
True
The governing board has ultimate authority over granting physicians a staff status
True
The professional practice experience completed in your final quarter is 160 hours
True
HIM students are required to have a background check in order to complete the PPE.
True
An RHIA is qualified to serve as an organizational chief privacy officer
True
Critical access hospitals are reimbursed the same way as metropolitan acute care facilities
False
CAHIIM is responsible for the accreditation of academic programs
True
Honorary staff routinely admit patients to the hospital
False
Free standing facilities are owned by a hospital, however, they are just located away from the main facility
False
Ambulatory status patients can stay up to 48 hours prior to discharge
False
An orthopedist would be an example of a secondary care physician
True
HIIM students will take milestone exams every so often during the curriculum after a pre established set of courses has been completed
True
EATALA is also known as the anti-dumping statute
True
TEFRA created the prospective payment system
True
Medicaid eligibility is based on being age 65
False
Accreditation by the joint commission is voluntary
True
The AMA was founded to improve the quality of care of surgery patients
False
The first hospital in the United States was located in Maryland
False
Blue cross was the first plan to guarentee hospital coverage for paid premiums
True
Physicians are required to submit to a background check through the NPDB during the credentialing process
True
COBRA allows former employees the option to seek unemployment payments for being terminated or a reduction in workforce
False
Quality improvement organizations monitor the utilization of services provided to medicare beneficiaries
True
Continuum of care matches the patient’s needs with options for services
True
The Louisiana Tech mascot is a bulldog
True
Provides medications to the nursing units in a hospital setting
Pharmacy
Coordinates the meals for the patients and visitors
Nutrition
Conducts hospital orientation for new hire employees
Human resources
24 hour triage for crisis patients
Emergency Room
Maintains the patient records for all patients receiving treatment in the facility
Health information management
Monitors the appropriateness of care and the outcomes of treatment
Performance improvement
Buys all the equipment utilized in the facility
Purchasing
Repairs the heating and cooling systems when required
Plant operations
Installs all computer software used in your HIIM department
Information systems
Discovered x-rays
Roentgen
Created medicare and medicaid in 1965
Social security act
Established the bill of rights in intermediate care facilities
Nursing home reform act
Overall responsibility for daily operations of the facility
CEO
Developed radium
Pierre and marie curie
Governs the privacy and security of health information
HIPAA
Required that consumers be given informed consent
Patient self determination act
Authorized 1.5 billion in incentive money to get your EHR installed and working
America reinvestment and reconciliation act
Reviews and verifies medical staff application data
Credentials committee
Created to elevate the standard of medical education in the US
American medical association
Monitors hospital acquired infections
Infection control
Evaluates the pre op and post up diagnosis for consistency.
Tissue review
Prepares and distributes patient bills
Business office
Assists with spiritual and religious needs of patients and families
Chaplain
Registers patients into the hospital computer system and obtains general consent to treat
Patient registration
Provides patients with wheelchairs, walkers, and other equipment as needed
Durable medical equipment
The oaks at willow creek has 200 beds and the average length of stay is 2.5 years. Most of the patients are elderly. What type of facility is the oaks?
Intermediate care facility-skilled nursing
Peaceful serenity is a facility that focuses totally on palliative care. What type of facility is peaceful serenity?
Hospice
Broken hips are our specialty. What type of facility are we?
Rehabilitation
The number of beds that facility has set up, equipped and staffed is the:
Bed count
A hospitalist specializes in treatment of patients in this type of care setting?
Acute care
Which of the following patients is considered inpatient for acute care?
Y’vonne who had an overnight stay for treatment of pneumonia and dehydration
Which of the following is an example of a diagnosis?
Tiger’s tonsillitis
All of the following are ancillary services except?
Shana’s emergency room visit
Health information management services include which of the following
Doris assigning codes and abstracting charts
Rehabilitation facilities are least likely to have
Operating room services
Nohemi is a healthcare professional responsible for insuring the timely, accurate and complete collection of cancer data. Nohemi is a?
Certified tumor registrar
Which healthcare professional is responsible for the admission orders to the facility
Both Dr. Kate and Linchi can write admission orders
Medicare is administered by
Center for medicare and medicaid services
which of the following agencies can qualify your facility for “deemed status”?
The joint commission
Which of the following is NOT an AHIMA credential?
CHS
Health information management professionals are responsible for all of the following
Both A and B (coding and billing & release of information)
Eligibility for medicaid is based on
Socioeconomic circumstances
Non profit facilities participate in which of the following activities?
Reinvest in the facility
Chesapeake shores facility provides care only to pediatric patients with cancer? which type of provider is Chesapeake shores?
Speciality
Erin has a serious, sudden onset, acute illness. Erin is going to be treated at the:
Emergency Room
Happy hills center treats patients that are dual diagnosed. what type of facility is happy hills?
Behavioral health
Forever and a day treats patients who are a ventilator dependent. what type of hospital is forever and a day?
Long term acute care
We keep our kars facility has a combination of custodial, living and non-medical care services. What type of facility is we keep our kars?
Assisted living
Keep is short and sweet is a facility with 25 beds or less. our patients stay less than 96 hours. What type of facility are we?
Critical access
Chania attends LaTech, her school colors are
Red and Blue
Patient complains of dizziness and shortness of breath. This is an example of which of the following components of medical decision making?
Subjective
“pupils equal, round, and reactive to light and accommodation” is an example of which of the following components of medical decision making?
Objective
“chest x-ray to rule out CHF” is an example of which of the following components of medical decision making
Plan
Authentication shows:
The person responsible for the data on a form
An electronic health care system that allows physicians to enter their orders through a computer is called:
Computerized provider order entry (CPOE)
SOAP notes are examples of __ data
Clinical
Which of the following data sets is used by acute care facilities?
UHDDS
A major disadvantage to EHR implementation is ____
A and B, but not C
Pre- and post-anesthesia evaluations would be found in a(n) ___ record
Surgical Care
Sam, the HIIM director at Providence Hospital, suspects that some of his employees have been viewing patients that they are not authorized to view. What can Sam do to investigate?
Perform and audit trail
Acronym that describes the medical decision making process. It also refers to the way physicians organize their progress notes
SOAP Format
Analysis of body fluids
Laboratory Tests
Examination of a patient using x-rays
Radiology Tests
Record of all drugs given to a patient during the hospitalization
Medication sheet
The diagnostic, therapeutic, or palliative measures that will be taken to investigate or treat the patient’s condition or disease
Plan of treatment
The physicians directions regarding the patient’s care. also refers to the data collection device on which these elements are captured
Physicians orders
The physician’s documentation of a surgical procedure, usually dictated and transcribed
Operative report
The physician’s record of each visit with the patient
Progress Note
A blank field must be occupied or completed with these
Characters and/or data
Which of the following should be collected during the patient registration process?
An advance directive, to specify the patient’s wishes for his/her care
All of the following is needed for a physicians verbal order EXCEPT:
The name of the payer or guarantor
The best place to find the medications administered for sedation is
Anesthesia record
The physician’s post-operative note must be completed?
Immediately after the procedure
A cardiology consultation is typically requested by:
Attending physician
Which of the following would not be found on an admission record or face sheet?
Nursing progress note
All of the following are elements of the UHDDS EXCEPT:
a. date of birth
b. gender
c. religion
d. discharge
Religion
In acute care, physician’s progress notes are:
a. written at least daily to validate the need for care
b. sometimes collected by physician residents, provided they are countersigned by the attending physician
c. only collected by the attending physician
d. both a and b
Both A and B
A patient’s record contains the following: “mary black is stable and has no complaint of pain. she can be released home. to be seen in my office in two weeks.” this is an example of a:
Discharge Order
Every report and every page/screen in a manual or computerized patient record must include:
a. patient name and date of birth
b. medical record number and date of birth
c. patient name and social security number
d. A & B
A & B
Medicare conditions of participation for hospitals require that a complete history and physical examination be performed no more than __ hours after admission
24
The Joint Commission requires patient records to be completed __ days after a patient is discharged
30
The principle diagnosis would be located in the
Discharge summary
Which filing order saves time in locating a lab report from today?
Reverse chronological order
A document that informs a healthcare provider of a patient’s desire regarding various life sustaining treatment is a:
Living will
To calculate the delinquent record rate divide the total number of delinquent records by the:
Total number of discharges in the period
Addendums cannot be made to the patient’s record by nursing staff.
False
The medical record is the property of the provider.
True
When an entry is made on the wrong chart it is blocked out with a sharpie and written over with the correct information
False
Conditions of admission also serves as the general consent to treatment
True
Surgical consent contains the procedure however it is not necessary to document the risk
False
Required for nurse practitioners who make rounds on patient in the hospital
Countersignatures
Third party vendor used to verify accurate payments to providers
Recovery audit contractor
Pre existing condition that extends the patient’s length of stay
Co-morbid diagnosis
Cholecystectomy performed to remove gallstones
Principal procedure
Condition acquired after hospitalization that lengthens to stay of the patient
Complication
Document that contains the cause of death and filed with the state Department of Health
Death certificate
Condition after study to be chiefly responsible for occasioning the admission to the hospital
Principal diagnosis
A late entry made into the discharge summary by the physician
Addendum
A stakeholder in the health information exchange
Physician
Contains records from different episodes of care over a period of time
Longitudinal record
