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Health Information Management > Final Study Guide > Flashcards

Final Study Guide Flashcards

1
Q

Services that include preventative and acute care and are provided by a general practitioner are known as what

A

Primary services

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2
Q

Healthcare information can be released only with patients ______________ or court order.

A

Written authorization

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3
Q

The assignment of numbers to diagnoses,services, and procedures based on patient record documentation is known as what

A

Coding

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4
Q

The insurance claims organization that offers certification as a certified medical billing specialist is the what

A

MAB

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5
Q

Each professional association has a ____________ which are judgments about what is right or wrong.

A

Code of ethics

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6
Q

A hospital that admits patients who are diagnosed with trauma or disease and need to learn how to function again is a what

A

Rehabilitation hospitals

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7
Q

The goal of hospice is _____________ instead of curative care.

A

Palliative care

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8
Q

The table of contents of a problem oriented record is known as the

A

Problem list

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9
Q

A note that is added to the record after an original note has been documented is called

A

Addendum

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10
Q

A document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries is known as a

A

Signature legend

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11
Q

When a patient is discharged, the ____________ is responsible for documenting the discharge summary.

A

Attending physician

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12
Q

AHIMA defines the _____________ as a computerized record of health information and associated processes

A

EHR

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13
Q

Reports produced by the Laboratory, radiology, and nuclear medicine department are known as

A

Ancillary reports

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14
Q

The gross findings, organs (examine visually or palpated) and techniques associated with the performance of surgery are documented in the

A

Operative report

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15
Q

A professional contract between a patient in a provider who deliver services or is professionally responsible for services delivered to a patient is known as a

A

Encounter

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16
Q

A practitioner must determine the _________ or the reason the patient sought treatment when more than one active problem or diagnosis is identified for an encounter.

A

Principal diagnosis

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17
Q

The use of a single location for all file storage is known as

A

Centralized filing system

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18
Q

Records are filed an exact chronic optical order according to a patient identification number with the

A

Straight numeric filing system

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19
Q

Because of the safety hazard to staff and possible damage in the event of flooding record should not be stored on the

A

Floor

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20
Q

To protect patient information from theft only __________ staff should have access to the file area.

A

Authorized

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21
Q

The HIPPA privacy rule establish standards for how ___________ should be controlled.

A

Protected health information

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22
Q

A public or private entity that processes or facilitates the processing of health information received from another entity from a non-standard format into a standard format is known as a

A

Clearinghouse

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23
Q

The _____________ was developed during the later part of the 16th century and is considered the first classification system

A

London bills of mortality

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24
Q

CPT is the abbreviation for

A

Current procedural terminology

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25
Q

A __________ is a vocabulary of clinical in medical terms

A

Medical nomenclature

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26
Q

A ________ (or coding system) organizes a medical nomenclature according to similar conditions diseases procedures and services

A

Classification system

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27
Q

A ___________ (or UB-04) is a standard institutional claim form submitted by hospitals skilled nursing facilities and other institutional based providers to payers to obtain reimbursement for healthcare services provided to the patients

A

CMS-1450

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28
Q

The ___________ is a universal claim form developed by CMS and used by providers of services to build professional fees to healthcare carriers

A

CMS-1500

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29
Q

__________ is a unique identifier required by hospitals doctors nursing homes and other healthcare providers. It consists of 10 numeric digits that are required by HIPPA for filing electronic claims.

A

National provider identifier

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30
Q

___________ are compiled for events which include birth death fetal death marriages and divorces

A

Vital statistics

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31
Q

The CPT coding book is published annually by the AMA to assign what types of codes?

A

Procedures and services

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32
Q

The assembly and analysis of discharge patient records is called

A

Incomplete record processing

33
Q

Health information management services include which of the following

A

Putting in abstracting patient registration

34
Q

Which of the following is a function of the admitting department

A

Register inpatients and outpatients

35
Q

Which is a characteristic of a governing board

A

It’s membership is represented by professionals from the community

36
Q

To professional associations that offer certification and coding are

A

AAPC and AHIMA

37
Q

What is the benefit of joining a professional association

A

That working with professional members

38
Q

A healthcare professional who has the primary responsibility of ensuring the timely accurate and complete collection and maintenance of cancer data is known as a

A

Cancer registrar

39
Q

Which professional is required to pass a licensing examination in all states and the District of Columbia

A

Nursing home administrator

40
Q

A _________ is either on site or available for 24 hour continuous duty to handle the inmates medical problems that may occur after normal working hours

A

Physician

41
Q

A patient who has a serious sudden or acute illness or injury would be treated in a

A

Acute care facility

42
Q

The type of care that provides comprehensive medical and supportive social emotionally and spiritual care to terminally ill patients and their families is known as what

A

Hospice

43
Q

Hospitals that provide specialized long-term acute care such as chemotherapy wound care or injury rehabilitation are known as what

A

Subacute hospitals

44
Q

What type of HMO that includes group in stock models which provide services at HMO own health centers or by physicians who belong to a specialty formed medical group is a what

A

Closed panel HMO

45
Q

Which is not a component of the problem oriented record

A

Table of contents

46
Q

The judgment opinion or evaluation made by a healthcare professional is documented in which section of an SOAP progress note

A

Assessment

47
Q

When the order of the record reads like a diary of the forms are said to be filed in a

A

Chronological date order

48
Q

What type of microfilm storage uses mylar film

A

Microfiche

49
Q

Which is a disadvantage of the problem oriented record

A

Filing of forms is time consuming

50
Q

In the period 1970 through 1980 the term ___________ was used to describe the early medical record automation attempts

A

Computerized medical records

51
Q

Records that are part paper and part electronic are known as

A

Hybrid records

52
Q

A group of characters form a

A

Field

53
Q

A system that collects and monitors patient physiological data and record the information is known as a

A

Patient monitoring system

54
Q

Raw facts that are not interpreted or processed such as numbers letters images symbols and sounds are referred to as

A

Data

55
Q

Which of the following is not an administrative application of an electronic record system

A

Pathology reports

56
Q

And electronic or paper medical records maintained and updated by individuals for their own personal use is known as a

A

Personal health record

57
Q

A chronological description of the patients present condition from the time of onset to present is a

A

History of the present illness

58
Q

Preprinted orders that are placed on the patient’s record upon admission are called

A

Routine orders

59
Q

The completion of the history and physical examination is the responsibility of the

A

Attending physician

60
Q

What is your report is also known as I

A

Pathology report

61
Q

A record documenting blood chemistry bowl gases and blood type is a

A

Laboratory report

62
Q

All patient information obtained through treatment and care of the patient is called

A

Clinical data

63
Q

A review of the medical events in the patient’s family including disease which may be hereditary or present the rest of the patient is part of the

A

Family history

64
Q

Written instruction given by a patient to a healthcare provider outlining the patients preference for care before the need for treatment is known as a

A

Advanced directive

65
Q

A document that provides a summary of a patient’s hospitalization is a

A

Clinical resume

66
Q

The first list a diagnosis and procedure is

A

Clinical data

67
Q

Healthcare facilities maintain a Master patient Index

A

Permanently

68
Q

Which is the study of types of patients treated by a facility

A

Case mix analysis

69
Q

Registers and registries contain information about a disease or event and or maintained by

A

Federal and state governmental agencies individual healthcare facilities and private organizations

70
Q

Disease procedure and physician indexes contain data abstracted from

A

Patient records

71
Q

Which is an example of an MPI’s continuity of care

A

Attending physician contact the health information department to request old records on a re-admitted patient

72
Q

And admission discharge transfer system interfaces with an automated MPI to

A

Input patient registration information

73
Q

The Master patient Index links the patient’s medical record number with

A

Common identification data elements

74
Q

A standard method for collecting and reporting individual elements is called a data

A

Set

75
Q

Safeguards that are implemented to ensure the facilities equipment and patient information are safe from damage theft or unauthorized access are known as

A

Safeguard security

76
Q

The American Medical Association publishes this coding system that classifies procedures and services performed by physicians

A

CPT

77
Q

The organization that reviews and revises ICD is

A

WHO

78
Q

Retail pharmacies use ________ to report pharmacy transactions

A

NDC

Health Information Management (1 decks)

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