Final Study Guide Flashcards
Services that include preventative and acute care and are provided by a general practitioner are known as what
Primary services
Healthcare information can be released only with patients ______________ or court order.
Written authorization
The assignment of numbers to diagnoses,services, and procedures based on patient record documentation is known as what
Coding
The insurance claims organization that offers certification as a certified medical billing specialist is the what
MAB
Each professional association has a ____________ which are judgments about what is right or wrong.
Code of ethics
A hospital that admits patients who are diagnosed with trauma or disease and need to learn how to function again is a what
Rehabilitation hospitals
The goal of hospice is _____________ instead of curative care.
Palliative care
The table of contents of a problem oriented record is known as the
Problem list
A note that is added to the record after an original note has been documented is called
Addendum
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
Signature legend
When a patient is discharged, the ____________ is responsible for documenting the discharge summary.
Attending physician
AHIMA defines the _____________ as a computerized record of health information and associated processes
EHR
Reports produced by the Laboratory, radiology, and nuclear medicine department are known as
Ancillary reports
The gross findings, organs (examine visually or palpated) and techniques associated with the performance of surgery are documented in the
Operative report
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
Encounter
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.
Principal diagnosis
The use of a single location for all file storage is known as
Centralized filing system
Records are filed an exact chronic optical order according to a patient identification number with the
Straight numeric filing system
Because of the safety hazard to staff and possible damage in the event of flooding record should not be stored on the
Floor
To protect patient information from theft only __________ staff should have access to the file area.
Authorized
The HIPPA privacy rule establish standards for how ___________ should be controlled.
Protected health information
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
Clearinghouse
The _____________ was developed during the later part of the 16th century and is considered the first classification system
London bills of mortality
CPT is the abbreviation for
Current procedural terminology
A __________ is a vocabulary of clinical in medical terms
Medical nomenclature
A ________ (or coding system) organizes a medical nomenclature according to similar conditions diseases procedures and services
Classification system
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
CMS-1450
The ___________ is a universal claim form developed by CMS and used by providers of services to build professional fees to healthcare carriers
CMS-1500
__________ 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.
National provider identifier
___________ are compiled for events which include birth death fetal death marriages and divorces
Vital statistics
The CPT coding book is published annually by the AMA to assign what types of codes?
Procedures and services
The assembly and analysis of discharge patient records is called
Incomplete record processing
Health information management services include which of the following
Putting in abstracting patient registration
Which of the following is a function of the admitting department
Register inpatients and outpatients
Which is a characteristic of a governing board
It’s membership is represented by professionals from the community
To professional associations that offer certification and coding are
AAPC and AHIMA
What is the benefit of joining a professional association
That working with professional members
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
Cancer registrar
Which professional is required to pass a licensing examination in all states and the District of Columbia
Nursing home administrator
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
Physician
A patient who has a serious sudden or acute illness or injury would be treated in a
Acute care facility
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
Hospice
Hospitals that provide specialized long-term acute care such as chemotherapy wound care or injury rehabilitation are known as what
Subacute hospitals
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
Closed panel HMO
Which is not a component of the problem oriented record
Table of contents
The judgment opinion or evaluation made by a healthcare professional is documented in which section of an SOAP progress note
Assessment
When the order of the record reads like a diary of the forms are said to be filed in a
Chronological date order
What type of microfilm storage uses mylar film
Microfiche
Which is a disadvantage of the problem oriented record
Filing of forms is time consuming
In the period 1970 through 1980 the term ___________ was used to describe the early medical record automation attempts
Computerized medical records
Records that are part paper and part electronic are known as
Hybrid records
A group of characters form a
Field
A system that collects and monitors patient physiological data and record the information is known as a
Patient monitoring system
Raw facts that are not interpreted or processed such as numbers letters images symbols and sounds are referred to as
Data
Which of the following is not an administrative application of an electronic record system
Pathology reports
And electronic or paper medical records maintained and updated by individuals for their own personal use is known as a
Personal health record
A chronological description of the patients present condition from the time of onset to present is a
History of the present illness
Preprinted orders that are placed on the patient’s record upon admission are called
Routine orders
The completion of the history and physical examination is the responsibility of the
Attending physician
What is your report is also known as I
Pathology report
A record documenting blood chemistry bowl gases and blood type is a
Laboratory report
All patient information obtained through treatment and care of the patient is called
Clinical data
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
Family history
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
Advanced directive
A document that provides a summary of a patient’s hospitalization is a
Clinical resume
The first list a diagnosis and procedure is
Clinical data
Healthcare facilities maintain a Master patient Index
Permanently
Which is the study of types of patients treated by a facility
Case mix analysis
Registers and registries contain information about a disease or event and or maintained by
Federal and state governmental agencies individual healthcare facilities and private organizations
Disease procedure and physician indexes contain data abstracted from
Patient records
Which is an example of an MPI’s continuity of care
Attending physician contact the health information department to request old records on a re-admitted patient
And admission discharge transfer system interfaces with an automated MPI to
Input patient registration information
The Master patient Index links the patient’s medical record number with
Common identification data elements
A standard method for collecting and reporting individual elements is called a data
Set
Safeguards that are implemented to ensure the facilities equipment and patient information are safe from damage theft or unauthorized access are known as
Safeguard security
The American Medical Association publishes this coding system that classifies procedures and services performed by physicians
CPT
The organization that reviews and revises ICD is
WHO
Retail pharmacies use ________ to report pharmacy transactions
NDC
