Final Study Guide

Question 1

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

Answer 1

Primary services

Question 2

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

Answer 2

Written authorization

Question 3

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

Answer 3

Coding

Question 4

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

Answer 4

MAB

Question 5

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

Answer 5

Code of ethics

Question 6

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

Answer 6

Rehabilitation hospitals

Question 7

The goal of hospice is _____________ instead of curative care.

Answer 7

Palliative care

Question 8

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

Answer 8

Problem list

Question 9

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

Answer 9

Addendum

Question 10

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

Answer 10

Signature legend

Question 11

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

Answer 11

Attending physician

Question 12

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

Answer 12

EHR

Question 13

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

Answer 13

Ancillary reports

Question 14

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

Answer 14

Operative report

Question 15

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

Answer 15

Encounter

Question 16

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.

Answer 16

Principal diagnosis

Question 17

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

Answer 17

Centralized filing system

Question 18

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

Answer 18

Straight numeric filing system

Question 19

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

Answer 19

Floor

Question 20

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

Answer 20

Authorized

Question 21

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

Answer 21

Protected health information

Question 22

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

Answer 22

Clearinghouse

Question 23

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

Answer 23

London bills of mortality

Question 24

CPT is the abbreviation for

Answer 24

Current procedural terminology

Question 25

A __________ is a vocabulary of clinical in medical terms

Answer 25

Medical nomenclature

Question 26

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

Answer 26

Classification system

Question 27

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

Answer 27

CMS-1450

Question 28

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

Answer 28

CMS-1500

Question 29

__________ 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.

Answer 29

National provider identifier

Question 30

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

Answer 30

Vital statistics

Question 31

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

Answer 31

Procedures and services

Question 32

The assembly and analysis of discharge patient records is called

Answer 32

Incomplete record processing

Question 33

Health information management services include which of the following

Answer 33

Putting in abstracting patient registration

Question 34

Which of the following is a function of the admitting department

Answer 34

Register inpatients and outpatients

Question 35

Which is a characteristic of a governing board

Answer 35

It's membership is represented by professionals from the community

Question 36

To professional associations that offer certification and coding are

Answer 36

AAPC and AHIMA

Question 37

What is the benefit of joining a professional association

Answer 37

That working with professional members

Question 38

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

Answer 38

Cancer registrar

Question 39

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

Answer 39

Nursing home administrator

Question 40

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

Answer 40

Physician

Question 41

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

Answer 41

Acute care facility

Question 42

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

Answer 42

Hospice

Question 43

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

Answer 43

Subacute hospitals

Question 44

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

Answer 44

Closed panel HMO

Question 45

Which is not a component of the problem oriented record

Answer 45

Table of contents

Question 46

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

Answer 46

Assessment

Question 47

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

Answer 47

Chronological date order

Question 48

What type of microfilm storage uses mylar film

Answer 48

Microfiche

Question 49

Which is a disadvantage of the problem oriented record

Answer 49

Filing of forms is time consuming

Question 50

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

Answer 50

Computerized medical records

Question 51

Records that are part paper and part electronic are known as

Answer 51

Hybrid records

Question 52

A group of characters form a

Answer 52

Field

Question 53

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

Answer 53

Patient monitoring system

Question 54

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

Answer 54

Data

Question 55

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

Answer 55

Pathology reports

Question 56

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

Answer 56

Personal health record

Question 57

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

Answer 57

History of the present illness

Question 58

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

Answer 58

Routine orders

Question 59

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

Answer 59

Attending physician

Question 60

What is your report is also known as I

Answer 60

Pathology report

Question 61

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

Answer 61

Laboratory report

Question 62

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

Answer 62

Clinical data

Question 63

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

Answer 63

Family history

Question 64

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

Answer 64

Advanced directive

Question 65

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

Answer 65

Clinical resume

Question 66

The first list a diagnosis and procedure is

Answer 66

Clinical data

Question 67

Healthcare facilities maintain a Master patient Index

Answer 67

Permanently

Question 68

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

Answer 68

Case mix analysis

Question 69

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

Answer 69

Federal and state governmental agencies individual healthcare facilities and private organizations

Question 70

Disease procedure and physician indexes contain data abstracted from

Answer 70

Patient records

Question 71

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

Answer 71

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

Question 72

And admission discharge transfer system interfaces with an automated MPI to

Answer 72

Input patient registration information

Question 73

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

Answer 73

Common identification data elements

Question 74

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

Answer 74

Set

Question 75

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

Answer 75

Safeguard security

Question 76

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

Answer 76

CPT

Question 77

The organization that reviews and revises ICD is

Answer 77

WHO

Question 78

Retail pharmacies use ________ to report pharmacy transactions

Answer 78

NDC