Mid Term EXAM Flashcards
Bloodwork results from the laboratory information systems, mammogram reports and films from radiology information systems, a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient’s EHR. These different information systems that feed information into the EHR are called ________.
A. Interoperability
B. Clinical decision support system
C. Continuity of care record
D. Source systems
Source Systems
The identification of who documented a note in the heath record is known as
A. Authentication
B. Authorship
C. Patient identification
D. Validation
Authorship
What is the benefit of front-end speech recognition
A. The document is available immediately upon completion of the dictation.
B. It does not impact the physician
C. It eliminates data quality issues
D. It speeds availability of the document
It speeds availability of the document
The healthcare facility has decided to adopt a tool that helps with multidisciplinary care planning. Select the tool that meets this criteria.
A. Clinical practice guidelines
B. Electronic health record
C. Clinical Pathways
D. Clinical provider order entry
Clinical Pathways
Amanda uploads her diet and fitness log from her smartwatch to her doctors office EHR. She also adds information about her previous medical history. What type of system is Amanda using?
A. CPOE
B. CCR
C. PHR
D. CDSS
PHR
The purpose of meaningful use is:
A. Improve healthcare quality, safety, and efficiency
B. Support the exchange of data across heathcare entities
C. Aid in coding and billing
D. Provide documentation standards
Improve healthcare quality, safety, and efficiency
Contemporary HIM practices focus on ________.
A. Data and information
B. Processing health records
C. Processes
D. Workflow
Data and information
A process used to identify what is likely to happen the future is known as _______.
A. Predictive modeling
B. Inferential statistics
C. Descriptive statistics
D. Data modeling
Predictive modeling
The combination of paper and electronic health records is called _________.
A. Hybrid
B. Half and half
C. Combo
D. Healthy
Hybrid
A home health agency has intalled a _______ where they store forms, policies, other resources for employees.
A. Firewall
B. Intranet
C. Extranet
D. Internet
Intranet
One of the first significat historical milestones in the development of systems is:
A. Interoperability
B. Clinical decision support
C. Computer-based record
D. CPOE
CPOE
An EHR that has been evaluated by a member of the office of the National Coordinator-Authorized Certification Bodies (ONC-ACBs) and verified that it meets the criteria set by the Meaningful Use incentive programs.
Certified EHR technology
Preprogrammed clinical decision support designed to assist the user through making an entry appropriately.
Computerized provider order entry(CPOE)
Also called narrative data, can be entered in a free text format by the user, usually by typing.
Unstructured data
A core data set, which is the most relevant administrative, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters.
Continuity of care record (CCR)
A permanent record of significant information listed in chronological order and maintained across time, ideally from birth to death.
Longitudinal health record
Edit checks identify ________.
A. Current Data
B. Illogical data
C. Accurate data
D. Outdated data
Illogical data
Which of the following is an example of information?
A. The number of denials has decreased by 45 percent over the past year.
B. HIM professionals roles have changed
C. Heathcare facilities utilize tablets and cellular phones
D. Mary was admitted to the hospital with a myocardial infarction.
The number of denials has decreased by 45 percent over the past year
Which of the following is a use of secondary data sources?
A. Research
B. Determining diagnosis
C. Consulting with another physician for patient care
D. Determining what test to order
Research
The point of care documentation is improved because __________.
A. It uses wireless technology
B. It uses evidence-based medicine
C. It is created as soon as the care is provided
D. It uses clinical practice guidelines
It is created as soon as the care is provided.
The fact that there is missing data would be identified in _________.
A. Data analysis
B. Authorship
C. Data cleansing
D. Data mapping
Data cleansing
A tools designed to coordinate multidisciplinary care planning for specific diagnosis and treatments.
Clinical pathways
Healthcare services based on clinical methods that have been thoroughly tested through controlled peer-reviewed biomedical studies.
Evidence-based medicine
A tool that provides a detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society.
Clinical practice guidelines
A discipline that emphasizes safety in healthcare through the prevention, reduction, reporting, and analysis of medical errors that often lead to adverse effects.
Patient safety
A set of the statistical techniques used to describe data such as means, frequency distributions, and standard deviations.
Descriptive statistics
Is set of statistical techniques that allows researchers to make generalizations about a population’s characteristics on the basis of a sample’s characteristics, such as HIM professionals continuing education efforts
Inferential statistics
To make conclusions about a population, use ______.
A. Descriptive statistics
B. Inferential statistics
C. Data modeling
D. Predictive modeling
Inferential statistics
Which of the following allows the healthcare provider to spend more time with patients instead of completing documentation tasks?
A. DQA
B. DQM
C. BESR
D. FESR
BESR
The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships that would be unnoticed without the analysis.
Data mining
A process of identifying patterns that can be used to predict the odds of a particular outcome based on observed data.
Predictive modeling
Raw facts and figures
Data
The science of examining raw data with the purpose of drawing conclusions about that information. This information then can be used to make business decisions concerning which services to provide and how to improve patient care.
Data analytics
The exchange of health information electronically between providers and others with the same level of interoperability.
Health information exchange (HIE)
A scientific discipline that is concerned with the cognitive, information-processing, and communication tasks of heathcare practice, education, and research, including the information science and technology to support these tasks.
Health informatics
What is used by the HIM professional as a method to detect whether elements of the patient’s health care record are missing?
A. Data cleansing
B. Qualitative analysis
C. Quantitative analysis
D. Data Mapping
Quantitative analysis
Choose one of the following statements to defend the need for version control.
A. Version control is required to manage screen design
B. Version control is required to manage documents
C. Version control is required to overcome issues related to copying and pasting
D. Version control is required to determine edits that have been failed
Version control is required to manage documents.
What component of an EHR provides communication between clinical and administrative staff members, offers access to various results reporting from lab and radiology, and to even communicate with patients?
A. Registration - admission, discharge, transfer (R-ADT)
B. Clinical decision support
C. Clinical messaging
D. Document management system
Clinical messaging
The first information systems used in healthcare were _________.
A. Mainframes
B. EHR
C. Dashboard
D. Financial applications
Financial applications
Identify the data analytics tool that includes frequency distributions.
A. Predictive modeling
B. Descriptive statistics
C. Data mining
D. Inferential statistics
Descriptive statistics
Edit checks ensure that __________.
A. The health record is complete
B. The data entered is accurate for that patient
C. The data entered is at the level appropriate for the situation
D. The format is appropriate for the data element
The format is appropriate for the data element.
A screen that allows for both free text and structured data entry is an example of ________.
A. Secondary data source
B. Direct data entry
C. Template-based data entry
Template-based data entry
Which of the following is a true statement about evidence-based medicine?
A. Evidence-based medicine is using the EHR to provide care
B. Evidence-based medicine is following policies and procedures established by the healthcare facility
C. Evidence-based medicine is services that have been peer tested
D. Evidence-based medicine is the latest and greatest technology
Evidence-based medicine is services that have been peer tested.
Uses a system of connections of private internet networks outside and organizations firewall and uses Internet technology to enable collaborative applications to allow external users to access the IS.
Extranet
A private information network that is similar to the Internet in that it uses Internet technologies; however, its servers are located inside a firewall or security barrier so that the general public can not gain access to information housed within the network.
Intranet
A system that operates on a computer that is owned and maintained by a vendor. Data storage is at a remote location and information is moved via the Internet.
Cloud computing
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Electronic health record(EHR)
A computer used at the point of care, which involves a wireless computer mounted on a mobile cart that can be moved from patient to patient.
Computer on Wheels (COW)
All of the processing is performed at the server or mainframe, used to input patient data, capturing various patient or clinical data for reporting purposes.
Dumb terminal
A nurse tried to enter a temperature of 134゚degrees, and the system would not accept it. what is this an example of?
A. Data collection
B. Hot spot
C. Edit check
D. Data reliability
Edit Check
The admission coordinator tried to enter the patient’s insurance type and the appropriate insurance was not one of the options. This is a problem with ________.
A. Data definition
B. Data relevancy
C. Data timeliness
D. Data Comprehensiveness
Data Comprehensiveness
The benefit of a personal computer over a dumb terminal is that _________.
A. Processing is performed at the server
B. Processing is performed on the PC
C. It contains a firewall
D. It contains a network
Processing is performed on the PC
Which of the following is NOT a barrier to EHR adoption?
A. Ability to prescribe medication safely
B. Limited health IT workforce
C. Cost
D. Suitability of products to meet practice needs
Ability to prescribe medication safely
What type of data integrity error occurs when patient A’s information is documented in patient B’s health record?
A. Patient identification
B. Authorship
C. Amendment error
D. Dictation error
Patient identification
Large computers that are used by the government and other organizations that require speed and the ability to process large amounts of data.
Mainframe computer
The place or location where the physician administers services to the patient, such as the patient’s bedsides.
Point of Care (POC)
Software applications that handle patient accounts, budgets, and other financial activities.
Financial applications
Advanced certification sponsored by AHIMA that covers data management, data analytics, and data reporting.
Certified Health Data Analyst (CHDA)
An automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate data.
Information system
Reports of process measures to help leaders follow progress to assist with strategic planning. Provides the status on key measures.
Dashboard
The facility wants to use historical data to determine what will happen in the future. This is known as _________.
A. Predictive modeling
B. Data modeling
C. Descriptive statistics
D. Inferential statistics
Predictive modeling
To reduce health disparities, what system is used to remind and ensure that all female emergency department patients over the age of 50 complaining of any pain above the waist are screened for acute myocardial infarction?
A. Clinical decision support system
B. Interoperability
C. Continuity of care record
D. Source systems
Clinical decision support system
That HIM director assessed a vendor’s _________ to determine if the supplies that she ordered had been shipped.
A. Firewall
B. Internet
C. Intranet
D. Extranet
Extranet
What is the term used to describe foundation systems that collect administrative and clinical data that make up the EHR?
A. Connectivity systems
B. Specialty clinical systems
C. Source systems
D. Smart peripherals
Source systems
The EHR indicates that Dr. Smith wrote the January 12th progress note at 11:04 a.m. We know he wrote it due to _________.
A. Integrity
B. Validation
C. Identification
D. Authorship
Authorship
Which of the following statements justifies the use of a dashboard?
A. It utilizes statistical techniques
B. It monitors key measures
C. It manages information system projects
D. It facilitates budget development
It monitors key measures
The impact of information systems specifically on HIM professionals includes _________.
A. The need to assign diagnosis and procedure codes
B. Skills required
C. Improving patient safety
D. Improving access to health information
Skills required
TRUE/FALSE: Data quality measures are used to compare healthcare facilities.
True
What term is used to describe EHR systems that have been tested and certified to perform up to national standards?
A. ONC
B. CPOE
C. CERT
D. CEHRT
CEHRT
The field that uses technology to manipulate and use information to improve healthcare is known as __________.
A. Population health
B. Data analytics
C. Data modeling
D. Health informatics
Health informatics
Which of the following is NOT a reason that many healthcare facilities were slow to adopt EHRs?
A. Concerns about technology B. Privacy and security concerns C. Financial constraints D. Fear of consumer dissatisfaction E. A lack of standards
Fear of consumer dissatisfaction
An EHR system is programmed by the vendor to not release certain patient data because it is considered proprietary to the vendor and HCO. The vendor is protecting its own business interests above that of the patient. This is an example of _________.
A. Health information blockin
B. HIPAA security breach
C. Continuity of care record
D. Graphical user interface
Health information blockin