Midterm Flashcards by Elise Stemple

The expectation that information shared with a health care provider during the course of treatment will be used only for its intended purpose and not disclosed otherwise is known as:

a. Conditions of participation
b. Boundaries
c. Confidentiality
d. Privacy

c. confidentiality

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Increased reliance on networked health care data has reduced that challenges associated with insuring and maintaining high quality data:

a. True
b. False

b. false

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What is a federally mandated standard assessment tool used to collect demographic and clinical information specifically about long-term facility residents.

a. ACDS
b. UHDDS
c. HEDIS
d. MDS

d. MDS

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What was the first comprehensive federal regulation that offers specific protection to private health care information?

a. The Patient Safety Act
b. The Freedom of Information Act (FOIA)
c. The HIPAA Privacy Rule
d. The Privacy Act of 1974

c. The HIPAA Privacy Rule

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Electronic signatures are now accepted by both the Joint Commission and CMS as legitimate forms of provider authentication

a. True
b. False

a. True

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Turnkey systems were software systems that could modified to meet a hospital’s unique information needs.

a. True
b. False

b. False

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Illegible handwriting is an example of a:

a. Methodical error
b. Random error
c. Systematic Error
d. Programming error

b. random error

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What system allows individuals/consumers to be more “involved” in their own care?

a. EMR
b. RHIO
c. PHR
d. EHR

c. PHR

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The main source(s) of data that go into hundreds of aggregate reports or queries that are often developed and used by providers and executives in health care organizations are:

a. Discharge data sets
b. Patient records
c. Uniform billing information
d. All of these

d. All of these

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The best-known health care accrediting agency in the United States is:

a. NCQA
b. CARF
c. The Joint Commission
d. CMS

c. The Joint Commission

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Using an abbreviation that has two different meanings is an example of a lack of:

a. Data precision
b. Data granularity
c. Data currency
d. Data consistency

d. data consistency

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Documenting health care information is an EHR thorough narrative form of unstructured fields allows for the full potential of the electronic record to be realized as a quality tool in insuring data consistency and comprehensiveness.

a. True
b. False

b. false

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In current management literature, the terms information system (IS) and information technology (IT) are often used interchangeably.

a. True
b. False

a. true

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Which organization is responsible for investigating fraud involving government health insurance programs?

a. CMS
b. OIG
c. AMA
d. WHO

b. OIG

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The electronic medical record shares information across different health organizations.

a. True
b. False

b. false

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Health care information systems and health care processes are closely entwined with one another.

a. True
b. False

a. true

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The component of the HIPAA Privacy Rule that specifies that entities that improperly handle PHI can be charged under criminal law and punished and are subject to civil recourse is known as:

a. Boundaries
b. Security
c. Public Responsibility
d. Accountability

d. accountability

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What is NOT considered a major effect of clinical information systems on patient quality?

a. Increased adherence to guideline-based care
b. Increased provider Productivity
c. Enhanced surveillance and monitoring
d. Decreased medication errors.

b. increased provider productivity

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The number-one reason for maintaining patient records is:

a. Communication
b. Legal documentation
c. Patient Care
d. Billing and reimbursement

c. patient care

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A method for measuring performance that allows for the design of measurement systems that align with the organization’s strategy goals and examines multiple measures along several dimensions is known as:

a. Balanced scorecard
b. Clinical Value Compass
c. Benchmarking
d. Outcome measures

a. balanced scorecard

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Which purpose of documentation uses the phrase, “If it was not documented, it was not done”

a. Legal documentation
b. Billing and Reimbursement
c. Patient care
d. communication

a. legal documentation

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Handwriting, speaking, typing, touching a screen or pointing and clicking on words or phrases are all examples of:

a. Data recording
b. Information Capture
c. Data processing
d. Report generation

b. information capture

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CPOE systems are easily implemented and operate on isolation

a. True
b. False

b. false

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An electronic health record (EHR) is an electronic record of health-related information that can be managed, shared, and controlled by that individual.

a. True
b. False

b. false

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The process that gives health care organization the authority to participate in the federal Medicare and Medicaid programs is knows as: a. Recognition b. Licensure c. Accreditation d. Certification

d. certification

Lack of training leads to random errors a. True b. False

b. false

In some instances patient-specific health care information can be released without the patient’s authorization. a. True b. False

a. true

The goal of the bar-coded-medication administration system ensures the five “rights” of the drug administration are met. a. True b. False

a. true

The majority of problems with health care data content can generally be traced to: a. Clinical procedures b. Documentation practices c. Employee incompetence d. Patients withholding information

b. documentation practices

What is NOT considered a major effect of clinical information systems on patient quality? a. Decreased Medication errors b. Increased adherence to guideline-based care c. Enhanced surveillance and monitoring d. Increased provider productivity

d. increased provider productivity

EHR systems can help healthcare organizations realize higher reimbursements due to higher-quality documentation and improved coding practices a. True b. False

a. true

Although state regulations may vary, the AHIMA currently recommends that patient health records for adults should be retained for how many years after the most recent encounter? a. 25 years b. 10 years c. 15 years d. 5 years

b. 10 years

Which standard billing form is submitted for health care provider services such as those provided by a physician’s office to third party payers: a. UB-82 b. CMS- 1450 c. UB-04 d. CMS-1500

d. CMS-1500

Home health and hospice agencies have experienced wide spread adoption of EHRs. a. True b. False

b. False

To identify quality data, it must conform to a recognized standard. a. True b. False

a. true

Monitoring patient blood sugar levels at home through a glucometer attached to a cell phone is an example of: a. Telemedicine b. Home Health c. Electronic consultation d. Telehealth

d. Telehealth

What is an example of a way that system design can help reduce errors during data collection and processing? a. Build human capacity by increasing staff training b. Standardize data entry fields c. Institute real-time quality checking d. All of these are acceptable ways

d. All of these are acceptable ways

HEDIS measures are specifically used to measure and compare the performance of: a. Hospitals b. Skilled nursing facilities c. Health plans d. Physician practices

c. Health plans

Health care data can provide different information to different users a. True b. False

a. true

The Joint Commission’s IM standards apply to both non-computerized systems and systems employing the latest technology. a. True b. False

a. true

An adverse drug event (ADE) may or may not have involved a medication error. a. True b. False

a. true

As part of telemedicine, Store and forward technology is used primarily to: a. Capture and monitor data from patients at home b. Perform surgery robotically c. Transfer digital images d. Allow face-to-face consultation

c. transfer digital images

Bar Coding technology is a clinical application used to promote patient safety by improving the process of: a. Chronic disease management b. Certified provider order entry c. Medication ordering d. Medication administration

d. medication administration

Raw unprocessed healthcare facts generally stored as characters, words, or symbols is known as: a. Health care data b. Health care text c. Health care knowledge d. Health care information

a. health care data

In order to be useful, data must be a. Filed immediately in the paper medical record b. Processed and manipulated into meaningful results c. Prepared using the systems analysis technique d. Collated and sorted one month after data entry

b. processed and manipulated into meaningful results

High-quality information is contingent upon a. Highly configured decision support b. Excellent systems integration c. Well thought out knowledge management process d. High-quality data.

d. high-quality data

What computer system was centralized and connected users via dumb terminals? a. Turnkey systems b. Microcomputer systems c. Main frame computers d. Internet

c. main frame computers

What classification system is currently being used today to code disease and inpatient procedure information? a. ICD-9-CM b. CPT c. ICD-10-CM/PCS d. DRG

c. ICD-10-CM/PCS

Best of breed selection of clinical information systems led to the use of integrated organizational systems. a. True b. False

b. false

What term is often used to describe hosted services that are delivered over the internet? a. Telemedicine b. Local Area Network (LAN) c. HIE d. Cloud Computing

d. cloud computing

Errors that can be attributed to a flaw or discrepancy in adherence to standard operating procedures or systems are known as: a. Random Errors b. Programming errors c. Systematic errors d. Methodical errors

c. systematic errors

Health care information standards and implementation specifications are examples of what type of barriers to adoption: a. Technical barriers b. Organizational and behavioral barriers c. Privacy and security barriers d. Financial barriers

a. technical errors

What is the highest level in the processing hierarchy? a. Data b. Knowledge c. Quality d. information

a. data

Those individuals and organizations that must comply

covered entities

Relates to physical or mental health, provision of or payment for health care, identifies the person, created or received by a covered entity and transmitted or maintained in any form.

protected health information (PHI)

PHI may be disclosed for health purposes only, with very limited exceptions

Boundaries

PHI should not be distributed without patient authorization, unless there is a clear basis for doing so, and the individuals who receive the information must safeguard it.

Security

Individuals are entitled to access and control their health records and are to be informed of the purposes for which the information is being disclosed and used.

Consumer Control

Entities that improperly handle PHI can be charged under criminal law and punished and are subject to civil recourse as well.

accountability

Individual interests must not override national priorities in public health, medical research, preventing healthcare fraud, and law enforcement in general.

Public Responsibility

Manages all types of results electronically (lab, radiology, etc.)

Results Management

Employs computerized reminders, alerts and computer-assisted diagnosing.

Decision support

Enables those involved in patient care to communicate effectively with each other and with the patient

Electronic communication and connectivity

Includes patient education materials, home monitoring, telehealth

patient support

Facilitates scheduling, prior authorizations, insurance verification, etc.

administrative process

Standardized terminology and data formats for public and private sector reporting requirements.

reporting and population health management

Lists medicines prescribed for and subsequently administered to the patient

Medication record/medication administration record (MAR)

Contains the results of tests conducted on body fluids, cells, and tissues

laboratory reports

Authorizes treatment and release of information

consent and authorization forms

Describes in detail any surgery that is performed

operative report

Describes any tissue removed during any surgical procedure

Pathology report

Gives an overall account of the patient’s hospital stay

discharge summary