Midterm Exam Review Flashcards
What organisations accredit hospitals?
- Joint Commission
- DNV (Det Norske Veritas)
- American Osteopathic Association Health Facilities Accreditation Program (AOA HFAP)
Remember, CMS (Medicare/Medicaid) certifies and states license.
The requirements for CMS certification are called…
Conditions of Participation
Deemed status is granted to:
1. Which hospitals?
2. By whom?
- Granted to accredited hospitals
- By the CMS
Note: means accredited hospitals automatically meet CMS conditions of participation.
HIM educational programs are accredited by…?
CAHIIM, or the Commission for Accreditation of Health Informatics and Information Management Educational Programs
Demographic information is:
1. What?
2. Found where in the medical record?
- Identifying information about the patient.
- Found in the administrative documents of the record. The patient’s name, medical record number, and date of birth will also usually appear on each screen.
What are the following components of the medical history?
1. CC
2. HPI
3. PMH
- CC = chief complaint (what brought the patient to the hospital)
- HPI = history of present illness (when did it start, symptoms)
- PMH = past medical history
What are the following components of the medical history?
1. SH
2. FH
3. ROS
- SH = Social History (occupation, use of alcohol, tobacco, drugs)
- FH = Family History
- ROS = Review Of Systems (note this is part of the history, not the physical exam)
We can say the medical history is the result of which of the following?:
A. examination of the patient
B. interview of the patient
B. Interview of the patient
What is the definition of the following techniques used to perform the physical exam?
1. Auscultation
2. Inspection
3. Palpation
4. Percussion
- Auscultation = Listen with stethoscope
- Inspection = Look
- Palpation = Touch
- Percussion = Tap and listen
What is the Joint Commission time requirement for the history and physical? (3 answers).
- Within 24 hours of admission
- Always before surgery
- Within 30 days prior to admission
Note: Interval History-the patient is readmitted within 30 days of discharge for the same condition, then just update the previous history
Patient admitted to have a repair of an inguinal hernia experiences a heart attack 4 hours after admission. What is the principal diagnosis?
The Inguinal hernia, because the principal diagnosis is the one that caused the admission.
For the same patient, what kind of diagnosis was the heart attack?
Complication – arose after admission
A complication is a type of secondary diagnosis.
If this patient was also diabetic at the time of admission, what type of diagnosis was diabetes?
Comorbidity = cosickness. Another illness that existed at the time of admission.
A comorbidity is also a type of secondary diagnosis.
Physicians write orders because they are the captains of the ships. What does this mean?
Physicians are in charge of their patients.
When are consents used? (Three answers)
- On admission for examination, treatment, taking of speciments
- Before special procedures such as surgery
- Before experimental treatments.
What are the different educational levels for the RHIT/RHIA?
RHIT = associate degree
RHIA = bachelor’s or master’s degrees
What are the requirements to become a RHIT/RHIA? (two steps)
- Graduate from an accredited program.
- Pass the national examination.
What is the continuing education requirement for the RHIA?
30 continuing education units every 2 years
What is the name of the national organization for our profession?
American Health Information Management Association (AHIMA)
(Located in Chicago)
An ECG (or EKG) test results in a tracing of the…?
Heart’s electrical activity
ECG = electrocardiogram
Which of the following are examples of diagnostic imaging?
a. X-ray
b. CT scan
c. MRI
d. ultrasound
e. All of the above.
e. All of the above.
note: diagnostic imaging produces pictures (images) from inside the body.
Physician progress notes should be written…? (two answers)
- Daily, or more often, as the patient’s condition warrants
- If the patient’s condition is rapidly changing, there should be more frequent notes.
The most important part of the Code of Ethics is that we…?
Protect the privacy of patient information.
What is “charting by exception?”
a documentation method used in healthcare to record only significant or abnormal findings
What are the vital signs? (4 answers)
- Temperature
- Pulse
- Blood pressure
- Respiration
Nursing progress notes should be written…?
At least once a shift, or more often, as the patient’s condition warrants.
Unless the hospital is using “charting by exception”. See the textbook, p. 114.
What does p.o. mean on a medication order?
Per os (Latin for by mouth) or orally
What are the following labs?
1. Hematology
2. Chemistry
3. Urinalysis
- Hematology - counts/percentages of components of whole blood
- Chemistry - levels of various chemicals found in blood serum
- Urinalysis - examination of urine
The legislative body of the AHIMA is the:
House of Delegates
What do the following abbreviations mean?
1. Dx
2. PDx
3. Hx
4. PE
- Dx = diagnosis
- PDx = Principal diagnosis
- Hx = History
- PE = Physical Examination
Sequence the levels of physician training from lowest to highest:
a. Medical student
b. Resident
c. Intern
d. Bachelor’s Degree student
e. Fellow
d, a, c, b, e
or
1. Bachelor’s degree student
2. Medical Student
3. Intern
4. Resident
5. Fellow
What is the difference between Medicare and Medicaid?
- Medicare – insurance program for elderly, permanently disabled, and end-stage kidney disease patients
Premiums paid out of social security/disability checks
All 65+ invited to participate
End-stage kidney disease is a catastrophic disease, so it was added to the program. (patients are not required to be 65+) - Medicaid
Funded by federal government and states
In NY, counties fund much of it
Covers the cost of the care for low income patients and families.
Is a DO a physician? What does DO stand for?
Yes. DO = doctor of osteopathy. They are licensed to practice medicine just like MDs are licensed.
The functions of the medical record are: (four answers)
- Patient care delivery
- Patient care support (looking at the needs of the patients to know how to run the healthcare facility)
- Patient care management (quality & appropriateness of medical care)
- Billing and Reimbursement
What document guides our behavior as health information managers?
AHIMA Code of Ethics
A consultation requires 3 elements:
- Examination of Patient
- Review of the Record
- Preparation of a report
What is a ‘span of control’?
The amount of people that report to one manager.
What does the Code of Ethics say about using the RHIA credential behind one’s name? (two parts)
- Only use it if the RHIA exam has been taken & passed & AHIMA notifies you of the credential.
- Only use it if the continuing education requirements are met so the RHIA is still valid.
Be sure to review the Code of Ethics on p. 895 of the textbook.
What is an organizational chart?
a visual representation of a company’s internal structure
What did Public Law 89-97 (1965) do?
Established Medicare and Medicaid
1965 is a key year to remember. It was the major health care legislation of the 1960’s.
What is an integrated delivery system?
Organization that provides all levels of care from acute care hospitals to nursing homes/rehab centers to individual physician offices.
What do the following medical history abbreviations mean?
1. CC
2. HPI
3. PMH
4. SH
5. ROS
- CC - Chief Complaint
- HPI - History of Present Illness
- PMH - Past Medical History
- SH - Social History
- ROS - Review of Systems
What are the components of a complete medication order? (5 parts)
- Name of the medication
- Dose
- Frequency (how often)
- Method of administration (e.g., oral, injection, IV, and so forth)
- Start/Stop dates
