RHIA Practice Exam Deck Flashcards
Sally is the HIM director at Memorial Hospital and has been asked to compose a record retention policy for the hospital. What should be her first consideration in determining how long paper and electronic records must be retained?
The amount of space allocated for record filing and server set up
The number of paper records currently filed and the number of electronic files added on a daily basis
The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
The cost of filing space and equipment
The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
Abdominal pain
Cholelithiasis
Exploratory laparoscopy
Ruptured appendix
Abdominal pain
Mrs. Smith’s admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith’s birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith’s health record?
Data accuracy
Data consistency
Data accessibility
Data comprehensiveness
Data consistency
The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours.
30 days, 48 hours, 24 hours
14 days, 24 hours, 48 hours
14 days, 48 hours, 24 hours
30 days, 24 hours, 48 hours
30 days, 24 hours, 48 hours
Which of the following is an acceptable means of authenticating a record entry?
The physician’s assistant electronically signs for the physician.
The HIM clerk electronically signs using the physician’s login.
The charge nurse electronically signs for the physician.
The physician personally signs the entry electronically.
The physician personally signs the entry electronically.
A method of documenting nurses’ progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:
Problem-oriented progress notes
Charting by exception
Consultative notations
Open charting
Charting by exception
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):
Resident Assessment Protocols (RAPs)
Resident Assessment Instrument (RAI)
Utilization Guidelines (UG)
Minimum Data Sets (MDS)
Resident Assessment Protocols (RAPs)
HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) ten that information is not shared with other departments within the healthcare entity. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Administration
Registration or patient access
Risk management
Radiology and laboratory
Registration or patient access
Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:
Closed review
Qualitative review
Concurrent review
Delinquent review
Concurrent review
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
Administrative information
Demographic information
Progress notes
Uniform data sets
Uniform data sets
The data elements in a patient’s automated laboratory result are examples of:
Unstructured data
Free-text data
Financial data
Structured data
Structured data
Which of the following materials are required elements in an emergency care record?
Patient’s instructions at discharge and a complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
Treatment rendered, instructions at discharge, and the patient’s complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n):
Indicator
Measurement
Assessment
Outcome
Indicator
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?
Master data
Metadata
Structured data
Unstructured data
Metadata
Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident’s care?
Case management
Minimum Data Set
Outcomes and assessment information set
Core measure abstracting
Minimum Data Set
Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John’s hospital bill. Upon discharge from the hospital, who owns John’s health record?
John
Blue Cross
University Hospital
Dr. Collins
University Hospital
Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value report she received during her last physical exam. Dr. Ward responded to Jane’s email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled?
Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient’s medical record.
Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.
Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.
Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?
Integrated
Practice-oriented
Chronological
Source-oriented
Source-oriented
A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility’s internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area?
Comparative performance data
Internal infection reporting
Master patient index
Provider performance data
Comparative performance data
According to Joint Commission Accreditation Standards, which document must be placed in the patient’s record before a surgical procedure may be performed?
Admission record
Physician’s order
Report of history and physical examination
Discharge summary
Report of history and physical examination
The following data have been collected by the hospital quality committee. What conclusions can be made from the data on the hospital’s quality of care between the first and second quarters?
Measure
1st Quarter
2nd Quarter
Medication errors
3.2%
10.4%
Patient falls
4.2%
8.6%
Hospital-acquired infections
1.8%
4.9%
Transfusion reactions
1.4%
2.5%
Quality of care improved between the first and second quarters.
Quality of care is about the same between the first and second quarters.
Quality of care declined between the first and second quarters.
Quality of care should not be judged by these types of measures.
Quality of care declined between the first and second quarters.
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data?
Laboratory
Radiology
Quality management
Registration
Laboratory
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:
Identification and demographic integrity
Authorship integrity
Statistical integrity
Auditing integrity
Authorship integrity
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:
Case-mix index
Master patient index
Health record matrix
Retention schedule
Health record matrix
Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:
Standardized data
Codified data
Aggregate data
Unstructured clinical information
Unstructured clinical information
Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:
Authorization
Certificate of destruction
Informed consent
Continuity of care record
Certificate of destruction
Decision-making and authority over data-related matters is known as:
Data management
Data administration
Data governance
Data modeling
Data governance
A professional basketball player from the local team was admitted to your facility for a procedure. During this patient’s hospital stay, access logs may need to be checked daily in order to determine:
Whether access by employees is appropriate
If the patient is satisfied with their stay
If it is necessary to order prescriptions for the patient
Whether the care to the patient meets quality standards
Whether access by employees is appropriate
A patient has the right to request a(n) ________, which describes where the covered entity has disclosed patient information for the past six years outside of treatment, payment, and healthcare operations.
Disclosure list
Designated record set
Amendment of medical record
Accounting of disclosures
Accounting of disclosures
Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information?
It can exist in separate and multiple paper-based or electronic systems.
The record is incomplete.
Numerous physicians have not given consent to release the record.
Risk management will not allow the legal health record to be released.
It can exist in separate and multiple paper-based or electronic systems.
Dr. Hansen saw a patient with measles in his office. He directed his office staff to call the local department of health to report this case of measles. The office manager called right away and completed the report as instructed. Which of the following provides the correct analysis of the actions taken by Dr. Hansen’s office?
Dr. Hansen’s office followed protocol and reported this case of measles correctly.
Dr. Hansen’s office did not need to report this case to the local health department.
Dr. Hansen’s office should have mailed a letter to the local health department to report this case.
Dr. Hansen’s office should have reported the case to the local hospital and not to the health department.
Dr. Hansen’s office followed protocol and reported this case of measles correctly.
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?
There is no impact.
The person making the entry in the health record may not be called as a witness in trial.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The incident report cannot be discovered even though it is mentioned in a discoverable document.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient’s records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?
Yes, HIPAA only requires that current records be produced for the patient.
Yes, this is hospital policy over which HIPAA has no control.
No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
No, the records from the previous hospital are not included in the designated record set but should be released anyway.
No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
John is the privacy officer at General Hospital and conducts audit log checks as part of his job duties. What does an audit log check for?
Loss of data
Presence of a virus
Successful completion of a backup
Unauthorized access to a system
Unauthorized access to a system
An outpatient laboratory routinely mails the results of health screening exams to its patients. The lab has received numerous complaints from patients who have received another patient’s health information. Even though multiple complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. How should the Privacy Officer for this healthcare entity respond to this situation?
Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule
Fire the responsible employees
Do nothing, as these types of errors occur in every healthcare entity
Retrain the entire hospital entity because these types of errors could result in a huge fine from the Office of Inspector General
Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule
Anywhere Hospital’s coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA Security Rule. What type of network uses a private tunnel through the Internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely?
Intranet
Local area network
Virtual private network
Wide area network
Virtual private network
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
Context-based
Role-based
Situation-based
User-based
Role-based
The Security Rule leaves the methods for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be:
Its own characteristics and environment
The potential threats and vulnerabilities
The level of risk
An assessment of current security measures
Its own characteristics and environment
Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room.
Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule.
Sally owns the information in her record, so she must be granted her request.
Sally’s request does not have to be granted because the hospital is responsible for the integrity of the medical record.
Patients should never be given access to their actual medical records.
Sally’s request does not have to be granted because the hospital is responsible for the integrity of the medical record.
Who has the legal right to refuse treatment?
1.
Juanita who is 98 years old and of sound mind.
2.
Christopher who is 10 years old and of sound mind.
3.
Jane who is 35, incompetent, and did not express her treatment wishes prior to becoming incompetent.
4.
Linda who is 35, incompetent, and created a living will prior to becoming incompetent stating that she did not wish to be kept alive by artificial means.
5.
William who is a 35-year-old born with an intellectual disability and has the mental capacity of a 12-year-old.
1 and 2
1 and 3
1 and 4
4 and 5
1 and 4
Linda Wallace is being admitted to the hospital. She is presented with a Notice of Privacy Practices. In the Notice, it is explained that her PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes. Of the options listed here, what is the best course of action?
The hospital must honor her wishes and not use her PHI for TPO.
The hospital may decline to treat Linda because of her refusal.
The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only.
The hospital is not required to honor her wishes for treatment purposes but must honor them for payment and operations purposes.
The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only.
Jack Mitchell, a patient in Ross Hospital, is being treated for heart failure. He has not opted out of the facility directory. Callers who request information about him may be given:
No information due to the highly sensitive nature of his illness
Admission date and location in the facility
General condition and acknowledgment of admission
Location in the facility and diagnosis
General condition and acknowledgment of admission
A data breach occurred in your organization, and after the investigation it was determined that a total of 785 individuals were impacted by the data breach. What must be completed within 60 days of learning about the data breach?
Update the notice of privacy practices and send to all patients
Report the incident to the individuals impacted, local media, and the Department of Health and Human Services
Conduct privacy training for members of the organization
Document a note mentioning the data breach in each of the patients’ charts and tell the local media
Report the incident to the individuals impacted, local media, and the Department of Health and Human Services
The “custodian of health records” refers to the individual within a healthcare entity who is responsible for which of the following actions?
Determining alternative treatment for the patient
Preparing physicians to testify
Testifying to the authenticity of records
Testifying regarding the care of the patient
Testifying to the authenticity of records
Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient’s physician. Of the options listed here, what is the best course of action?
Allow Dr. Smith to see the records because he was the daughter’s guardian at the time of the tonsillectomy.
Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff.
Inform Dr. Smith that he cannot access his daughter’s health record without her signed authorization allowing him access to the record.
Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.
Inform Dr. Smith that he cannot access his daughter’s health record without her signed authorization allowing him access to the record.
St. Joseph’s Hospital has a psychiatric service on the sixth floor. A 31-year-old male came to the HIM department and requested to see a copy of his health record. He told the clerk he was a patient of Dr. Schmidt, a psychiatrist, and had been on the sixth floor of St. Joseph’s for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is:
Prohibit the patient from accessing his record as it contains psychiatric diagnoses that may greatly upset him.
Allow the patient to access his record.
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.
Deny access because HIPAA prevents patients from reviewing their psychiatric records.
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.
You are a member of the hospital’s Health Information Management Committee. The committee has created a HIPAA-compliant authorization form. Which of the following items does the Privacy Rule require for the form?
Signature of the patient’s attending physician
Identification of the patient’s next of kin
Identification of the person or entity authorized to receive PHI
Patient’s insurance information
Identification of the person or entity authorized to receive PHI
Protected health information that is maintained in a designated record set can be accessed by the patient or other authorized party upon request. Covered entities must respond to requests within what timeframe after receipt of the request?
15 days
30 days
60 days
90 days
30 days
A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient’s medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?
Inform defense and plaintiff lawyers that the records no longer exist
Submit a certification of destruction in response to the subpoena
Refuse the subpoena since no records exist
Contact the clerk of the court and explain the situation
Submit a certification of destruction in response to the subpoena
An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s).
A list of newborns to the local newspaper for publication in the birth announcements section
Data about cancer patients to the state health department cancer surveillance program
Birth information to the country registrar
Information about patients with sexually transmitted infections to the county health department
A list of newborns to the local newspaper for publication in the birth announcements section
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?
There is no impact.
The person making the entry in the health record may not be called as a witness in trial.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The incident report cannot be discovered even though it is mentioned in a discoverable document.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration is called:
Secure messaging
Consumer informatics
Personalized medicine
Telehealth
Telehealth
In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n):
Primary key interface (PKI)
Application programming interface (API)
Continuity of care record (CCR)
Record locator service (RLS)
Record locator service (RLS)
Which of the following is the unique identifier in the relational database patient table?
Patient Table
Patient #
Patient Last Name
Patient First Name
Date of Birth
021234
Smith
Donna
03/21/1944
022366
Jones
Donna
04/09/1960
034457
Smith
Mary
08/21/1977
Patient last name
Patient last and first name
Patient date of birth
Patient number
Patient number
In a relational database, which of the following is an example of a many-to-many relationship?
Patients to hospital admissions
Patients to consulting physicians
Patients to hospital health records
Primary care physician to patients
Patients to consulting physicians
A possible justification for building an information system in-house rather than purchasing one from a vendor is that:
It is cheaper to buy than to build
The facility has development teams they do not want to give up
Integration of systems will be easier
Vendor products are not comprehensive enough
The facility has development teams they do not want to give up
What is the formatting problem in the following table?
Medical Center Hospital Admission Types
Elective
2,843
62.4
Emergency admission
942
37.6
Total
3,785
100.0
The variable names are missing
The title of the table is missing
The column headings are missing
The column totals are inaccurate
The column headings are missing
Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital’s gross death rate for the month of June was:
0.05%
2%
5%
20%
5%
In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed?
Initial study
Design
Testing
Operation
Testing
In the data warehouse, the patient’s last name and first name are entered into separate fields. This is an example of what?
Query
Normalization
Key field
Slicing and dicing
Normalization
A physician is interested in conducting research on herniated intervertebral disc disease. She wants to compare the success of conservative medical care versus surgical intervention. The best source of this information is the:
Disease index
Operative index
Master patient index
Trauma registry
Disease index
The health information services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do?
The manager should have each employee complete a serial work request.
The manager should have each employee complete a work distribution chart.
The manager should have the employees complete a use case analysis.
The manager should develop a flow process chart.
The manager should have each employee complete a work distribution chart.
By querying the healthcare entity data, you find that patients admitted on a weekend have a mean length of stay that is 1.3 days longer than patients who are admitted Monday through Friday. This method of finding information is called:
Structuring query language
Data mining
Multidimensional data structuring
Satisficing
Data mining
A health information professional is preparing statistical information about the third-party payers that reimburse care in the facility. She finds the following information: Medicare reimburses 46 percent; Medicaid reimburses 13 percent; Blue Cross reimburses 21 percent; workers’ compensation reimburses 1 percent; commercial plans reimburse 15 percent; and other payers or self-payers reimburse 4 percent. What is the best graphic tool to use to display this data?
Histogram
Pie chart
Line graph
Table
Pie chart
During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30 percent of the nursing home’s population. This rate represents the:
Distribution
Frequency
Incidence
Prevalence
Incidence
When a physician office acquires a new EHR in place of its old EHR, the old EHR data will require:
Chart conversion
Chart transition
Data conversion
Data processing
Data conversion
Using the admission criteria provided, determine if the following patient meets the severity of illness and intensity of service criteria for admission.
Severity of Illness
Intensity of Service
Persistent fever
Inpatient-approved surgery/procedure within 24 hours of admission
Active bleeding
Intravenous medications or fluid replacement
Wound dehiscence
Vital signs every 2 hours or more often
Sue presents with vaginal bleeding. An ultrasound showed a missed abortion, so she is being admitted to the outpatient surgery suite for a D&C.
The patient does not meet both severity of illness and intensity of service criteria.
The patient does meet both severity of illness and intensity of service criteria.
The patient meets intensity of service criteria but not severity of illness.
The patient meets severity of illness criteria but not intensity of service.
The patient meets severity of illness criteria but not intensity of service.
The user needs a list of all of the patients that were diagnosed with a cerebral infarction or a cerebral hemorrhage. What type of search would be used in this situation?
Structured query language
Wildcard search
Truncation
Boolean search
Boolean search
A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as:
Identify needs
Monitor results
Record feedback
Specify requirements
Monitor results
Community Memorial Hospital discharged nine patients on April 1. The length of stay for each patient is shown in the following table. The average length of stay for these nine patients was:
Patient
Number of Days
A
1
B
5
C
3
D
3
E
8
F
8
G
8
H
9
I
9
5 days
6 days
8 days
9 days
6 days
The department of surgery has acquired an analytics engine to enable it to provide predictive information at the point of care via the EHR. However, the department is struggling to get physicians to use the functionality because it does not have support staff to program or train users. This situation refers to the fact that the project plan did not illustrate:
Conflicts
Dependencies
Environmental issues
Policy decisions
Dependencies
This Health Information Exchange (HIE) consent model requires the patient to give their consent for the inclusion of their data in the HIE.
Opt-in
Opt-out
Automatic consent
No-consent
Opt-in
Given the information here, the case-mix index would be:
MS-DRG
MDC
Type
MS-DRG Title
Weight
Discharges
Geometric Mean
Arithmetic Mean
191
04
MED
Chronic obstructive pulmonary disease w CC
0.8642
10
2.7
3.3
192
04
MED
Chronic obstructive pulmonary disease w/o CC/MCC
0.6521
20
2.2
2.6
193
04
MED
Simple pneumonia & pleurisy w MCC
1.2987
10
4.0
5.1
194
04
MED
Simple pneumonia & pleurisy w CC
0.8402
20
2.9
3.6
195
04
MED
Simple pneumonia & pleurisy w/o CC/MCC
0.6418
10
2.3
2.8
0.09
0.6521
0.8270
82.70
0.8270
A super user of health IT has complained to her supervisor that she is being asked by a physician to perform his data entry. What should the super user’s role be?
Aid others in using a new system during go-live and getting to adoption
Serve as a scribe for physicians who are new to data entry
Train users to learn how to use the system prior to go-live
Troubleshoot issues with the system that did not come to light during testing
Aid others in using a new system during go-live and getting to adoption
Which of the following do HIE participants use to search for health records on other healthcare organization systems using patient indexing and identification software?
Admit, discharge, transfer
Advance patient identifier
Continuity of care document
Record locator service
Record locator service
Which of the following would likely be recorded on an information systems issues log?
Alan is present every day there is a system test.
Betty reported receiving 25 erroneous e-mail messages.
Dr. Brown effectively uses e-prescribing.
John requested a supply of tamperproof paper for his office.
Betty reported receiving 25 erroneous e-mail messages.
A physician is concerned that the data patients enter into an EHR is not as reliable as data entered by another provider. What function serves to distinguish the source of data in an EHR?
Data dictionary
Data provenance
Data quality
Data registry
Data provenance
A coding manager wants to display the patient types that have the most coding errors in relationship to coder years of service. The desire of the coding manager is to display how coder years of service is responsible for coding errors. The type of graph or chart best suited for this is a:
Bar graph
Pareto chart
Pie chart
Line graph
Pareto chart
The best way to ensure that elements of a health information system work together is to:
Adopt all components from a single vendor
Ensure standards are applied to software development that support interoperability
Use an application service provider that supports all vendors
Verify that a vendor applies a systems’ view to its product development
Ensure standards are applied to software development that support interoperability
Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute PATIENT_MRN represent?
A screenshot of a computerDescription automatically generated
It is the foreign key in PATIENT and the primary key in VISIT.
It is the primary key in PATIENT and the foreign key in VISIT.
It is the primary key in both PATIENT and VISIT.
It is the foreign key in both PATIENT and VISIT.
It is the primary key in PATIENT and the foreign key in VISIT.
A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step in the systems development life cycle is typically referred to as _____.
Identify needs
Monitor results
Record feedback
Specify requirements
Monitor results
Patients at the new cardiac clinic at ABC Hospital are given smart watches with special sensors to monitor their blood pressure, heart rate, and rhythm in ECG format to identify any abnormalities during their daily routine. The information generated from these smart devices is considered a:
Source system
Interoperability system
Virtual system
Hybrid system
Source system
One of the older cardiologists expressed dissatisfaction with using an EHR, stating that he does not understand why it’s necessary. Sandy, as the EHR Clinical Coordinator, talks about his work as the first physician at ABC Hospital to use computerized technology for cardiac patients, and how cardiac diagnosis outcomes improved. She relates to him that the EHR will have the same impact and that the best reason to implement an EHR is to:
Determine the cost of care
Improve patient care
Eliminate medical errors
Meet Joint Commission mandate for the EHR
Eliminate medical errors
Dr. Wilson asks you, the EHR Manager, to explain the difference between an alert and a reminder. You explain that reminders are typically used for things that can be scheduled or that occur on a regular basis. An example of a reminder that would be given to Dr. Wilson would be:
Use of anticoagulant is contraindicated
Patient is due for MMR immunization
Patient is allergic to sulfa drugs
Drug does not come in this format
Patient is due for MMR immunization
Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute CLINIC_ID represent?
A screenshot of a computerDescription automatically generated
It is the foreign key in CLINIC and the primary key in VISIT.
It is the primary key in CLINIC and the foreign key in VISIT.
It is the primary key in both CLINIC and VISIT.
It is the foreign key in both CLINIC and VISIT.
It is the primary key in CLINIC and the foreign key in VISIT.
A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.
D25.9
Leiomyoma of uterus, unspecified
D50.0
Iron deficiency anemia secondary to blood loss (chronic)
D62
Acute posthemorrhagic anemia
N93.8 Other specified abnormal uterine and vaginal bleeding
D50.0, N93.8
D62, N93.8
N93.8, D50.0
D50.0, D25.9
D50.0, N93.8
A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm?
Insomnia
Hypertension
Mental or behavioral problems
Rheumatoid arthritis
Mental or behavioral problems
A patient has a malunion of an intertrochanteric fracture of the right hip that is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure?
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Lower Bones
Excision
Upper Femur, Right
Open
No Device
No Qualifier
0
Q
B
6
0
Z
Z
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Lower Bones
Division
Upper Femur, Right
Open
No Device
No Qualifier
0
Q
8
6
0
Z
Z
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Lower Joints
Excision
Hip Joint, Right
Open
No Device
No Qualifier
0
S
B
9
0
Z
Z
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Lower Joints
Release
Hip Joint, Right
Open
No Device
No Qualifier
0
S
N
9
0
Z
Z
0QB60ZZ
0Q860ZZ
0SB90ZZ
0SN90ZZ
0Q860ZZ
Medical identity thefts are situations in which the following occurs:
When health information on the wrong patient is put in the incorrect record
When financial information is used to purchase nonmedical items
When demographic and financial information is used to acquire medical services
When demographic information is used to purchase nonmedical items
When demographic and financial information is used to acquire medical services
A patient is admitted with right diabetic cataract and extracapsular cataract extraction with simultaneous insertion of intraocular lens.
E11.36
Type 2 diabetes mellitus with diabetic cataract
E11.9
Type 2 diabetes mellitus without complications
H25.9
Unspecified age-related cataract
H26.9
Unspecified cataract
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Eye System
Extraction
Lens, Right
Percutaneous
No Device
No Qualifier
0
8
D
J
3
Z
Z
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Medical and Surgical
Eye System
Replacement
Lens, Right
Percutaneous
Synthetic Substitute
No Qualifier
0
8
R
J
3
J
Z
H25.9, E11.36, 08DJ3ZZ
E11.36, 08RJ3JZ
E11.9, E11.36, H26.9, 08DJ3ZZ
E25.9, E11.9, 08RJ3JZ
E11.36, 08RJ3JZ
The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:
Unbundling
Billing for services not provided
Medically unnecessary services
Upcoding
Upcoding
You are the coding supervisor, and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough, and the record states “rule out lung cancer.” What should have been coded as the patient’s diagnosis?
Chronic cough
Observation and evaluation without need for further medical care
Diagnosis of unknown etiology
Lung cancer
Chronic cough
Using the following custom revenue production report, which coding error may be demonstrated in the report?
Revenue Production Report—Small Multispecialty Group Month: January
Code
Quantity
Fee
Projected Revenue
Actual Insurance Revenue
99202
3
$75
$225
$164.10
99203
4
$90
$360
$267.94
99204
0
$120
$0
$0.00
99205
0
$150
$0
$0.00
99211
703
$28
$19,684
$14,988.32
99212
489
$47
$22,983
$18,092.65
99213
1853
$63
$116,739
$92,890.38
99214
41
$89
$3,649
$2,799.11
99215
7
$135
$945
$722.87
99242
9
$125
$1,125
$156.23
99243
27
$150
$4,050
$610.45
99244
10
$175
$1,750
$124.32
99245
1
$200
$200
$53.10
Clustering
Unbundling
Missed charges
Overcoding
Clustering
Jim was admitted for hip replacement surgery, and during his procedure he was administered blood products. Postoperatively, Jim developed a rash and fever. The presence of these symptoms will be investigated by the hospital as a possible:
Blood verification
Core measure
Comorbidity
Transfusion reaction
Transfusion reaction
Community Hospital has received a large number of claims denials for CT scans that were provided to patients. After review of the denied claims, the hospital has determined that clinical indications for the CT scan were not present. For which of the following reasons were these claims denied for payment?
Patient preferences were ignored.
These scans did not meet medical necessity.
No order was present in the record for the scans.
Best practices for billing were not used.
Best practices for billing were not used.
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients, so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan?
Traditional retrospective
Capitated rate
Relative value
Discounted fee schedule
Capitated rate
Jennifer, the HIM Assistant Director, is establishing her yearly calendar with all the dates for standing monthly committee meetings, weekly production reports, daily census tracking graphs, quarterly payroll accounts, etc. Identify the frequency Jennifer would schedule the chargemaster software updates.
Annually
Quarterly
Monthly
Weekly
Annually
The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is:
Optical character recognition
Bar coding
Neural networks
Electronic data interchange
Electronic data interchange
A physician performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy on his patient at Community Hospital. His office billed the following:
58150
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
58720
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
Why was this claim rejected?
Billed hysterectomy with wrong CPT code
Not a covered procedure
Unbundled procedures
Covered procedure but insurance company requires additional information
Unbundled procedures
A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers’ compensation insurance. The workers’ compensation insurance paid the neurosurgeon fees. Which entity is the “third party”?
Patient
Neurosurgeon
Basic Manufacturing Company
Workers’ compensation insurance
Workers’ compensation insurance
Alfred is tracking the amount of time it takes for physicians to respond to coding queries. He has found that these delays have caused a 30% increase in turn-around time for submitting the bills for reimbursement. The system would assist him and the coders to have the necessary information to make timely coding assignment.
CDM
CPT
CDI
RCM
CDI
A physician query may not be appropriate in which of the following instances?
Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae
Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay
Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI
Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
The financial manager of the physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group practice receiving?
Traditional
Episode-of-care
Per diem
Fee-for-service
Episode-of-care
Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors according to which of the following Code of Ethics principles?
Advocate and uphold the right to privacy
Respect the inherent dignity and worth of every person
Represent the profession accurately to the public
Put service before self-interest
Put service before self-interest
Community Hospital is trying to improve its compliance with Medicare quality reporting requirements and, in turn, its reimbursement from Medicare’s Hospital Value-Based Purchasing Program. The hospital has added a ________ to assist in educating medical staff members on documentation needed for accurate billing.
Physician advisor
Compliance officer
Chargemaster coordinator
Data monitor
Physician advisor
The following table is an example of an:
Patient/Service
Service Date(s)
(A) Total Charge
(B) Not Payable by Plan
Plan Paid Amount
White, Jane
Office Visit
02/17/201X
$56.00
$10.00
CP*
$46.00
100%
X-Ray
02/17/201X
$268.00
$250.00
$3.60
DD* CI*
$14.40
80%
Lab
02/17/201X
$20.00
$15.00
CP*
$5.00
100%
Total
*CI: Coinsurance; CP: Copayment; DD: Deductible
Insurance coverage advanced notice service waiver
Explanation of benefits
Insurance claim form
Encounter form
Explanation of benefits
Which of the following healthcare entities’ mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments?
Accountable care entity
Managed care entity
Revenue reduction contractor
Recovery audit contractor
Recovery audit contractor
The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue?
Have coders continue to query the attending physician for this documentation.
Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines.
Do nothing because coding compliance guidelines do not allow any action.
Place all offending physicians on suspension if the documentation issues continue.
Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines.
A patient arrived via ambulance to the emergency department following a motor vehicle accident. The patient sustained a fracture of the ankle, a 3.0-cm superficial laceration of the left arm, a 5.0-cm laceration of the scalp with exposure of the fascia, and a concussion. The patient received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture requiring closed manipulative reduction, simple suturing of the arm laceration, and layer closure of the scalp. Provide CPT codes for the procedures performed in the emergency department for the facility bill.
12002
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
12004
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
12032
Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm
27810
Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation
27818
Closed treatment of trimalleolar ankle fracture; with manipulation
–58
Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
–59
Distinct procedural service
27810, 12032
27818, 12004, 12032-58
27810, 12032, 12002-59
27810, 12004
27810, 12032, 12002-59
What qualifier is used with the root operation excision, extraction, or drainage that are considered diagnostic?
D
J
X
Z
X
In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient’s skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician’s documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
Note the condition as present on admission
Query the physician to determine if the condition was present on admission
Note the condition as unknown on admission
Note the condition as not present on admission
Query the physician to determine if the condition was present on admission
Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil’s recovery included several settings in the continuum of care: acute-care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled?
Bills for each service from each physician, each facility, and each other healthcare provider from every encounter
Bills for each service from each physician, each facility, and each other healthcare provider at the end of the 10-month period
Consolidated billing for each encounter that includes the bills from all the physicians, facilities, and other healthcare providers involved in the encounter
One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers
One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers
The coding supervisor has compiled a report on the number of coding errors made each day by
the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what action should the coding supervisor take?
Counsel Tim and Jane because they have the highest error rates
Encourage Tim and Jane to get additional training
Provide Bob and Susan with incentive pay for low coding error rates
Take no action since not enough information is given to make a judgment
Take no action since not enough information is given to make a judgment
Once all data has been posted to patient’s account, the claim can be reviewed for accuracy and completeness. Many facilities have an internal auditing system that runs each claim through a set of edits. This internal auditing system is known as a:
Chargemaster
Superbill
Scrubber
Grouper
Scrubber
Which of the following terms is used to describe the requirement of the healthcare provider to obtain permission from the health insurer prior to providing service to the patient?
Preauthorization
Advance beneficiary notification
Point of care collection
Local coverage determination
Preauthorization
Joan is educating the physicians in her hospital about the Medicare Hospital Value-Based Purchasing (VBP) Program. As part of this education, she explains to her audience that the HCAHPS survey results are a part of the ________ domain in the Medicare VBP program.
Safety
Clinical Care
Efficiency and Cost Reduction
Person/Community Engagement
Person/Community Engagement
A series of terms in parentheses that sometimes directly follow main terms in the alphabetic index to diseases ICD-10-CM coding system is called:
exclude note
sub-term
nonessential modifier
essential modifier
nonessential modifier
Sam is the new HIM supervisor. His first assignment is to evaluate the efficiency and effectiveness of his work unit. He has met with the unit’s customers to determine their expectations and met with his staff to understand their roles. In setting up systems to measure work performance, it is critical for Sam to establish:
Proper ergonomics
Standards
Action plans
Work distribution charts
Standards
Pressed for time, Sara hired a new release of information clerk without doing a reference check. When the new clerk committed a violation of patient confidentiality, it came to light that she had committed similar violations at her previous place of employment. By not checking the clerk’s references, Sara has opened the hospital to charge of:
Discrimination
Harassment
Negligent hiring
Overcompensation
Negligent hiring
The slightly higher wage paid to an employee who works a less desirable shift is called a:
Shift rotation
Performance incentive
Shift differential
Work distribution ladder
Shift differential
Which of the following best differentiates the role of strategic management and strategic thinking as compared to other management tools and approaches?
A component of each of the major functions of management
An additional function that one learns after mastering other management functions
A replacement for certain management functions
A role for senior managers and board of trustees
A component of each of the major functions of management
Jan, the new release of information manager, is participating in management orientation for the healthcare organization. One section of orientation thoroughly reviews the tools and practices for setting sustainable performance goals for employees, how to monitor employee progress toward job performance goals, and ways to provide feedback to employees regarding job performance. This section of orientation is called:
Performance management
Situational strength
Critical incident method
Benchmarking
Performance management
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of current patients?
Priority focus review
Periodic performance review
Tracer methodology
Performance improvement
Tracer methodology
Employees covered by the provisions of the Fair Labor Standards Act (FLSA) are called ________ employees.
Waged
Salaried
Exempt
Nonexempt
Nonexempt
A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called:
Strategy map
Process innovations
Balanced scorecard methodology
SWOT analysis
Balanced scorecard methodology
As part of his role at the local hospital, Jake is reviewing Joint Commission standards to ensure that the organization is meeting the accreditation requirements. As part of the review, Jake is looking at a specific set of standards that are primarily focused on documentation. Some of the standard requirements include care provided, procedures that were done on the patient, and the progress of the patient. Based on this scenario, which set of Joint Commission standards is Jake reviewing?
Information management standards
Record of care standards
Performance improvement standards
Information resource standards
Record of care standards
During new employee orientation, Elise, the assistant director of human resources, oversees diversity and sexual harassment training. This orientation is taking place at what level?
Organizational
Departmental
Individual
Administrative
Organizational
The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a(n):
Favorable variance of $2,000
Unfavorable variance of $2,000
Favorable variance of $23,000
Unfavorable variance of $23,000
Unfavorable variance of $2,000
Joe Smith, RHIA, works for an outsourcing company as interim health information department director in a large hospital. By the terms of the contract, the hospital pays the company for Joe’s services based on a 40-hour workweek with overtime for any hours exceeding 40. Joe typically works 9 hours per day, Monday through Thursday, and 4 hours on Friday. He then flies home for the weekend. After several months, he discovers the hospital is billed for 44 to 48 hours per week almost every week. Joe confronts the company billing department because this practice conflicts with the tenet of the AHIMA Code of Ethics that states that health information management professionals:
Respect the rights and dignity of all individuals
Adhere to the vision, mission, and values of the association
Promote and protect the confidentiality and security of health records and health information
Refuse to participate in or conceal unethical practices or procedures
Refuse to participate in or conceal unethical practices or procedures
Agreements that are reached in a participant agreement or vendor contract should be developed into:
Operational policies
Strategy plans
Admit, discharge, transfer notifications
Long-term vision for technical interoperability
Operational policies
The process of reviewing and validating a physician’s education and experience prior to granting medical staff membership is called:
Outcomes management
Credentialing
Surveillance
Utilization review
Credentialing
Which of the following would be an indicator of process problems in a health information department?
5% decline in the number of patients who indicate satisfaction with hospital care
10% increase in the average length of stay
15% reduction in bed turnover rate
18% error rate on abstracting data
18% error rate on abstracting data
Which of the following is a true statement about business process reengineering?
It is intended to make small incremental changes to improve a process.
It seeks to reevaluate and redesign organizational processes to make dramatic performance improvements.
It implies making few changes to achieve significant improvements in cost, quality, service, and speed.
Its main focus is to reduce services.
It seeks to reevaluate and redesign organizational processes to make dramatic performance improvements.
Strategic thinkers exhibit which of the following skills?
Discomfort with uncertainty and risk
The ability to gain a powerful core of healthcare entity supporters and customers
Flexibility but lacking creativity
An ability to implement the vision and plan and be uncomfortable with change
The ability to gain a powerful core of healthcare entity supporters and customers
For Medicare patients, how often must the home health agency’s assessment and care plan be updated?
At least every 60 days or as often as the severity of the patient’s condition requires
Every 30 days
As often as the severity of the patient’s condition requires
Every 60 days
At least every 60 days or as often as the severity of the patient’s condition requires
A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called:
Training
Job analysis
Orientation
Job rotation
Orientation
Sarah, a coding manager, realizes that one of her long-term employees is experiencing a decrease in her coding quality. Sarah has counseled the employee several times and she has documented the issues and placed them in the employee’s file. Sarah has been advised by her manager that she needs to initiate a performance improvement plan for the employee. The next step that Sarah needs to do is:
Document performance issues
Meet with the employee to review the performance improvement plan
Develop an action plan incorporating SMART goals that will assist employee in achieving performance goals
Review the performance improvement plan with the HIM manager and human resources
Develop an action plan incorporating SMART goals that will assist employee in achieving performance goals
Kelly’s husband is being transferred to a new position in another state. Kelly has to resign her position as director of HIM at Memorial Hospital, a job she has enjoyed for five years. This is an example of what type of employee turnover?
Functional
Voluntary
Involuntary
Separation
Voluntary
The following information was abstracted from Community Hospital’s balance sheet.
Total assets
$25,000,000
Current assets
$4,000,000
Total liabilities
$10,000,000
Current liabilities
$5,000,000
A vendor selling a large dollar amount of goods to this hospital on credit would:
Not be concerned because total assets exceed total liabilities
Not be concerned because the debt ratio is less than one half
Be somewhat concerned because the current ratio is less than one
Not analyze the balance sheet because the vendor would care more about the income statement
Be somewhat concerned because the current ratio is less than one
Community Hospital is evaluating the following three investments. Which one has the highest profitability index?
Radiology Investment
Cardiology Investment
Pharmacy Investment
Present value of cash inflows
$2,000,000
$1,200,000
$40,000
Present value of cash outflows
$500,000
$300,000
$10,000
Radiology investment
Cardiology investment
Pharmacy investment
All three are equally profitable
All three are equally profitable
The HIM manager is developing performance standards for the analysts. The manager will use these performance standards in order to:
Assign daily work
Communicate performance expectations
Describe the elements of a job
Prepare a job advertisement
Communicate performance expectations
What type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation?
Vocational review
Compulsory review
Complimentary review
Voluntary review
Voluntary review
A SWOT analysis created by the director of the HIM department indicates that all of the coding staff are credentialed and up to date on their continuing education credits. In a SWOT analysis, this would be considered a:
Strength
Weakness
Opportunity
Threat
Strength
Aaron’s workspace is filled with notes posted to the walls regarding coding rules. He has even created file folders for coding tips according to body system. Aaron is most likely what type of sensory learner?
Auditory
Kinesthetic
Tactile
Visual
Visual
An accrediting agency’s published rules, which serve as the basis for comparative assessment during the review or survey process, are called:
Accreditation controls
Accreditation guides
Accreditation policies
Accreditation standards
Accreditation standards
Contracting for staffing to handle a complete function within the HIM department, such as the Cancer Registry function, would be considered what type of contracting arrangement?
Full-service
Part-time
Project-based
Temporary
Full-service
Dr. Smith, an OB-GYN specialist, has just become a staff member at Medical Center Hospital, where she may offer care and treatment related to obstetrics and gynecology including performing deliveries and gynecological surgery. The process of defining what services she may perform is called:
Outcomes management
Care mapping
Granting privileges
Retrospective review
Granting privileges
Every year, a director of health information services sponsors a series of presentations about the confidentiality of patient information. All facility employees are required to attend a session. This method of educational delivery is called:
Career development
In-service education
On-the-job training
Orientation
In-service education
In the HIM department at Memorial Hospital, each newly hired coder spends an afternoon with a medical biller. The coder follows the biller around as they complete job tasks to get an idea of how coding and billing impact one another. This is an example of what type of on-the-job training?
Job rotation
Job shadowing
Cross-training
Coaching
Job shadowing
Identify the true statement regarding training.
A variety of methods should be used to accommodate different learning styles.
Training should be limited to the information system only.
Training should be performed a minimum of six months prior to implementation of the information system.
In order to facilitate training, all employees should receive the exact same training regardless of their position.
A variety of methods should be used to accommodate different learning styles.
