Unit 1

Question 1

Guide that serves as a pointer or indicator to locate something

Answer 1

Index

Question 2

Facility database of all patients treated in that facility

Answer 2

Master patient index

Question 3

Database used to track patients across multiple facilities (IDS)

Answer 3

Enterprise master patient index

Question 4

Database used to track patients with specific disease processes or a particular surgical procedure

Answer 4

Disease and operation index

Question 5

Database used to track medical cases associated with specific physician(s)

Answer 5

Physician index

Question 6

Chronological listing of all data in a hospital setting

Answer 6

Registry

Question 7

What is the most important resource in any healthcare facility?

Answer 7

The MPI

Question 8

At a minimum the MPI should be able to:

Answer 8

Match the name of the patient coming in for treatment with their MPI record
Minimize duplicate records within a facility
Make it easier to merge MPIs
Create an ease for providers to access health records across an IDS or IDN

Question 9

What does AHIMA stand for?

Answer 9

American Health Information Management Associate

Question 10

Who are clinical professionals

Answer 10

Physicians, registered nurses, and physician assistants

Question 11

What was the Hill-Burton Act?

Answer 11

Grants authorizing states to build new hospitals and modernize old ones

Question 12

What does HIPAA stand for?

Answer 12

Health Insurance Portability and Accountability Act

Question 13

What is meant by “continuum of care?”

Answer 13

The right provider, right facility, right time, right care as well as the range of services provided to the patient from emergency to routine

Question 14

What came into play with the passage of the Public Law 89-97?

Answer 14

Medicare and Medicaid

Question 15

An inpatient is treated in what kind of facility?

Answer 15

Acute care

Question 16

What was the Social Security Act of 1935?

Answer 16

It extended the federal governments hand in providing assistance for public health, started during the Great Depression, and provided matching funds for individual states for maternal and infant care, rehab of crippled children, general public health and aid to children under the age of 16

Question 17

What association(s) provides members with local access to professional HIM education?

Answer 17

The Component State and Local Association

Question 18

What is an “integrated delivery network?”

Answer 18

A group of providers, facilities, and community agencies working together

Question 19

In the AHIMA organization, what functions as the legislative body?

Answer 19

The House of Delegates

Question 20

The right of an individual to control access to their PHI is the definition for…?

Answer 20

Privacy

Question 21

In data quality, expected data values is the definition for…?

Answer 21

Precision

Question 22

The expectation that PHI will be used for its intended purpose during the course of care is known as…?

Answer 22

Confidentiality

Question 23

Data are true to the source and have not been altered or destroyed is the definition for…?

Answer 23

Integrity

Question 24

Authorized users of the health record must be able to access information easily when and where they need it, regardless of format. What data characteristic does to describe?

Answer 24

Accessibility

Question 25

The data quality management domain that refers to the purpose for which data is collected is known as...?

Answer 25

Data application

Question 26

A data characteristic that describes data that are correct and valid is...?

Answer 26

Accuracy

Question 27

ICD-10 CM was developed by...?

Answer 27

WHO

Question 28

The list of data elements collected in individual health records is called...?

Answer 28

Data dictionary

Question 29

What organization is the largest user of healthcare data?

Answer 29

TJC

Question 30

Describes a single fact or measurement=fact

Answer 30

Data Element

Question 31

Refers to data elements that can be used for specific purpose=meaning

Answer 31

Information

Question 32

Recommended data elements with uniform definitions that are relevant for a particular use

Answer 32

Data Set

Question 33

List of data elements collected in individual health records

Answer 33

Data Dictionary

Question 34

Statement of expected behavior against which structures, processes and outcomes can be measured

Answer 34

Standards

Question 35

Data that is extracted from individual health records and combined to create a specific set of information that can be used for many different things

Answer 35

Aggregate data

Question 36

Data that is extracted from individual health records and the patient is identified within this data

Answer 36

Patient-specific/identified data or patient identifiable data

Question 37

Coordinator for development of voluntary standards for several industries

Answer 37

ANSI-American National Standards Institute

Question 38

Not for profit organization that provides standards and guidelines to make data exchange possible for hospitals, physicians and other types of healthcare provider systems

Answer 38

HL7 Health Level 7

Question 39

Not for profit organization that guides, develops and implements standards and guidelines that help labs improve the quality of lab testing

Answer 39

CLNI Clinical and Lab Standards Institute

Question 40

Developed as a universal language for facilities to be able to store, retrieve, and transit data

Answer 40

XML Extensive Markup Language

Question 41

Credentialed healthcare worker who is not a physician, nurse, psychologist or pharmacist

Answer 41

Allied Health Professional

Question 42

National trade organization that provides education, conducts research, and represents the hospitals industry interests in national legislative matters is...?

Answer 42

AHA American Hospital Association

Question 43

National professional membership organization for physicians

Answer 43

AMA American Medical Association

Question 44

Number of days stay as an in-patient in the hospital setting

Answer 44

ALOS Average Length of Stay

Question 45

Continuous cycle of planning, measuring, and monitoring performance and making improvements

Answer 45

CQI Continuous Quality Improvemnt

Question 46

Determine if the medical care to a specific patient was necessary according to the screening criteria

Answer 46

UR Utilization Review

Question 47

What is ARRA?

Answer 47

American Recovery and Reinvestment Act Provided stimulus funding during time of economic crisis. Initiated the beginning of the HITECH Act (Health Information Technology for Economic and Clinical Health)

Question 48

What are the two types of delivery systems?

Answer 48

IDN-Integrated Delivery Network | IDS-Integrated Delivery System

Question 49

Admitted into the acute care setting greater than 24 hours depending on the diagnosis and/or procedure

Answer 49

Inpatient

Question 50

The patient that is there for 23 hours or less; usually admitted and discharged the same day

Answer 50

Outpatient

Question 51

The patient that is admitted for healthcare monitoring for greater than 1 hour but less than 48 hours

Answer 51

Observation

Question 52

Short term care provided to diagnose and treat an illness or injury, average length of stay is 30 days or less.

Answer 52

Acute Care

Question 53

Preventative and/or corrective healthcare provided in a physicians office, clinic, or hospital, implies the patients is treated and returns home the same day

Answer 53

Ambulatory Care

Question 54

Post hospital care for someone still too ill to return home, can be provided in an assisted living facility or a long term care facility

Answer 54

Sub-acute Care

Question 55

Care provided to someone that is no longer able to be cared for in the home environment

Answer 55

Long-term Care aka-Skilled Nursing Facility (LTC)

Question 56

Healthcare services that are provided to assist patients in achieving and maintaining their optimal level of function, self care, and independence after some type of disability, usually from a car accident or stroke

Answer 56

Rehabilitiatin

Question 57

Care provided to those patients with long term disability that only want to receive palliative (comfort) care, this care is provided in the setting of the clients choice

Answer 57

Hospice Care

Question 58

Care provided in the patients home with the goal of promoting, maintaining or restoring health or minimizing the effects of their disability or illness, which may include a terminal illness

Answer 58

Home Health Care

Question 59

What kind of setting will you have a patient record?

Answer 59

Acute care setting

Question 60

What type of setting will you have a medical record?

Answer 60

Outpatient setting

Question 61

What type of setting will you have a resident record?

Answer 61

Long term care

Question 62

What type of setting will you have a chart?

Answer 62

Acute care/paper record

Question 63

What type of setting will you have a client record?

Answer 63

Ambulatory, behavioral health, or home health

Question 64

What are the three types of health records?

Answer 64

Paper, electronic, and hybrid

Question 65

What is PHI?

Answer 65

Personal health information

Question 66

A paper or computer based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility is...?

Answer 66

Health record

Question 67

What is the CCHIIM?

Answer 67

Commission on Certification for Health Informatics and Information Management They set the strategic direction for certifications

Question 68

Non-for-profit association dedicated to health information management is...?

Answer 68

AHIMA

Question 69

AHIMA outlined data quality management as falling under four domains. What are those?

Answer 69

Data applications, data collection, data warehousing, and data analyssi

Question 70

Virtual network used by AHIMA members is...?

Answer 70

Communities of Practice

Question 71

True or False | The lab test "hemoglobin: 14.6 gm/110ml" is considered information.

Answer 71

False

Question 72

T or F | All the primary purposes of the health record are associated directly with the provision of patent care

Answer 72

False

Question 73

T or F Submitting health record documentation to a third party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record

Answer 73

True

Question 74

Data is up to date

Answer 74

Currency

Question 75

Data and information documented is defined or pertinent

Answer 75

Definition

Question 76

Attributes and values of data be defined at the or correct level of detail for intended data usage

Answer 76

Granularity

Question 77

What is SDO?

Answer 77

Standard Development Organizations | Ex: ANSI, HL7, CLNI, & XML

Question 78

What is CCR?

Answer 78

Continuity of Care Record

Question 79

What is CDA?

Answer 79

Exchange model for clinical docs

Question 80

What is IEEE?

Answer 80

Open systems communication

Question 81

What is CCD?

Answer 81

Continuity of Care Document

Question 82

Where are UHDDS used?

Answer 82

Hospitals

Question 83

Where are UACDS used?

Answer 83

Ambulatory care

Question 84

What is RAP?

Answer 84

Resident Assessment Protocol

Question 85

What is OASIS-C?

Answer 85

Medicare beneficiaries who receive care from home healthcare agency

Question 86

What is HEDIS?

Answer 86

Health Plan Employer Data and Information set- designed to collect admin, claims, and health record review data

Question 87

What is DEEDS?

Answer 87

Data Elements for Emergency Department Systems

Question 88

What is EDI?

Answer 88

Electronic Data Interchange

Question 89

What is ORYX?

Answer 89

JC introduced to integrate outcomes data and other performance measurement data

Question 90

What is NHIN?

Answer 90

National Health Information Network

Question 91

What is DICOM?

Answer 91

Digital Imaging and Communication in Medicine

Question 92

What is AOA?

Answer 92

Type of accrediting body | Is a member association that represents osteopathic physicians