Health Information Management: Key Concepts and Applications, Exams of Nursing

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AHIMA Computer Basics in Healthcare HIM professionals use computers to facilitate the ease of ______________, ____________, ________________, and _________________ data. - entering, analyzing, using, maintaining List the areas of healthcare that have been impacted by the use of computers in HIM. - Patient care Finance and reimbursement Public health and epidemiology Research Education Patient safety Quality of patient care Access to information Privacy and security __________ enables applications to communicate with each other so that systems can be interated. - An interface Categorize as organizational or information software: statistical - information Categorize as organizational or informational software: content management - information Categorize as organizational or informational software: financial - organizational Categorize as organizational or informational software: IT help desk - organizational Categorize as organizational or informational software: database management system - organizational Categorize as organizational or informational software: email server - organizational Categorize as organizational or informational software: spreadsheet - information Categorize as organizational or informational software: word processing - information Categorize as organizational or informational software: accounting - information Categorize as organizational or informational software: supply management - organizational A network connection that sends signals from a router to the PC without utilizing cables is known as a(n) ____________________ connection. - wireless A(n) ___________________ looks like any other website; however, the firewall security to restrict unauthorized users is what primarily distinguishes it from the Internet. - intranet _____________________ does not direct the project or provide assignments to the team; guides the manager to create the guidelines for the project, plan its scope and outline, and assign tasks to the members on the team. It facilitates keeping the project on target throughout the life of the project. - Project management software A _______ is conducted/developed by a healthcare organization to determine if an information system (IS) that has been proposed for implementation is appropriate to meet their established objectives. - feasibility study What is an example of proper email etiquette? - including a short but meaningful subject line Which software application would be used to send a business memo to multiple staff members in the HIM department? - e-mail _______ is an interdisciplinary field whose goal is to improve healthcare. - Health informatics A(n) _______ allows health information to be exchanged electronically between providers and others who have the same level of interoperability. - HIE (health information exchange) Which input device is used to index documents that are scanned into a document management system? - barcode Evaluating the way an organization performs business functions in order to become more efficient is _______. - reengineering A system that can be used by healthcare facilities to give patients the ability to access health information and schedule appointments and uses connections of internet networks beyond the organization's firewall is a(n) _______ . - extranet The use of technology (the EHR) has improved the care provided to patients by: - Allowing immediate access to a patient's healthcare information Creating reminders to physicians of tests they should consider in the treatment of a patient Helping to produce quality documentation The intranet _______. - is a private network that uses a firewall to restrict unauthorized users Clicking a picture of a file folder to open a file is an example of a(n) _______. - GUI (graphical user interface) A social security number entered as 123456789 is displayed as 123-45-6789. This is an example of a _______. - mask A system that allows an organization to store data and run applications for several healthcare organizations at a remote location is known as _______. - cloud computing What software application would be used to generate a list of all inpatients discharged in the month of April with a diagnosis of pneumonia? - database A feature in project management software that lists tasks to be completed, milestones, and start and end dates is known as a _______. - Gannt chart The importance of ______________ of healthcare data cannot be overemphasized. - quality Numbers and figures contained in the record, by themselves, are _________________. - data When we make sense of that data by arranging and interpreting, it is known as _______________. - information HIM professionals must remember that data quality, which is the HIM professional's responsibility, is the key to ensuring a ______________________________. - legal electronic health record The _________________________ is a recognized and award-winning international leader with a long- proven ability to identify, test, and specify standardized performance measures. - Joint Commission What data set is used to report the minimally required data for inpatient discharges by acute-care hospitals? - UHDDS (Uniform Hospital Discharge Data Set) Which is NOT a type of data field? - GIGO (garbage in, garbage out) The level of detail of data is also known as: - data granularity Which is NOT an example of data cleansing? - ensuring that a data backup is performed regularly What is the name of the data contained in a data dictionary known as? - metadata Two coding professionals have found the same abbreviation on two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation on another patient's record was used to mean "overdose" on an abuse record. What data quality component is lacking here? - consistency A review of medical record number 214-53-29 revealed there was no H&P on the record at 7 hours past this patient's admission time. This is an example of _______. - quantitative analysis A large database within a facility that holds all data regarding patients for access and use is known as a _______. - CDR True or False: MyAHIMA is the place an AHIMA member would go to change their contact information, such as mailing address. - True True or False: The AHIMA Body of Knowledge™ is designed to enable HIM professionals to quickly and easily access the information needed to be successful professionals. - True Which of the following is not contained in the AHIMA Body of Knowledge™? - a tool to network with your peers Filling in missing data and correcting some data entry problems is the process of _______. - data cleansing A message flag that appears to indicate that the procedure codes for a hysterectomy on a male patient is invalid is an example of a(n) _______. - edit check AHIMA's Engage Online Communities are an online interaction tool. Which is not a feature of Engage Online Communities? - accessible to members only True or False: Requiring information in a data field is a preferred method to ensure that the data is captured. - True Which system is used by clinicians to dictate medical reports? - dictation system True or False? An ROI system and a disclosure management system are considered the same system. - False Which of the following provides a list of diagnoses and procedures in alphabetic order? - automated codebook encoder The following system collects information mandated by the National Center for Health Statistics. - Birth Certificate Information System A phonetic-based index system embedded into computer software to search for names that sound alike but are spelled differently is called: - Soundex The R-ADT application is updated with demographic information and is considered the foundation of the master patient index. What does R-ADT stand for? - registration - admission, discharge, transfer Which information system would most likely be found in a physician practice? - Practice Management System Which information system takes data and turns it into information? - Decision Support System The Five Rights of Clinical Decision Support - the right information to the right person in the right intervention format through the right channel at the right time in workflow True or False? The ability for images such as X-rays, mammograms, and ultrasounds to be viewed by a user from any location is called teleradiology. - True True or False? An electronic health record (EHR) and a document management system (DMS) are considered to be similar systems capable of the same functions. - False Why does a barcode make indexing more efficient? - It automatically enters the metadata from the barcode. The computer system that coding professionals use to select appropriate ICD-10-CM diagnosis codes is a(n) _______. - encoder Health Records that are found to have omissions in their documentation requirements are tracked in the _______ system. - chart deficiency What is used to identify every patient who has been admitted to the facility and is the key to locating all patient records? - master patient index (MPI) Which of the following clinical information systems easily operates with the clinical provider order entry (CPOE)? - pharmacy information system Which system is used by a physician to orally document various medical reports that are subsequently transcribed by a transcriptionist? - dictation Patient follow-up is a key part of what HIM system? - cancer registry software A request for an accounting of disclosure has been received. What system is accessed to fulfill this request? - disclosure management system Pages that tell the scanner information about the pages that follow are called _______. - target sheets Soundex is used within the _______ system. - MPI In the Registration process, the R-ADT system collects what kind of data? - patient demographic data The DMS uses scanning as a means to capture patient information from a paper record. What does DMS stand for? - document management system The electronic medication administration record can use barcodes or ________ to properly identify the patient. - RFID (radio frequency identification devices) Health information exchange or HIE allows for the ________ of health information. - exchange What is the primary barrier to Electronic Health Record (EHR) implementation? - cost True or False? In HIPPA, PHI stands for patient health information. - False (stands for Protected Health Information) True or False? Under the HIPAA Security Rule, an addressable standard does not have to be implemented. The covered entity is only required to document why it is not reasonable to do so. - False If a company contracts with a hospital to work with their PHI, under HIPAA what is the company referred to as? - business associate The HIPAA Privacy Rule is made up of all the following safeguards EXCEPT: Administrative Technical Physical - None of the above (includes all three safeguards) Who is responsible for establishing the content that accredits masters, bachelors, and associate programs? - The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) The Registered Health Information Administrator (RHIA) credential is for individuals who have graduated from an accredited _______ or Master degree program. - Bachelor What kinds of roles are available in vendor environments? - System development Customer service System implementation What role completes tasks such as data collection, data analysis, and developing data flow diagrams? - data analyst The Chief ________ Officer helps to develop the healthcare organization's strategic business plan as it relates to technology and information systems. - Technology What system uses computer software to automate the generation of code sets for review and validation? - Computer-Assisted Coding (CAC) Reduction in healthcare costs Improvement in patient safety Decreased disaster response times - all of the above Patients can refuse to participate in HIEs based on _______ guidance. - HIPAA The computer notified the privacy officer that a user accessed the PHI of a patient with the same last name. This is an example of a(n) _______. - trigger Which of the following roles is a more traditional information system role? System analyst Data integrity analyst Data analyst Content analyst - system analyst True or False? Interim HIM management is an example of a role found in a consulting firm. - True Which component of the EHR could use bar codes to identify patients? - Electronic medication administration record I review medical records for any incomplete documentation and then work with clinical staff to clarify any ambiguities. My role is a _______. - clinical documentation improvement coordinator The management of the usability, integrity, security, and availability of data in an organization or enterprise is called _______. - data governance Which of the following is an example of interoperability? NLP FOSS E-prescribing PHR - E-prescribing The physicians are concerned about implementing an EHR. What is a benefit that could be used to alleviate their concerns? - The EHR improves communications between healthcare providers. Tokens used in conjunction with a password provide _______. - two-factor authentication Which of the following is an incorrect statement regarding the benefits of an EHR? - Uniform standards support the functions and purpose of the EHR. My job is to design the clinical information system that will be implemented. I am a ________. - content analyst