Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

110 Cards in this Set

  • Front
  • Back
What group is the primary accreditation organization for facilities that treat individuals who have functional disabilities ?
Commission on Accreditation of Rehabilitation Facilities
Which of the following is a disadvantage of alphabetic filing ?
Uneven expansion of file shelves or cabinets
Critique this statement, "the PHR and EHR are synonyms for each other".
FALSE...the PHR is controlled by the patient, while the EHR is controlled by the care provider
In which department or unit does the health record typically begin ?
Patient registration
Which of the following is not usually a component of acute care patient records ?
Problem list
When correcting erroneous information in a health record, which of the following is NOT appropriate ?
Using a black pen to obliterate the entry
A health record with deficiencies that is not completed within the time frame specified in the medical staff rules and regulations is called "what" ?
Who is responsible for final approval of the AHIMA code of ethics ?
the AHIMA Home of Delegates
Which of the following actively promotes education and research in health information management ?
Which organization developed the first hospital standardization program ?
American College of Surgeons
As many public and private standards groups promulgate health informatics standards, the office of the national coordinator of health information and technology has been given the responsibility for "what"?
Building software systems to support EHR development
What is the primary goal of integrated health delivery systems ?
To insure that patients receive high quality cost effective care in the most appropriate setting.
While the focus of inpatient data collection is on the principle diagnosis, the focus of outpatient data collection is "what" ?
Reason for the encounter
What was the main result of the publication of the Flexner Report ?
Medical school standards were established
Documentation of genetic information, immunizations, hospitalizations, surgeries, medicines, family, occupation, and environmental histories are maintained over a lifetime in what type of record ?
Personal Health Record (PHR)
Members of the AHIMA House of Delegates are.....
Elected to members in state component organizations
Which of the following filing systems is considered the most efficient ?
Terminal Digit
Which of the following is an advantage of paper based records ?
Standardized familiar format
HIM has been recognized as an allied health profession since "when" ?
The Joint Commission requires that the medical record delinquency rate quarter averaged from the last 4 quarterly measurements is not greater than _____ of the monthly discharge rate.
I am arguing against the copy/paste function in the EHR...what would be my argument ?
I am unable to identify the author
Where was the first hospital organnized in the British Colonies of North America ?
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits ?
The Joint Commission
AHIMA strongly opposes using "this" as a patient identifier in an electronic record ?
Social Security Number
What federal legislation provides funding for the implementation of nationwide health information exchange ?
American Recovery and Reinvestment Act of 2009
Which of the following accredits accademic programs in health information management ?
Which federal legislation enacted the Medicare and Medicaid programs ?
Public Law 89 - 97 of 1965
Which of the following is an example of data capture technology ?
Document imaging
A critical early step in designing an EHR is to develp a __________ in which the characteristics of each data element are defined.
Data Dictionary
What was the primary objective of the original social security act which became law in 1935 ?
To provide retirement income for the elderly
The individuals right to control access to his or her personal information is known as "what" ?
Which of the following best describes "data accessibility" ?
Data are easily attainable
A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is called a ____________ review ?
After patient leaves the hospital the review is called "what" ?
The _______ makes up a virtual network of AHIMA members who communicate via a web based program managed by AHIMA.
Communities of Practice
Which of the following best describes "data accuracy" ?
Data are correct
Which of the following best describes "data completeness" ?
Data includes all required elements
I have been asked to list institutional users of the health record. Which one of the following would I include on my list ?
Blue Cross and Blue Shield
Which type of patient record includes documentation of a family bereavement period ?
Hospice record
Which type of health record is designated to measure clinical outcomes, collect data at the point of care, and provide medical alerts ?
Electronic record
In long term care, the resident's care plan is based on data collected in ___________.
MDS Version 2.0
Reimbursement for home health services is dependent of data collected from ________.
As many private and pubic standards groups promulgate health imformatics standards, the Office of the National Coordinator of Health Informatiion and Technology has been given responsibility for ___________.
Harmonization of standards from multiple sources
Which of the following is not ususally a part of a quantitative analysis review ?
Checking that every word in the record is spelled correctly
In health organizations, what is the database that is used to locate the medical record number usually called ?
Master Patient Index
What component of the budget would include money for the purchase of an EHR ?
Capital Budget
Which of the following task would the HIM department not perform in an electronic health record system ?
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers filed together within the filing system.

Terminal Digit
Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long roll ?
Microfilm Roll
Which of the following historical events had the most influence on the U.S. Government's role in financing healthcare delivery ?
The Great Depression
Which of the following is a secondary purpose of the health record ?
Support for research
The National Centers for Health Statistics is responsible for updating the diagnosis classifications of ICD-9-CM.
Volume 3 of ICD-9-CM is part of the international version of ICD-9 and is used only in the United States.
V-codes and E-codes are referred to as supplementary classifications in ICD-9.
ICD-10 is used in the United States for morbidity reporting.
An encoder is a tool that aids coders in assigning diagnostic and procedure codes.
The 3rd volume of ICD-9-CM contains the tabular and alphabetic listsof diseases.
The International Classification of Diseases for Oncology 3rd edition is a system used for classifying incidences of benign diseases.
CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services.
AHIMA has developed Standards of Ethical Coding.
To avoid fraudulent behaviors, healthcare providers must develop compliance plans and establish internal controls.
Providers should base their complinace programs on the compliance programs released by the AMA.
Designation of a Chief Compliance Officer and a corporate compliance committee charged with the responsibility for operating and monitoring the compliance program and who reports directly to the CEO and the governing body is required for corporate compliance.
Which of the following should be a violation of a corporate compliance plan ?
Coders are given a bonus if the CMI exceeds a specified value.
We have a hotline that employees can call to report compliance issues. This is mandated by the...
Seven Elements of Corporate Compliance Plan
I need to confirm the patient's principle diagnosis for the chart I am coding. How should I do this ?
Review documents, such as the discharge summary
The degree to which codes accurately reflect the patient's diagnosis and procedure is called "what" ?
Standardized vocabulary is needed to ......
Facilitate the indexing, storage, and retrieval information in an EHR
Which of the following would be an argument for the transition to ICE-10-CM/PCS ?
More detail in the code
Which of the following would be classified in ICD-9-CM with an "E-code" ?
A fall from a curb
I work at a substance abuse center. What system should I use to code diagnoses ?
MEAN: Add up all numbers given, and divide by the amount of numbers that were given...the "average"
MEDIAN: Place the numbers from lowest to highest and find the MIDDLE NUMBER, or average the two center numbers if a middle number is unavailable
MODE: Place the numbers from lowest to highest, then find the number(s) that occurs MOST OFTEN
RANGE: Place the numbers from lowest to highest, then subtract the lowest number from the highest number...this will give you your range.
PERCENTAGE: See the notes we took in class for this is the one where she multiplied by 100 then divided by "something"
Which of the following is an example of an ancillary system ?
Lab System
Discrete data are generally entered into an EHR via....
The ability to electronically put tasks into a queue for someone to perform is called "what" ?
Work Flow
In a Regional Health Information Organization (RHIO), patients would most likely be identified using "what" ?
Record Locator Service
A special web page that offers secure access to data is called a(n).....
To run an analysis on a large set of data from many patients, the best tool is a(n).....
Clinical Data Warehouse (CDW)
An "interface" is....
a program to exchange data
Standards from "which organization" would be used for enabling exchange of clinical images ?
Semantics refers to....
meaning of a clinical concept
Which of the following vocabularies is likely to be used to describe drus in a clinically relevant form ?
Which of the following is a core ethical obligation of HITs ?
Protecting patient's privacy and confidential communications
Which of the follwoing terms means "promoting good" ?
Which of the following terms means "treating others fairly"?
Which of the following ethical principles is being followed when an HIT professional ensures that patient information is ONLY released to those who have the leal right to access it ?
Which of the following priciples is being followed when an HIT professional applies rules fairly to all ?
Which of the following ethical principles is being followed when an HIT professional refuses to participate in a fraudulent act ?
Which of the following activities is considered an unethical practice ?
Backdating progress notes
Privacy can be defined as ......
The right of an individual to be left alone
Confidentiality can be defined as .....
The limitation of the use and disclosure of private information
Which of the following represent(s) examples of the ethical obligations of HIT professionals ?
Respecting and following the policies of their employers
Complying with all laws, regulations, and policies that govern the health information system
Refusing to participate in or conceal unethical practices
The Health Insurance Portability and Accountablity Act (HIPAA).....
provides a federal floor for healthcare privacy
The content of the health record is defined by _______.
State licensing rules and laws
Accrediting body standards
Medical staff bylaws
What are the sources of law ?
Statutes and constitutions
Judicial decisions
Administrative laws
Which type of law defines the rights and duties among people and private businesses ?
Private Law
Law enacted by leislative body is a _________.
Which document directs an individual to bring originals or copies of records to court ?
Subpoena duces tecum
The physical health record is usually considered the property of ____________.
The organization or provider that maintains and stores the record
Under the HIPAA privacy rule, covered entities refers to
Healthcare providers
Healthcare clearinghouses
Under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________.
30 days
In which of the following instances can PHI (Personal Health Information) be used without patient authorization ?
Release to an insurance company for payment
Release to another healthcare provider for treatment
Release to public health authorities as required by law
Which of the following provides a complete description to patients about how PHI (personal health information) is used in a healthcare facility ?
Notice of Privacy Practices
The form and content of the health record are determined by __________?
Accreditation standards and public health reporting requirements

The needs of individual healthcare organizations


State and Federal laws and regulatory requirements
When a healthcare provider purposely commits a wrongful act that results in injury to a patient, the provider can be held responsible for an intentional tort.
The Joint Commission sets the official record retention standards for hospitals and other healthcare facilities.

the retention standards are set by the state
Stricter state statutes related to the confidentiality of healthcare information takes precedence over the provisions of the HIPAA privacy rule.
Which of the following spells out the powers of the three branches of the federal government?
United States Constitution
AHIMA's record retention guidelines recommended that the master patient index be maintained __________.
Which of the following parties are considered covered entities under the HIPAA privacy rule ?