RHIT #2 Flashcards

graphical user interface

A type of software that provides a front-end structure/interface that
presents information in a familiar format leading to a natural style
of interaction through the use of icons and a mouse


the ability to transfer data from one system to another system

data mart

a subset of the data warehouse that is usually oriented to a specific
business line or team (smaller database)

clinical data repository

is a real time database that consolidates data from a variety of
clinicalsources to present a unified view of a single patient

executive information system

a type of management information systemthat facilitates and supports
senior executive information and decision-making needs

business continuity plan

a plan to help ensure that business processes can continue during a
time of emergency or disaster

database that stores the data in tables


how to handle versioning of documents in the EDMS

Display the second version but identify that a previous version exists

probabilistic algorithm

The comparison methodology that identifies multiple records that
represent the same person

use cases

a series of related interactions between a user and a system that
enables the user to achieve a goal

database that must be able to store video, images, and audio



Digital Imaging and Communications in Medicine

Digital Imaging and Communications in Medicine (DICOM)

a standard for handling, storing, printing, and transmitting
information in medical imaging

HL7 EHR functional model

provides Healthcare service providers and IT providers a standardized
reference list and model of functions to be present in an Electronic
Health Record System

incidental disclosure

a secondary use or disclosure that cannot reasonably be prevented, is
limited in nature, and that occurs as a result of another use
ordisclosure that is permitted by the Rule

privacy incident

A (reportable) breach is the unauthorized acquisition, access, use,
or disclosure of PHI in a manner not permitted by law or regulation
and which compromises the security and privacy of the PHI

How long must the training records for the HIPAA privacy training be
kept before destruction?

7 years


negligent, reckless, and intentional destruction of evidence

workforce clearance procedure

ensures that the access to the ePHI is appropriate (Before an
employee can be given access to the EHR, someone has to determine what
they have access to)


To neutralize or rebalance the magnetic field of a magnetized object,
such as a computer monitor or the read/write head of a disk drive or
tape recorder

Physical safeguards include

tools to control access to computer systems and fire protection

denial of service

an interruption in an authorized user's access to a computer network,
typically one caused with malicious intent


software that enables a user to obtain covert information about
another's computer activities by transmitting data covertly from their
hard drive


the activity of defrauding an online account holder of financial
information by posing as a legitimate company

virus (worm, Trojan Horse)

a piece of code that is capable of copying itself and typically has a
detrimental effect, such as corrupting the system or destroying data


software that is intended to damage or disable computers and computer systems

minimum necessary rule

requires that department of mental health, its offices, facilities,
programs and Workforce Members, when using, disclosing, or requesting
PHI, must make reasonable efforts to limit PHI to the minimum amount
necessary to accomplish the intended purpose of the use, disclosure or request

limited data set

may be disclosed to an outside party without a patient�s
authorization if certain conditions are met

intrusion detection

a device or software application that monitors network or system
activities for malicious activities or policy violations and produces
electronic reports to a management station

why would you are conduct a risk assessment?

to prevent breach of confidentiality


a program or system intended to distinguish human from machine input,
typically as a way of thwarting spam and automated extraction of data
from websites

A certification agency validates the use of encryption between two
organization's websites. How?

hypertext markup language

digital certificate

an electronic document used to prove ownership of a public key

The HIPAA security rule impacts

clinical data repository

The security rule only applies to


The three components of a security program

protecting the privacy of data
ensuring the integrity of data
ensuring the availability of data

security token

a small hardware device that the owner carries to authorize access to
a network service. The device may be in the form of a smart card or
may be embedded in a commonly used object such as a key fob

What would be an example of two-factor authentication?

password and token

A covered entity includes

health care providers who perform specified actions electronically

covered entities

(1) health plans, (2) health care clearinghouses, and (3) health care
providers who electronically transmit any health information in
connection with transactions for which HHS has adopted standards.

information system activity review

procedures to regularly review records of information of system
activity, such as audit logs, access reports, and security incident
tracking reports

What type of digital signature uses encryption?

digital signature

Breach notification is required unless

the probability of PHI being compromised is low

You have been assigned the responsibility of performing an audit to
confirm that all of the workforce's access is appropriate for their
role in the organization. This process is called

workforce clearance procedure

SWOT analysis

a study undertaken by an organization to identify its internal
strengths and weaknesses, as well as its external opportunities and threats

Electronic protected health information (ePHI)

any protected health information that is covered under HIPAA security
regulations and is produced, saved, transferred or received in an
electronic form


an individual with extensive computer knowledge whose purpose is to
breach or bypass internet security or gain access to software without
paying royalties. The general view is that, while hackers build
things, crackers break things.

SSL (Secure Sockets Layer)

the standard security technology for establishing an encrypted link
between a web server and a browser

CCOW )Clinical Context Object Workgroup)

an Health Level Seven International standard protocol designed to
enable disparate applications to synchronize in real time, and at the
user-interface level

packet filter

a firewall technique used to control network access by monitoring
outgoing and incoming packets and allowing them to pass or halt based
on the source and destination Internet Protocol (IP) addresses,
protocols and ports

To prevent their network from going down, a company has duplicated
much of its hardware and cables. This duplication is called


All patients except ______________ must be given a notice of privacy practices.


Who/which entity would the Privacy Act of 1974 apply to?

the federal government

an example of an administrative safeguard would include


what is the timeframe the facility must provide to a patient who has
asked to view his medical record?

30 days

private key encryption

A private key is a tiny bit of code that is paired with a public key
to set off algorithms for text encryption and decryption.
Public encryption uses a private and public key

You are reviewing your privacy and security policies, procedures,
training program, and so on, and comparing them to the HIPAA and ARRA
regulations. You are conducting a

risk assessment

Intrusion detection systems analyze

network traffic

Someone accessed the covered entity's electronic health record and
sold the information that was accessed. This person is known as

a cracker

Before we can go any further with our risk analysis, we need to
determine what systems/information need to be protected. This step is
known as

system characterization

The hospital has received a request for an amendment. How long does
the facility have in order to accept or deny the request?

60 days

Average daily census includes

adult and pediatrics, but NOT newborns

relative risk (formula)

RR = risk exposed divided by risk not exposed

The primary difference between an experimental (randomized) clinical
trial and other observational study designs is that in an experimental
trial, the

investigator determines who is and who is not exposed

sequence organizations use when collecting statistics to increase
their knowledge

data ? information ? facts ? knowledge

variable sampling

The process of predicting a given variable of a population through sampling.

convenience sampling

is made up of people who are easy to reach

stratified sampling

the researcher divides the population into separate groups, called
strata. Then, a probability sample (often a simple random sample ) is
drawn from each group.

systematic sampling

a type of probability sampling method in which sample members from a
larger population are selected according to a random starting point
and a fixed, periodic interval

A distribution is said to be positively skewed when the mean is

shifted to the right

interrater reliability

the degree of agreement among raters. It gives a score of how much
homogeneity, or consensus, there is in the ratings given by judges.

When very long length of stay is calculated in the average length of
stay, this will

result in a special cause variation in the average length of stay

common cause variation

fluctuation caused by unknown factors resulting in a steady but
random distribution of output around the average of the data

special cause variation

a shift in output caused by a specific factor such as environmental
conditions or process input parameters. It can be accounted for
directly and potentially removed and is a measure of process control

case-control study model

A study that compares patients who have a disease or outcome of
interest (cases) with patients who do not have the disease or outcome
(controls), and looks back retrospectively to compare how frequently
the exposure to a risk factor is present in each group to determine
the relationship between the risk factor and the disease.

prospective studies

watches for outcomes, such as the development of a disease, during
the study period and relates this to other factors such as suspected
risk or protection factor(s). The study usually involves taking a
cohort of subjects and watching them over a long period.

elements of negligence must be present in order to recover damages

duty of care; breach of duty of care; suffered an injury; defendant's
conduct caused the plaintiff harm

Spoliation addresses what method of discovery?


What would be considered "best practice" for handling fax
transmission of a physician's orders?

Treat faxed orders like verbal orders and require authentication of
the orders by appropriate medical staff within the required period

One of the greatest threats to the confidentiality of health data is

disclosure of information for purposes not authorized in writing by
the patient

A written consent from the patient is required from this entity in
order to learn a patient's HIV status

insurance companies

In this type of facility the Privacy Act of 1974 permit patients to
request amendments to their medical record

Department of Defense health care facility


The action or crime of making a false spoken
statement damaging to a person's reputation; make false and damaging
statements about someone


the action of damaging the good reputation of someone;
slander or libel


a published false statement that is damaging to a person's
reputation; a written defamation


the offense of willfully telling an untruth in a court after having
taken an oath or affirmation

The legislation that required all federally funded facilities to
inform patients of their rights under state law to accept or refuse
medical treatment is known as

Patient Self-Determination Act

To be admitted into court as evidence, medical records or health
information are introduced as

business records or exception to hearsay rule

The doctrine that the decisions of the court should stand as
precedents for future guidance is

stare decisis

Who determines the retention period for health records?

state and federal governments

What health care system has to comply with the requirements of the
Freedom of Information Act?

veterans' hospitals

When a health care facility fails to investigate the qualifications
of a physician hired to work as an independent contractor in the
emergency room and is accused of negligence, the health care facility
can be held liable under

corporate negligence

corporate negligence

the legal doctrine that holds health-care facilities, such as
hospitals, nursing homes and medical clinics, responsible for the
well-being of patients

contributory negligence

failure of an injured plaintiff to act prudently, considered to be a
contributory factor in the injury suffered, and sometimes reducing the
amount recovered from the defendant

respondeat superior

let the master answer"
a US legal doctrine which states that, in many
circumstances, an employer is responsible for the actions of
employees performed within the course of their employment.

general negligence

a failure to exercise the care that a reasonably prudent person would
exercise in like circumstances


a wrongful act or an infringement of a right (other than under
contract) leading to civil legal liability

A valid authorization for the disclosure of health information should
not be

dated prior to discharge of the patient

Which type of law is constituted by rules and principles determined
by legislative bodies?

statutory law

statutory law

the term used to define written laws, usually enacted by a
legislative body

case law

the law as established by the outcome of former cases

common law

the part of law that is derived from custom and judicial precedent
rather than statutes

administrative law

the body of law that regulates the operation and procedures of
government agencies

The Darling v. Charleston Community Memorial Hospital case
established the this doctrine for hospitals to observe and changed the
way hospitals dealt with liability.

doctrine of corporate negligence

In what circumstance would a release of information without the
patient's authorization be permissible?

release to state workers' compensation agencies

HIM professionals have a duty to maintain health information that
complies with

federal statutes, state statutes, and accreditation standards

Courts have released adoption records based on

a court order for good cause

The minimum record retention period for patients who are minors is

age of majority plus the statute of limitations

Hospitals that destroy their own medical records must have a policy that

ensures records are destroyed and confidentiality is protected

The premise that charitable institutions could be held blameless for
their negligent acts is known as

doctrine of charitable immunity

Substance abuse records cannot be redisclosed by a receiving facility
to another health care facility unless the

patient gives written consent

What legal requirement would compel you to produce the original
record for the court?

best evidence rule

best evidence rule

a legal principle that holds an original copy of a document as
superior evidence

constitutional law

refers to rights carved out in the federal and state constitutions

The body of law founded on custom, natural justice and reason, and
sanctioned by usage and judicial decision is known as

common law

doctrine of res ipsa loquitur

a doctrine that infers negligence from the very nature of an accident
or injury, in the absence of direct evidence on how any defendant behaved

Under the RBRVS, each HCPCS/CPT code contains three components, each
having assigned relative value units. These three components are

physician work, practice expense, and malpractice insurance expense

The category �Commercial payers� includes private health information and

employer-based group health insurers

Under APCs, payment status indicator "V" means

clinic or emergency department visit (medical visits)

What would be considered "technical" components?

radiologic technicians, radiological equipment, and radiological supplies.

Currently, which prospective payment system is used to determine the
payment to the "physician" for physician services covered
under Medicare Part B, such as outpatient surgery performed on a
Medicare patient?


This is the amount the facility actually bills for the services it provides.


lifetime reserve days

Original Medicare covers up to 90 days in a hospital per benefit
period and offers an additional 60 days of coverage with a high
coinsurance. These 60 reserve days can be used only once during your
lifetime but do not have to be applied towards the same hospital stay.

The Health Insurance Portability and Accountability Act (HIPAA)
requires the retention of health insurance claims and accounting
records for a minimum of ____ years, unless state law specifies a
longer period.


These are assigned to every HCPCS/CPT code under the Medicare
hospital outpatient prospective payment system to identify how the
service or procedure described by the code would be paid.

payment status indicator

This best describes the situation of a provider who agrees to accept
assignment for Medicare Part B services

The provider cannot bill the patients for the balance between the
MPFS amount and the total charges

This is the difference between what is charged and what is paid.

contractual allowance`

the OIG's Workplan

This document is published by the Office of Inspector General (OIG)
every year. It details the OIG's focus for Medicare fraud and abuse
for that year. It gives health care providers an indication of general
and specific areas that are targeted for review. It can be found on
the Internet on CMS's Web site.

Medicare Physician Fee Schedule (MPFS)

This prospective payment system replaced the Medicare physician
payment system of "customary, prevailing, and reasonable
(CPR)" charges whereby physicians were reimbursed according to
their historical record of the charge for the provision of each service.

In 1987, OBRA helped shift the focus in long-term care to patient
outcomes. As a result, core assessment data elements are collected on
each SNF resident as defined in the


OBRA mandates

comprehensive functional assessments of long-term care residents
using the Minimum Data Set for Long-Term Care

When health care providers are found guilty under any of the civil
false claims statutes, the Office of Inspector General is responsible
for negotiating these settlements and the provider is placed under a

Corporate Integrity Agreement

Corporate Integrity Agreement (CIA)

an enforcement tool used by the Office of the Inspector General (OIG)
within the Department of Health and Human Services (HHS), to improve
the quality of health care and to promote compliance to health care regulations

You want to construct a data display for a frequency distribution.
You will use a

frequency polygon or histogram

patient encounter

All cases where the EP and the patient have an actual physical
encounter with the patient in which they render any service to the
patient should be included in the denominator as seen by the EP.

analytic study design

groups of subjects are compared in order to estimate the magnitude of
association between exposures and outcomes

descriptive study

Any study that is not truly experimental

The best form/graph for demonstrating trends over time would be

line graph

If a constant is added to all measurements within a sample

the standard deviation remains the same

A researcher has repeated the same study 10 times. Each time the
study is repeated, the p value decreases. As the p
value approaches zero, the

chance that the results are due to a sampling error decreases


the theory that all knowledge is derived from sense-experience

inductive reasoning

a logical process in which multiple premises, all believed true or
found true most of the time, are combined to obtain a specific
conclusion, is often used in applications that involve prediction,
forecasting, or behavior.

deductive reasoning

a logical process in which a conclusion is based on the concordance
of multiple premises that are generally assumed to be true, is
sometimes referred to as top-down logic.

The name given to the error committed when the null hypothesis is
rejected and it is actually true is

type I error

type I error

the incorrect rejection of a true null hypothesis (a "false positive")

type II error

the failure to reject a false null hypothesis (a "false negative")

null hypothesis

(in a statistical test) the hypothesis that there is no significant
difference between specified populations, any observed difference
being due to sampling or experimental error

alternative hypothesis

the hypothesis to be accepted if the null hypothesis is rejected

selection bias

the selection of individuals, groups or data for analysis in such a
way that proper randomization is not achieved, thereby ensuring that
the sample obtained is not representative of the population intended
to be analyzed.

Given a positively skewed frequency distribution

larger frequencies are concentrated at the low end of the variable

central tendency

the degree of clustering of the values of a statistical distribution
that is usually measured by the arithmetic mean, mode, or median.

You have made a list of the advantages and disadvantages of a measure
of central tendency.
The measure of central tendency you are describing is the


Measurements within sample A are assumed to be more variable than
measurements within sample B when

individuals within sample A differ more from one another than
individuals within sample B

descriptive stats

a set of brief descriptive coefficients that summarizes a given data
set, which can either be a representation of the entire population or
a sample

T test

a statistical examination of two population means. examines whether
two samples are different and is commonly used when the variances of
two normal distributions are unknown and when an experiment uses a
small sample size.


analysis of variance, a statistical method in which the variation in
a set of observations is divided into distinct components

gross (hospital) death rate

total inpatient deaths x 100/total discharges = % death rate
Fetal deaths and outpatient deaths are not included in this calculation.

the direct method, bed turnover

adult and peds discharges/total adult and peds beds = % turnover

Twelve new cases of a certain disease occurred during the month of
August. If 4,000 persons were at risk during August, then the

incidence was 3 per 1,000 persons


the fact or condition of being prevalent; commonness


the occurrence, rate, or frequency of a disease, crime, or something
else undesirable

Multiple births are _____ delivery


fetal deaths are counted as


According to current theory in the quality management field, should
concurrent data collection or retrospective data collection be utilized?

Concurrent and retrospective data collection methods are both
necessary in order to effect meaningful interventions and contain costs.

The person or group who is overall responsible and accountable for
maintaining the quality and safety of patient care is the

Board of Directors (BOD) or governing body

type of review in which a physician's record is reviewed by his or
her professional colleagues

peer review

What is the best tool for differentiating between common cause
variation and special cause variation?

control chart

To properly implement performance improvement (PI), organizations
should ensure that all employees participate in an integrated,
continuous PI program. This is known as ______.

shared leadership

Which quality management theorist focused on zero defects as the goal
of performance improvement efforts?


The U.S. federal government's CMS substitutes compliance of its
Conditions of Participation requirements to hospitals that already
have accreditation awarded by various other agencies that include the
Joint Commission, CARF, AOA, or AAAHC. This is known as

deemed status

The FOCUS PDCA model used in performance improvement is best known
for its change strategy technique of

Plan, Do, Study, Act

UCL (upper control limit)

A value that indicates the highest level of quality acceptable for a
product or service.

What criterion is critical in selecting performance indicators for a
health information management department?

The indicators must include the most important aspects of performance

affinity diagram

a tool that gathers large amounts of language data (ideas, opinions,
issues) and organizes them into groupings based on their natural
relationships (Viewgraph 1). The Affinity process is often used to
group ideas generated by Brainstorming.


a diagram of the sequence of movements or actions of people or things
involved in a complex system or activity

What quality indicator would identify improvement needs in hospital
electronic transmission of health care claims and remittances to allow
interoperability with ICD-10 codes?

an increase in 5010 rejections

5010 rejections

HIPAA form/rejections

Your hospital is required by the Joint Commission and CMS to
participate in national benchmarking on specific disease entities for
quality of care measurement. This required collection and reporting of
disease-specific data is considered

a series of core measures

core measures

standardized best practices designed to improve patient care

clinical pertinence review

a retrospective review of patient medical records to ensure proper documentation

The Recovery Audit Contractor (RAC) program was developed to identify
and reduce improper payments for

Medicare claims

What feature is a trademark of an effective PI program?

a continuous cycle of improvement projects over time

The type of indicator about the placement and number of fire
extinguishers would be a(n)


The manager of the utilization review department wants to monitor and
evaluate the prevention of inappropriate admissions. When would the
manager need to collect data?

prospective review

When the policy and procedures manual no longer reflect current
practices, it creates a situation that becomes a risk management issue because

policy and procedures should represent the normal course of business

If administrators of a home health agency wanted to measure the
outcomes of adult patients receiving their agency's services, which
tool would they use?


Which data bank is a result of HIPAA legislation?

Health Care Integrity and Protection Data Bank

The responsibility for performing quality monitoring and evaluation
activities in a departmentalized hospital is delegated to the

clinical chairpersons of medical staff committees or ancillary
department directors

Most acute care facilities use this type of screening criteria for
utilization review purposes to determine the need for inpatient
services and justification for continued stay

severity of illness/intensity of service criteria (SI/IS)

The quality review process of invasive and noninvasive procedures to
ensure performance of appropriate procedure, preparation of patient,
monitoring and postoperative care, and education of patient describes

surgical review

nominal group technique

a group process involving problem identification, solution
generation, and decision making

Which quality management theorist believed that merit raises, formal
evaluations, and quotas established through benchmarking hinder worker
productivity and growth?

W. Edwards Deming

What quality indicator would identify improvement needs in hospital
electronic transmission of health care claims and remittances to allow
interoperability with ICD-10 codes?

an increase in 5010 rejections

The Joint Commission on-site survey process incorporates tracer
methodology, which emphasizes surveyor review by means of

both system tracers and patient tracers

Storyboards are a method used in health care that

graphically display a performance improvement project conducted

The medical malpractice crisis of the 1970s prompted the development
of _____________________ in health care facilities.

risk management

The primary advantage of concurrent quality data collection is that

chart completion issues can be remedied promptly

The Joint Commission's emphasis on improving quality of patient care
for a participating facility is exemplary through the required
self-assessment process tool known as

intracycle monitoring

intracycle monitoring

helps organizations with their continuous standards compliance
efforts. Every accredited organization has access to an ICM Profile,
an online workspace on The Joint Commission Connect extranet.

real-time analytics

the use of, or the capacity to use, all available enterprise data and
resources when they are needed. It consists of dynamic analysis and
reporting, based on data entered into a system less than one minute
before the actual time of use.

focused standards asessment

provides organizations with an easy-to-use, interactive standards
self-assessment scoring tool and is located within the ICM Profile

total quality management (TQM)

A management approach to long�term success through customer
satisfaction. All members of an organization participate in improving
processes, products, services, and the culture in which they work.

What feature distinguishes the Nominal Group Technique (NGT) from brainstorming?

NGT determines the importance of responses through a rating system

What quality improvement (QI) tool uses criteria to weigh different
alternatives? This display would assist in viewing all relevant
information at the same time.

a decision matrix



PDSA method

a �trial-and-learning� method to test changes quickly to see how they work

The U.S. federal government's CMS substitutes compliance of its
Conditions of Participation requirements to hospitals that already
have accreditation awarded by various other agencies that include the
Joint Commission, CARF, AOA, or AAAHC. This is known as

deemed status

The process of reviewing and validating qualifications, granting
professional or medical staff membership, and awarding delineated
privileges is called the _____.


What is this chart:

affinity diagram

What is this chart:

arrow diagram

What is this chart:

bar chart

What is this chart:

cause-and-effect diagram

What is this chart:


What is this chart:

control chart

What is this chart:

decision matrix

What is this chart:

line chart

What is this chart:

Pareto chart

What is this chart:

run chart

What is this chart:

scatter diagram

The Occupational Safety and Health Act of 1970, the Americans with
Disability Act, and the Vocational Rehabilitation Act are all federal
legislation designed to

keep the workplace safe and accessible to all employees and customers

Qualified employees should be given priority when vacancies
within the organization occur" is an example of

a policy of the organization

when setting productivity levels, a supervisor must

determine the productivity standards for each area and job function

A job analysis includes the

collection of data to determine the content of a job

A rule

predecides issues

Personal experience is


first trimester

week 1 through week 12

second trimester

week 13 to week 27

third trimester

week 28 to the birth

In project management, the series of specific tasks that determine
the overall project duration is referred to as

critical path

project network

is always drawn from left to right to reflect project chronology

The formalized road map that describes how your institution executes
the chosen strategy defines

strategic planning

the Wagner Act

The National Labor Relations Act (NLRA), which serves as the
foundation for U.S. labor laws and collective bargaining

Strong lateral relationships within a facility are most likely when

individual departments cooperate together to achieve organizational goals


a tool for strategic thinking

executive dashboard

a manager's version of a pilot's cockpit that contains all the
critical information for leading the organization

payback period (formula)

initial investment/annual cash flow

Lilly Ledbetter Fair Pay Act

An amendment to the Civil Rights Act of 1964 that extends the 180-day
statute of limitations previously applied to the filing of an
equal-pay lawsuit

unity of command

an employee is responsible to only one supervisor, who in turn is
responsible to only one supervisor, and so on up the organizational hierarchy

grievance procedure

a means of dispute resolution that can be used by a company to
address complaints by employees, suppliers, customers, and/or competitors

span of control

the area of activity or number of functions, people, or things for
which an individual or organization is responsible

organizational function

an organization's reporting relationships are grouped based on
specialty, or functional area

replacement chart

a forecasting technique used in succession planning to help companies
visualise key job roles, current employees and existing and future
vacancies. Positions are mapped alongside information such as
potential replacements, gender and promotion potential.

A basic concept of office layout and workflow is that the

paper moves to the employee

strategic plans

Written documents that assist an organization in achieving its
objectives and carrying out its mission statement

calculate the minimum number of FTEs for transcription (formula)

lines per day X workdays per month / lines transcribed per month

cost per line (formula)

total hours worked X hourly cost / lines per month

The span of control in an organization refers to the

number of people who report to one supervisor

information governance

An initiative that focuses on the view that data as a strategic asset
needs to be protected and accounted for across all levels of the
health care enterprise

percentage of cost variance (formula)

budgeted expense � actual expense = ? ? X 100 / budgeted expense

�A job analysis includes the

collection of data to determine the content of a job

Maslow's hierarchy of needs

From bottom up on the pyramid: "physiological",
"safety", "belongingness/love",
"esteem", "self-actualization",

Love and belongingness needs

friendship, intimacy, affection and love, - from work group, family,
friends, romantic relationships.

Biological and Physiological needs

air, food, drink, shelter, warmth, sex, sleep

Safety needs

protection from elements, security, order, law, stability, freedom
from fear

Esteem needs

achievement, mastery, independence, status, dominance, prestige,
self-respect, respect from others

Self-Actualization needs

realizing personal potential, self-fulfillment, seeking personal
growth and peak experiences

percentage of time was spent on coding (formula)

Remember to convert the hours to minutes!
Charts coded X minutes per chart = ? minutes coding
Hours worked X 60 minutes = ? minutes worked
Minutes coding / minutes worked = % spent on coding

sequence of steps most effective in order to improve efficiency and productivity

Know the objective
break down the work into component activities
group activities into proper organizational units

job grading

a systematic way of determining the value/worth of a job in relation
to other jobs in an organization

factor comparison

A scientific method designed to rank job roles based on a breakdown
of factors rather than the role as a whole. The ultimate goal is to
assign the relative parts of each job role a financial value i.e. the
amount of compensation offered for that part of the role.

job ranking

jobs are arranged in order of their value or merit to the organization

The MDS is designed for use in

long-term care facilities

APCs, payment status indicator "T" means

significant procedure, multiple procedure reduction applies.


(of training) intended for those actively engaged in the profession
or activity concerned.

information system analysis phases

the health information managers primary goal is to provide a system
that meets user or department needs and that also supports the
strategic objectives of the enterprise including current and emerging
privacy and security concerns

initiation IS life cycle

is the method through which organizations make decisions to invest in
particular information systems

implementation IS life cycle

involves making the system operational in the organization

operations IS life cycle

personnel (clinical and administrative) who use the systems grow
dependent on them to do their jobs. (It is running well and meeting
the needs of the department.)

What type of system would be purchased to provide information on the
census, update the master patient index, and distribute demographic data?

executive information system

The patient has the right to control access to his or her health
information. This is known as


scope creep

in project management refers to uncontrolled changes or continuous
growth in a project's scope. This can occur when the scopeof a project
is not properly defined, documented, or controlled. It is generally
considered harmful.


an official appointed to investigate individuals' complaints against
maladministration, especially that of public authorities

Donabedian's framework

structure, process, and outcome

nuchal rigidity

impaired neck flexion resulting from muscle spasm (not actual
rigidity) of the extensor muscles of the neck; usually attributed to
meningeal irritation

Human Resources use a systematic procedure to determine the relative
worth of a position to the organization. When this approach is used,
compensation for the position is most likely based on

job evaluation

root cause analysis

fishbone diagram

Fulguration of anal warts. Identify the approach.


The most important consideration in planning the office layout for a
Health Information Services department is the


Spinal fusion cervical C1-C2 (root operation)


In statistics, the notation "?XY" means

multiplied each pair of the X and Y scores, then summed their values

Removal of a foreign body right external auditory canal (root operation)


Angioplasty abdominal iliac artery (root operation)


forming stage

The stage of group development when the team discusses its purpose,
defines and assigns tasks, establishes timelines, and begins forming
personal relationships.

storming stage

The stage of group development when the team clarifies its goals and
its strategy for achieving them (often-contentious).

norming stage

The stage of group development when the team establishes its values
for how individuals will interact and collaborate.

performing stage

The stage of group development when team members have productive
relationships and are able to communicate and coordinate effectively
and efficiently.

The Phalen's wrist flexor test is a noninvasive method for diagnosing

carpal tunnel syndrome

Radiology codes would be used for

the supervision and interpretation

What federal legislation passed in 1986 gave immunity from legal
action to practitioners regarding some peer review process activities?

Healthcare Quality Improvement Act

Colon polyp fulguration (root operation)



a congenital condition that is the most severe neural tube defect

An area identified for needed improvement through benchmarking and
continuous quality improvement is known as a

key performance indicator

Percutaneous placement of pacemaker lead. Identify the approach.


Stopping of postoperative tonsillectomy hemorrhaging is coded to
which root operation?


Which endocrine gland secretes epinephrine, which activates the
�fight or flight� response and increases blood pressure and metabolism?

adrenal medulla

Needlesticks, patient or employee falls, medication errors, or any
event not consistent with routine patient care activities would
require risk reporting documentation in the form of an

incident report

Excision gallbladder (root operation)


A major disadvantage of cross-sectional studies is that

the time sequence of exposure and disease is usually not known

Removal deep left vein thrombosis (root operation)


A histogram is a valuable tool for representing

a frequency distribution with continuous-interval data

delineation of privileges

(Physician credentialing) those specific services and procedures that
a physician is deemed qualified to provide or perform

The Director of a Health Information Department prepared a document
in which the following information could be obtained: job title,
reporting line, span of control, and routes of promotion. The document
she was preparing was a(n)

organizational chart

An elevated serum amylase would be characteristic of

acute pancreatitis

A complete redo of a knee replacement requiring a new prosthesis is
coded to which root operation(s)?

Removal, Replacement

What process is mandatory for health care facilities?


With the passage of Medicare (Title XVIII of the Social Security Act)
in 1965, what function became mandatory?

utilization review

The PQRS is a reporting system established by the federal government
for physician practices who participate in Medicare for

quality measure reporting


Physician Quality Reporting System

Dilation of the ureter with insertion of a stent is coded to which
root operation?


cross-sectional or prevalence studies are known for

concurrently describing characteristics and health outcomes at one
specific point in time

The standard deviation of a particular set of measures was found to
be 20.00. The sample variance would then be:


Diabetic microvascular disease occurs

as a direct result of elevated serum glucose

cells produce histamine in a type I hypersensitivity reaction

mast cells

Which type of joint, such as the sutures of the skull, has no movement?


Percutaneous needle biopsy left lung (root operation)


In the Medical Surgical Section, the seventh character position represents?


Lithotripsy left ureter with removal of fragment (root operation)


ERCP. Identify the approach.



Endoscopic retrograde cholangiopancreatography

Scabies, a highly contagious condition that produces intense pruritus
and a rash, is caused by

itch mites

The most fatal type of lung cancer is

small cell cancer

Ligation right fallopian tube (root operation)


ESWL left ureter. Identify the approach.



Extracorporeal shock wave lithotripsy




(of a quantity) having only magnitude, not direction. a scalar quantity.

chain of command principle

(sometimes called the scaler chain) is the formal line of authority,
communication, and responsibility within an organization. The chain of
command is usually depicted on an organizational chart.

According to Frederick Herzberg, challenging work, recognition of
workers and their accomplishments, and employee self-improvement are
examples of


Removal cardiac pacemaker (root operation)


What method of performance appraisal requires the supervisor to
document exceptional behavior by the employee?

Critical Incident Method

Creation of arteriovenous graft brachial artery left arm for
hemodialysis (root operation)


The Six Sigma methodology differs from other quality improvement
models by defining improvement opportunities using

critical quality tree

The credentialing process requires healthcare facilities to

watch the provider perform surgery

What process assists a health care facility in continuously looking
at the ways that problems develop and seeking ways to prevent problems
from happening in the future?

performance improvement


necessary for (someone) as a duty or responsibility


of or relating to illness caused by medical examination or treatment


is a system for documenting the extent or spread of cancer

The special form or view that plays the central role in planning and
providing care at skilled nursing, psychiatric, and rehabilitation
facilities is the

interdisciplinary patient care plan

Release of information has increased its use of part-time prn
clerical support in order to respond to increased requests for release
of information. The budget variance report will reflect

the increase in the cost of part-time clerical support for ROI but
not the increase in revenue from this area


regional health information organization

regional health information organization (RHIO)

a type of health information exchange organization (HIO) that brings
together health care stakeholders within a defined geographic area and
governs health information exchange among them for the purpose of
improving health and care in that community.

The purpose of a Health Information Exchange (HIE) is to

improve health care delivery and information gathering

A _________uses a private tunnel through the Internet as a transport
medium between locations for secure access and transmission.


Authentication is one of the components necessary to produce a legal
document in an EHR. This means

identifying who created a document and when

An effective means of protecting the security of computerized health
information would be to

develop clear policies on data security that are supported by the top
management of the facility

In order to prevent the accidental introduction of a virus into your
facility's local area network, your facility has a policy that
strictly prohibits

downloading executable files from electronic bulletin boards


request for proposal

The decision makers in the HIM department have decided to use the
decision analysis matrix method to select coding software. Use of this
method will help ensure

consistent criteria are used to evaluate the alternatives/vendors

A section of a job description states that the incumbent will handle
day-to-day operations in the transcription and release of information
areas. This section defines the

scope of responsibility in the job

You are calculating the fee schedule payment amount for physician
services covered under Medicare Part B. You already have the relative
value unit figure. The only other information you need is

a national conversion factor

Down syndrome, Edwards' syndrome, and Patau's syndrome are all
examples of __________defects.


In your state, it is legal for minors to seek medical treatment for a
sexually transmitted disease without parental consent. When this
occurs, who would be expected to authorize the release of the medical
information documented in this episode of care to the patient's insurers?

the patient

WORM technology

a data storage technology that allows information to be written to a
disc a single time and prevents the drive from erasing the data


write once, read many

the primary consideration when making retention decisions must be

statutory requirements

Identification of threats and vulnerabilities, security measures, and
implementation priorities are part of a health care organization's

risk management plan

What condition is always considered "present on admission" (POA)?

congenital conditions

You have been asked to reduce your department's operating budget by
20%. In order to do so, you will have to effect reductions in your
largest budget line. You will have to make cuts in


The coding supervisor tends to deal with issues as they come up,
prioritizing only when problems are pressing or appear to be important
to upper management. This crisis manager is particularly weak in which
management function?


The transcriptionists have collected data on the number and types of
problems with the dictation equipment. The best tool to display the
data they collected is a

Pareto chart

A union campaign is being conducted at your facility. As a department
manager, it is appropriate for you to tell employees that

you are opposed to the union

A common goal of the Office of the National Coordinator for Health
Information Technology, RHIOs, and a national infrastructure for
information is

sharing information among providers

Health information exchange is a term used to refer to a

plan in which health information is shared among providers.

Your HIM department is moving to a new location and in order to
arrange your employees and functions for optimal work flow efficiency
and to decide which employees need to be placed close to each other,
the tool you decide to use is a

flow process chart

In reviewing the policies on release of information in respect to the
privacy rules, you note that it is still acceptable to allow release
of protected health information without patient permission to

the quality assurance committee for review purposes

The purpose of the Correct Coding Initiative is to

detect and prevent payment for improperly coded services

A run or line chart would be most useful for collecting data on

waiting time in the Pediatrics Clinic

E-mails and text messages are

considered health care business records and are subject to the same
regulations as records created in face-to-face patient encounters

Critical to implementations and project success, the WBS

lists steps needed to complete the project

Evidence-based management and decision making is an emerging model
now used to make more informed decisions. The premise of this model is

using the best clinical and research practices available

Community Hospital reported an average LOS in December of 3.7 days
with a standard deviation of 23. This information indicates that

there was a large variation in the LOS at Community Hospital


Picture archiving and communication systems

Access to radiologic images has been improved through the use of


Picture archiving and communication systems (PACS) provide

a means to store and rapidly access digitized file images

The committee that is preparing your acute care hospital for an
electronic health record is planning for an imaging system for record
archiving in the immediate future. They are looking for a solution for
data interfacing or integration of the imaging system into other
computer systems. You recommend

Health Level 7 standards.

A patient has written to request a copy of his own record. When the
clerk checked the record, it was noted that the patient was last
admitted to the psychiatric unit of the facility. You advise the clerk to

contact the patient's attending physician before complying.

A p value of less than 0.05 is what researchers commonly use
to reject the null hypothesis. A smaller p value may place
interpretation of the results of the study at risk for a

sampling error

Joanie Howell presents to Dr. Franklin requesting rhinoplasty.
Because Howell is covered by Medicare, Dr. Franklin must provide
Howell with

an Advance Beneficiary Notice, because Howell's rhinoplasty may not
be medically necessary

The protocol that allows a browser to connect to a server and
authenticate identities for data transfer is known as a(n)
____________ connection.

secure socket layer

Generally, CMS requires the submission of a claim (CMS 1450) for
inpatient services provided to a Medicare beneficiary for inpatient
services. An exception to this requirement would be when

the beneficiary refuses to authorize the submission of a bill to Medicare

According to CPT, a biopsy of the breast that involves removal of
only a portion of the lesion for pathologic examination is


a checklist for assessing an obstetric patient's lochia, fundus, and
perineum would be on what type of document

postpartum record

The discharge diagnosis for this inpatient encounter is rule out
myocardial infarction. The coder would assign

a code for a myocardial infarction

A piece of objective data collected upon initial assessment of the
patient is the

vital signs

A major key to forms control in this setting is

giving each form or view an identifiable name, number, and revision date

As part of a team responsible for revenue analysis at your facility,
you recommend a yearly review of

the OIG Workplan

compression fracture of the vertebrae as a result of bone metastasis

a pathologic fracture

A technique that uncovers new information from existing information
by probing data sets is known as

data mining

The 2014 AHIMA Foundation's �Clinical Documentation Improvement Job
Description Summative Report� identified that most Clinical
Documentation Improvement Specialists report directly to the

HIM Department

The use of "public" and "private" keys is part of
what type of data protection?


The CFO of your facility asks you to prepare a budget for the fiscal
year based on the past volume and expected capacity for the coming
year. This process is an example of using the
"_____________" budgeting method.

fixed budget

Reference checks are conducted on potential employees to help assess
the applicant's fit with the position and also to

confirm the accuracy of information provided on the application

ORYX is a program that was developed by

Joint Commission to link patient outcomes to accreditation

The most sophisticated level of interoperability of an EHR and other
such systems is the ______________ level.


define the Global Surgical Package

all necessary services normally furnished by a surgeon before,
during, and after a procedure defined by Medicare.


home medical equipment (HME) / durable medical equipment (DME)

ER physician performs an LP and orders a CSF analysis with a
bacterial culture and sensitivity. The physician is attempting to
comfirm a diagnosis of

meningitis due to Neisseria meningitidis-positive cerebrospinal fluid.

Which department will most likely be responsible for taking
corrective action regarding the number of insurance claims requiring
resubmission due to errors (not related to coding) not exceeding 3%?

Business Office

root cause analysis

a method of problem solving used for identifying the root causes of
faults or problems and is reportable to the Joint Commission

To ensure consistency of coverage among trainers, you may want to develop

training manuals

In statistics, the notation "?XY" means

multiplied each pair of the X and Y scores, then summed their values

Information Governance

the activities and technologies that organizations employ to maximize
the value of their information while minimizing associated risks and costs.

information governance initiative

a cross-disciplinary consortium and think tank dedicated to advancing
the adoption of information governance practices and technologies
through research, publishing, advocacy and peer-to-peer networking.

What is the stage where teams may experience disequilibrium?


delineation of privileges

specific services and procedures that a physician is deemed qualified
to provide or perform

When a physician orders a liver panel, what tests would be included?

albumin, bilirubin, alkaline phosphatase

pulmonary angiography

Pulmonary blood vessels are x-rayed to detect arteriovenous malformations.

Direct angiography

the injection of radiocontrast into the circulation with subsequent
fluoroscopy (direct X-ray visualisation) of the lungs

lung scan

a nuclear scanning test that is most commonly used to detect a blood
clot that is preventing normal blood flow to part of a lung (pulmonary embolism)


the progression of cancer


request for proposal

What system might an HIM Director most likely recommend in the early
stages of the project as a transition strategy for having the entire
health record content recorded in discrete form within the next 10 years?

electronic document management system

A final progress note is an appropriate discharge summary for

the delivery a healthy 8-pound baby without complications for either
mother or child, and both discharged within 36 hours of admission

A surgical operation is

one or more surgical procedures performed at one time for one patient
using a common approach or for a common purpose

A patient is admitted through the emergency department. Three days
after admission, the physician documents uncontrolled diabetes
mellitus. What is the "present on admission" (POA) indicator
for uncontrolled diabetes mellitus?


respondeat superior

let the master answer"
a US legal doctrine which states that, in many circumstances, an
employer is responsible for the actions of employees performed within
the course of their employment.


work breakdown structure

work breakdown structure (WBS)

a chart in which the critical work elements, called tasks, of a
project are illustrated to portray their relationships to each other
and to the project as a whole.


records what the patient states is the problem


records what the practitioner identifies through history, physical
examination, and diagnostic tests


combines the subjective and objective into a conclusion


what approach is going to be taken to resolve the problem


Advance Beneficiary Notice

Advance Beneficiary Notice (ABN)

also known as a waiver of liability
a notice you should receive when a provider or supplier offers
you a service or item they believe Medicare will not cover. ABNs only
apply if you have Original Medicare, not if you are in a Medicare
Advantage private health plan.

Generally, CMS requires the submission of a claim (CMS 1450) for
inpatient services provided to a Medicare beneficiary for inpatient
services. An exception to this requirement would be when

the beneficiary refuses to authorize the submission of a bill to Medicare

CMS 1500

Health Insurance Claim Form

CMS 1450

(aka UB-04 at present)
can be used by an institutional provider to bill a Medicare
fiscal intermediary (FI) when a provider qualifies for a waiver from
the Administrative Simplification Compliance Act (ASCA) requirement
for electronic submission of claims. It is also used for billing of
institutional charges to most Medicaid State Agencies.

an obstetric patient's lochia, fundus, and perineum may be found on
what document?

postpartum record

As the Information Security Officer at your facility, you have been
asked to provide examples of technical security safeguards adopted as
a result of HIPAA legislation. Which of the following would you provide?

surge protectors

You are conducting an educational session on benchmarking. You tell
your audience that the key to benchmarking is to use the comparison to

improve your department's processes

The most sophisticated level of interoperability of an EHR and other
such systems is the ______________ level.


PDSA cycle

is shorthand for testing a change�by planning it, trying it,
observing the results, and acting on what is learned.

You are implementing a quality improvement plan that utilizes the
PDSA cycle. If you correctly implement PDSA, which phase of the
project will take the most of your time?


The EHR system implementation team is using simulated patients and
simulated patient information to add progress notes, nurses' notes,
and so on, to the EHR prior to implementation. Which system
development life cycle phase is the team involved in?


What Web 2.0 technology would you recommend for someone who wants to
share their battle with cancer?

a blog

Your facility has decided to implement the new laboratory information
system on one unit and then add more units as your confidence in the
system grows. What go-live model are you using?


You need a system that will work with your existing system but not
necessarily from the same vendor. What type of system are you looking for?


What type of system would be purchased to provide information on the
census, update the master patient index, and distribute demographic data?

executive information system

You have been asked to develop scenarios that will be used to design
and program a new release of information system. These scenarios will
include the processes to be used in detail. What are you designing?

use cases

The patient has the right to control access to his or her health
information. This is known as


A record destruction program should include

the method of destruction

2 techniques a facility would employ for access control

automatic logoff and unique user identification

You are defining the designated record set for South Beach Healthcare
Center. What would be included?

discharge summary

Mountain Hospital has discovered a security breach. Someone hacked
into the system and viewed 50 medical records. According to ARRA, what
is the responsibility of the covered entity?

All individuals must be notified within 60 days.

The information system has just notified you that someone has
attempted to access the system inappropriately. This process is known as

intrusion detection

an example of administrative safeguards under the security rule would be

monitoring the computer access activity of the user

The police came to the HIM Department today and asked that a
patient's right to an accounting of disclosure be suspended for two
months. What is the proper response to this request?

Certainly officer. We will be glad to do that as soon as we
have the request in writing.

To prevent their network from going down, a company has duplicated
much of its hardware and cables. This duplication is called


HIPAA states that release to a coroner is allowed. State law says
that the coroner must provide a subpoena.

Follow the state law since it is stricter.

the Privacy Act of 1974 applies to the

federal government

an example of an administrative safeguard would be


Richard has asked to view his medical record. Within what timeframe
must the facility provide this record to him?

30 days

You are reviewing your privacy and security policies, procedures,
training program, and so on, and comparing them to the HIPAA and ARRA
regulations. You are conducting a

risk assessment

Your department was unable to provide a patient with a copy of his
record within the 30-day limitation. What should you do?

Write the patient and tell him that you will need a 30-day extension.

A patient signed an authorization to release information to a
physician but decided not to go see that physician. Can he stop the release?

Yes, as long has it has not been released already

Miles has asked you to explain the rights he has via HIPAA privacy
standards. What is one of his HIPAA-given rights?

He can ask to be contacted at an alternative site.

Before we can go any further with our risk analysis, we need to
determine what systems/information need to be protected. This step is
known as

system characterization

The hospital has received a request for an amendment. How long does
the facility have in order to accept or deny the request?

60 days

The main layers of the epidermis

stratum corneum
stratum lucidium
stratum granulosm
stratum spinosum
stratum germinativum (aka stratum basale)

How can Graves' disease be treated?

radioactive iodine therapy, antithyroid drugs, and surgery

When a decubitus ulcer has progressed to a stage in which
osteomyelitis is present, the ulcer has extended to the


United States healthcare providers are concerned about a possible
pandemic of avian flu because

there is no vaccine currently available, it is caused by a group of
viruses that mutate very easily, and the causative virus is being
spread around the world by migratory birds.

Clinical manifestations of this disease include polydipsia, polyuria,
polyphagia, weight loss, and hyperglycemia. What test(s) would be
ordered to confirm the disease?

glucose tolerance test

Henrietta Dawson presents with a chief complaint of pain and weakness
in her arms and neck. After an H and P and a review of diagnostic
tests that include a myelogram, her doctor diagnoses a herniated
nucleus pulposus at the _________ level of her spine.


A physician prescribes a diuretic for his patient. He could be treating

congestive heart failure, pulmonary edema, or mitral stenosis.

unity of command

an employee is responsible to only one supervisor, who in turn is
responsible to only one supervisor, and so on up the organizational hierarchy

Research has shown that productivity increases when

employees are rewarded for extra output, it becomes the primary goal
of management, and it is measured.

Employers may be able to demonstrate that age is a reasonable
requirement for a position. Such an exception to the Age
Discrimination in Employment Act (ADEA) is called a

bona fide occupational qualification

As a new RHIA and coding manager, how likely is it that you will
participate on committees?

Occasionally, mostly with your staff.

Which appraisal method places the employees into a set of ordered
groups (e.g., top 10%, above average 20%, middle 40%) on the basis of
a global measure?

forced ranking

The teaching method selected by an instructor influences the
student's ability to understand the material. Instructor-led
classrooms work best when

in-depth training and interaction are desired.

Under the Immigration Reform and Control Act

applicant must have I-9 documentation, noncitizens may not be
discriminated against, and undocumented workers may not be hired

Mission Health Systems has contracted with an agency to conduct
recruitment and screening of potential candidates. This approach is called


The term "hard coding" refers to

HCPCS/CPT codes that appear in the hospital's chargemaster and will
be included automatically on the patient's bill.

The Correct Coding Initiative (CCI) edits contain a listing of codes
under two columns titled "comprehensive codes" and
"component codes." According to the CCI edits, when a
provider bills Medicare for a procedure that appears in both columns
for the same beneficiary on the same date of service code

only the comprehensive code

Under Medicare Part B

collections are restricted to only the deductible and coinsurance due
at the time of service on an assigned claim.
fees are restricted to charging no more than the "limiting
charge" on nonassigned claims.
providers must file all Medicare claims.

The _______________ is a statement sent to the provider to explain
payments made by third-party payers.

remittance advice

What type of filing system is being used if records are filed in the
following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79?

straight numeric

In a terminal digit filing system, what would be the record number
immediately in front of record number 01-06-26?


Some advantages of a computerized master patient index are

it solves most space and retrieval problems
it allows access to data alphabetically, phonetically, or by date
of birth, social security number, medical record, or billing number
it provides other departments with immediate access to the
information maintained in the master patient index.

Lewis-Beck Medical Center has been collecting data on patient
satisfaction for six months. It is ready to start retrieving data from
the database to improve clinical services. Which tool should be used?


What would be the most cost-effective and prudent course of action
for the storage or disposition of 250,000 records at a large teaching
and research hospital?

scanning all 250,000 records for a cost of $195,000

A health information manager develops a formal plan or record
retention schedule for the automatic transfer of records to inactive
storage and potential destruction based on

volume of research, statute of limitations, and readmission rate

University Hospital, a 900-bed tertiary health care organization, is
undergoing an information systems development. What system would best
meet its needs?

Application service provider model

A file area has limited space, medium file activity, and two file
clerks. The HIM department would benefit from choosing which type of
storage equipment?

compressible filing units

The hospital administrator is making a strategic decision by querying
various institutional databases for information. What type of system
is the hospital administrator using?

executive information system

Case finding methods for patients with diabetes include a review of

medication lists
billing data
health plans

The master patient index must, at a minimum, include sufficient
information to

uniquely identify the patient

an advantage of straight numeric filing over terminal digit filing

The training period is short

For a health care facility to meet its document destruction needs,
the certificate of destruction should include

location of destruction, unique and serialized transaction number,
and acceptance of fiduciary responsibility

A health care facility has made a decision to destroy computerized
data. AHIMA recommends what as the preferred method of destruction for
computerized data?

magnetic degaussing

Color coding of record folders is used to assist in the control of


Factors to consider when developing a record retention program include

cost of space to maintain paper records, legal requirements as
determined by statute of limitations, and record usage in the facility
determined by health care provider activity

Strategies when purchasing an electronic health record system include

identify system requirements, recognize stakeholders from different
organizational levels and engage them appropriately, and determine
return on investment or cost-benefit analysis.

What data cannot be retrieved from the MEDPAR?

Non-Medicare patient data

When evaluating an outside contract microfilm company, important
factors to rate would include

cost, emergency returns, and storage after filming

data retrieval tools


In your facility, the health care providers from every discipline
document progress notes sequentially on the same form. Your facility
is utilizing

integrated progress notes

You try to convince the entire health care team to consistently enter
data into the patient's record at the time and location of service
instead of waiting for retrospective analysis to alert them to
complete the record. You are proposing

point-of-care documentation

Which of the four distinct components of the problem-oriented record
serves to help index documentation throughout the record?

problem list

The foundation for communicating all patient care goals in long-term
care settings is the

interdisciplinary plan of care

You notice on the admission H&P that Mr. McKahan, a Medicare
patient, was admitted for disc surgery, but the progress notes
indicate that due to some heart irregularities, he may not be a good
surgical risk. Because of your knowledge of COP regulations, you
expect that a _______________ will be added to his health record.

consultation report

As a new HIM manager of an acute care facility, you have been asked
to update the facility's policy for a physician's verbal orders in
accordance with Joint Commission standards and state law. Your first
area of concern is the qualifications of those individuals in your
facility who have been authorized to record verbal orders. For this
information, you will consult the

Hospital Bylaws, Rules, and Regulations

The first patient with cancer seen in your facility on January 1,
2015, was diagnosed with colon cancer with no known history of
previous malignancies. The accession number assigned to this patient is


Gerda Smith has presented to the ER in a coma with injuries sustained
in a motor vehicle accident. According to her sister, Gerda has had a
recent medical history taken at the public health department. The
physician on call is grateful that she can access this patient
information using the area's


In determining your acute care facility's degree of compliance with
prospective payment requirements for Medicare, the best resource to
reference for recent certification standards is the

Federal Register

Data reliability implies

that data are consistent no matter how many times the same data are
collected and entered into the system

Accessibility implies

that data are available to authorized people when and where needed

Legibility implies

data that are readable

Completeness implies

that all required data are present in the information system

Data comprehensiveness

refers specifically to the presence of all required data elements

Quantitative analysis involves

checking for the presence or absence of necessary reports and/or signatures

Qualitative analysis may involve

checking documentation consistency, such as comparing a patient's
pharmacy drug profile with the medication administration record

Data Elements for Emergency Departments

recommended data set for hospital-based emergency departments

Uniform Hospital Data Set

required data set for acute care hospitals

Minimum Data Set

required data set for long-term care facilities


an initiative of Joint Commission whereby five core measures are
implemented to improve safety and quality of health care

Data accuracy denotes that

data are correct values

Data comprehensiveness denotes that

all data items are included

Data granularity denotes that

the attributes and values of data should be defined at the correct
level of detail

Data precision denotes that

data values should be just large enough to support the application of process

Time and means of arrival is required on

ED records only

Evidence of known advance directive is required on

inpatient records only

Problem list is required on

ambulatory records by the third visit

One record documentation requirement shared by BOTH acute care and
emergency departments is

patient's condition on discharge

The Minimum Data Set is a basic component of the

long-term care RAI

UHDDS is used in

acute care

OASIS is used in

home health

DEEDS is used in

emergency departments

The federally mandated resident assessment instrument used in
long-term care facilities consists of three basic components,
including the new care area assessment, utilization guidelines, and the


In creating a new form or computer view, the designer should be most
driven by

needs of the users

Managers are

Held responsible for handling the organization�s resources

The practice of management is

Influenced by the context of the organization

Systems thinking

Is an objective way of looking at ideas and processes

A graphic representation of the organization�s formal structure is called

An organizational chart

The mission statement

Is updated regularly as part of the strategic planning process

Supervisory managers are primarily responsible for

Monitoring everyday performance

Developing, implementing, and revising the organization�s policies is
the role of

Middle managers

Ultimate responsibility for the operation of healthcare organizations
lies with

The board of directors

Planning, organizing, controlling, decision making, and leadership
are the functions of


Strategic planning is primarily concerned with

How the organization will respond to changes in the environment

Within an organization it is the supervisor�s role to determine

How the work will be accomplished by the team

In modern management theory, control is most important when applied to

Processes and other resources

The director of the department is Bob. Sally, the coding supervisor
and five other supervisors, report to Bob. Tim and 10 other coders
report to Sally. This describes what management concept?

Chain of command

Strengthening others by sharing information and power is a
characteristic of


A summary of the position, a list of duties, and the qualifications
required to perform the job are all elements of a

Position description

Performance standards are used to

Communicate performance expectations

Position descriptions, policies and procedures, training checklists,
and performance standards are all examples of

Human resource tools

Procedures should be complete enough so that

Anyone generally competent for that position can perform the task

The department�s orientation checklist would include a

Review of communication policies
Description of how to request time off
Review of departmental goals

During training, the employee should be

Encouraged to ask questions

Teams often fail to succeed when

The leader dominates the team

Setting a clear deadline is an important step in


Discovering each individual�s talents and maximizing them is the role
of the


Periodic performance reviews

Encourage good performance

Disciplinary action

Should be documented at each step

Constructive confrontation is one form of

Conflict management

Grievance procedures

Are defined in the union contract

On-the-job training

Is one option for staff development

During times of change, it is important for the supervisor to

Hold on to the vision

The budget

Is the financial plan for the coming time period

Zero-based budgeting is not

Based on work volume and unit cost

Before beginning to budget at the department level, it is important
to understand

What the organization�s budget assumptions are

Monitoring ongoing revenues and expenses and verifying actual
expenses are important steps in

Financial control

What is the goal of clinical practice guidelines?

To standardize clinical decision making

What is the largest healthcare standards-setting body in the world?

Joint Commission

What is not a responsibility of a healthcare organization�s
quality management department?

Using medical peer review to identify patterns of care

What are the responsibilities of a healthcare organization�s quality
management department?

Helping departments to identify potential clinical quality problems
Participating in regular departmental meetings across the organization
Determining the method for studying potential problems

Problems in patient care and other areas of the healthcare
organization are usually symptoms inherent in a


Define utilization management

It is a set of processes used to determine the appropriateness of
medical services provided during specific episodes of care.

What are types of utilization review?

Preadmission utilization review
Discharge utilization review
Documentation utilization review

What is the role of the case manager?

Coordinate medical care and ensure the necessity of the services
provided to beneficiaries

What roles are representative of the ombudsman in patient advocacy?


A hospital�s C-section rate is an example of a

Clinical performance measure

The process that involves ongoing surveillance and prevention of
infections so as to ensure the quality and safety of healthcare for
patients and employees is known as

Infection control

The traditional approach to assuring quality was to study a process
only when there was failure to

Meet established standards

Donabedian proposed three types of quality indicators: structure
indicators, process indicators, and

Outcome indicators

Many organizations and quality experts define quality as meeting or exceeding

Customer expectations

What is a technique used to generate a large number of creative ideas
from a group?


What is a data collection tool that records and compiles observations
or occurrences?


What is used to plot the points for two variables that may be related
to each other in some way?

Scatter diagram

The leader of the coding performance improvement team wants all of
her team members to clearly understand the coding process. What would
be the best tool for accomplishing this objective?


The medical transcription improvement team wants to identify the
cause of poor transcription quality. What tool would best aid the team
in identifying the root cause of the problem?

Fishbone diagram

According to the Pareto principle

20 percent of the sources of a problem are responsible for 80 percent
of its actual effects

is a methodology
for assessing compliance with Joint Commission standards during the
survey process.

Tracer methodology

are contracted to
the federal government to use medical peer review, data analysis, and
other tools to identify patterns of care and outcomes that need
improvement and then to work cooperatively with facilities and
individual physicians to improve care.


refers to
initiatives and programs that reward organizations and providers for
quality outcomes.

Pay for performance

refers to
computerized systems into which physicians or hospital staff directly
enter medication orders and therefore benefit from immediate alerts
and pharmaceutical information in order to reduce the frequency of
medication errors.


are Joint
Commission�s standards for improving patient safety.



Quality Improvement Organization

Which piece of legislation created a program for detecting fraudulent
health plans?

Health Insurance Portability and Accountability Act of 1996

Which of the following is a basic assumption of normative decision theory?

Decision makers have total knowledge of the available options.

Which of the following is an advantage of the case-control study design?

The case-control study design requires few subjects relative to other
study designs.


Long term care