1. The primary function of the American Health Information Management Association is ____.

a. To ensure that acurate and complete medical records are written for every hospital patient.

b. To standardize the content and format of the health records maintained by acute and emergency care facilities.

c. To promote the accuracy, confidentiality, and accessibility od health records in every healthcare setting.

d. To provide support of two-and-four-year health information management educational programs.

c. To promote the accuracy, confidentiality, and accessibility od health records in every healthcare setting.

2. HIM has been recognized as an allied health health profession since:

a. 1928

b. 1966

c. 1980

d. 2006

a. 1928

3. The _____ makes up a virtual network of AHIMA members who communicate via a Web based program managed by AHIMA.

a. Board of Directors

b. Communities of Practice

c. Commission on Certification for Health Informatics and Information Management

d. House of Delegates

b. Communities of Practice

4. Which of the following accredits academic programs in health information management?

a. AHIMA Board of Directors

b. CAHIIM (Commission on Accreditation for Health Informatics and Information Management)

c. CCHIIM (Certification)

d. House of Delegates

b. CAHIIM (Commission on Accreditation for Health Informatics and Information Management)

5. Members of the AHIMA House of Delegates are ____.

a. Appointed by the AHIMA Board of Directors.

b. Elected by the AHIMA Board of Directors.

c. Elected by members in state component organizations.

d. Elected by the AHIMA Nominating Committee.

c. Elected by members in state component organizations. 

6. Who is responsible for final approval of the AHIMA Code of Ethics?

a. AHIMA Board of Directors

b. AHIMA Commission on Certification for Health Informatics and Information Management. (CCHIM)

c. AHIMA Ethics Committee

d. AHIMA House of Delegates

c. AHIMA House of Delegates

7. Which of the following actively promotes education and research in health information management?

a. Commission on Certification for Health Informatics and Information Management.

b. CAHIIM

c. AHIMA Foundation

d. House of Delegates

c. AHIMA Foundation

8. The primary goal of the Hospital Standardization Program was ____.

a. To raise standards of surgical practice.

b. To train physicians and nurses for American hospitals.

c. To standardize the educational curricula of American medical schools.

d. To force substandard hospitals to close.

a. To raise standards of surgical practice.

9. Which of the following activities is not a traditional medical records function?

a. Forms control

b. Quantitative analysis

c. Productivity monitoring

d. Data administration

d. Data administration

10 The only requirements for professional certification through the AHIMA are graduating from an accredited two-year or four-year educational program.

a. Yes

b. No

b. No

11. Which of the foloowing is true about the AHIMA certification program?

a. The eligibility requirements for all credentials are the same.

b. Candidates must pass an examination before obtaining any of the credentials.

c. Candidates must be college graduates before they can obtain any of the credentials.

d. Candidates must have work experience and pass a certiciation exam before they can obtain any of the credentials.

b. Candidates must pass an examination before obtaining any of the credentials.

12. WHich of the following classes of AHIMA membership requires that individuals hold an AHIMA credential?

a. Active membership.

b. Associate membership.

c. Student membership.

d. Honorary membership.

a. Active membership.

13. Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs and operations of AHIMA?

a. House of Delegates.

b. Board of Directors.

c. Communities of Practice.

d. Component of State Associations.

b. Board of Directors

14. The accreditation program of AHIMA is concerned with ____?

a. Establishing standards for the content of college programs in HIT and HIM.

b. Making sure that AHIMA has good certification examinations.

c. Ensuring that AHIMA manages its property and affairs appropriately.

d. Establishing policies and procedures to be followed by the Communities of Practice.

a. Establishing standards for the content of college programs for HIT and HIM.

15. The new opportunity for HIM professionals that deals with data repositories and data warehouse is:

a. Health information manager.

b. Clinical data specialist

c. Enterprise content and information manager

d. Data resource administrator

d. Data resource administrator

16. Critique this statement: Electronic health record systems have the same access control requirements as paper-based systems.

a. This is a true statement.

b. This is a false statement as the requirements for the electornic health record are less stringent.

c. This is a false statement as the requirements for the electronic health record are more stringent.

d. Electronic health records are inherently less secure.

a. This is a true statement.

17. How do patient care manager and support staff use the data documented in the health record?

a. to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided

b. to communicate vital information among departments and across disciplines and settings

c. to generate patient bills and/or third party payer claims for reimbursement

d. to determine the extent and effects of occupational hazards

a. to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided

18. Which of the following statements does not pertain to electronic health records (EHRs)?

a. EHR technologies and systems must not intrude on the patient and provider relationship

b. EHRs are filed in paper folders

c. In the United States, a national health information infrastructure is being designed to support EHRs

d. Clinicians use computer keybords when documenting in the EHR

b. EHRs are filed in paper folders

19. Use of health record to monitor bioterrorism activity is considered

a. a primary purpose of the health record

b. a secondary purpose of the health record

c. a patient use of health record

d. a healthcare licenscing agency function

b. a secondary purpose of the health record

20. How do research organizations use health record?

a. to examine results of experimental protocols

b. for reporting of communicable dissease

c. to investigate domestic violence

d. to manage disability insurance benefits

a. to examine results of experimental protocols

21. Attorneys for healthcare organizations use the health record to

a. support claims for medical practice

b. protect the legal interests of the facility and its health care providers

c. plan and market services

d. locate missing persons

b. protect the legal interests of the facility and its health care providers

22. Our record has all of the lab filed together, all of the progress notes file together, and so on. What format are we using?

a. source oriented health record

b. integrated health record

c. patient-oriented health record

d. problem-oriented health record

a. source oriented health record

23. Protection of healthcare information from damage, loss, and unauthorized alteration is also known as

a. privacy

b. result management

c. security

d. data accuracy

c. security

24. Since we implemented a new technology, we have eliminated lost orders and problems with legibility. What technology are we using?

a. computerized physician/provider order entry

b. electronic health record

c. results management

d. clinical decision report

a. computerized physician/provider order entry

The paper-based health record format that organizes all forms in chronological order is known as

a. the problem-oriented health record

b. the integrated health record

c. the patient-oriented health record

d. the source-oriented health record

b. the integrated health record

26. An individual's right to control access to his or her personal information is known as

a. security

b. confidentiality

c. privacy

d. all of the above

c. privacy

27. When all required data elements are included in the health record, the quality characteristic for is met. 

a. data security

b. data accessibility

c. data flexibility

d. data comprehensiveness

d. data comprehensiveness

28. Which of the following best describes the most important function of the health record?

a. Communicating instructions between physicians and nurses.

b. Providing information to support reimbursement claims.

c. Storing patient care documentation.

d. Providing informatino to support managed care.

c. Storing patient care documentation.

29. Which of the following best describes data accuracy?

a. data are correct

b. data are easy to obtain

c. data include all required elements

d. data are reliable

a. data are correct

30. Which of the following best describes data completeness?

a. data are correct

b. data are easy to obtain

c. data include all required data element

d. data are reliable

c. data include all required data element

31. Which of the following best describes data accessibility?

a. data are correct

b. data are easy to obtain

c. data include all required data element

d. data are reliable

b. data are easy to obtain

32. Data definition refers to _____.

a. the meaning of data

b. the completeness of data

c. the consistency of data

d. the detail of the data

a. the meaning of the data

33. Healthcare information systems need to exchange information. This linkage between system is referred to as:

a. connectivity

b. efficiency

c. flexibility

d. security

a. connectivity

34. Which of the following represents an example of data granularity?

a. a progress note recorded at or near the time of the observation

b. an acceptable range of values defined for a clinical characteristic

c. a numerical measurement carried out to the appropriate decimal place

d. a health record that includes all of the required components

c. a numerical measurement carried out to the appropriate decimal place

35. What is the defining characteristic of an integrated health record format?

a. each section of the record is maintained by the patient care department that provided the care

b. integrated health records are intended to be used in ambulatory settings

c. integrated health records include both paper forms and computer printouts

d. integrated health record components are arranged in strict chronological order

d. integrated health record componens are arranged in strict chronological order

36. Patient history questionnaires are most often used in:

a. long-term care

b. rehabilitative care

c. home health care

d. ambulatory care

d. ambulatory care

37. An RAI/MDS (Resident Assesment Instrument/Minimum Data Set) and care plan are found in records of patients in _____.

a. home health care

b. long-term care

c. behavioral healthcare

d. rehabilitative care

b. long-term care

38. In which setting may treatment records travel with the patient between treatment centers?

a. ambulatory care

b. behavioral healthcare

c. correctional facility care

d. long-term care

c. correctional facility care

39. The attending physician is responsible for which of the following types of acute care documentation?

a. consultation report

b. discharge summary

c. laboratory report

d. pathology report

b. discharge summary

40. Which of the following clinical data elements is not usually documented in the acute care health record?

a. clinical observations

b. discharge information

c. medical history

d. records of immunizations

d. records of immunizations

41. Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?

a. The Health Information Access and Disclosure Act

b. The Health Insurance Portability and Accountability Act

c. The Patient Self-determination Act

d. The Social Security Act

b. The Health Insurance Portability and Accountability Act

42. Which of the following is an example of an advance directive?

a. a living will

b. an authorization to release information

c. a treatment consent

d. a patient's rights acknowledgement

a. a living will

43. Which of the following materials is not documented in an emergency care record?

a. patient's instructions at discharge

b. time and means of the patient's arrival

c. patient's complete medical history

d. emergency care administered before arrival at the facility

c. patient's complete medical history

44. Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

a. patient assessment instrument

b. minimum data set for long term care

c. resident assessment protocol

d. Outcomes and Assessment Information Set

d. Outcomes and Assessment Information Set

45. Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?

a. The correction should be dated and signed or initialed.

b. The reason for the change should be noted.

c. The incorrect information should be obliterated.

d. The word error should be noted on the entry.

c. The incorrect information should be obliterated.

46. WHich of the following types of healthcare facilities may seek accreditation from the JCAHO?

a. acute care hospitals

b. psychiatric hospitals

c. ambulatory care organizations

d. home care providers

e. all of the above

e. all of the above

47. The federal Conditions of Participation apply to which type of healthcare organization?

a. any organization that is accredited

b. any organization that treats Medicare and Medicaid patients

c. any organization that provides acute care services

d. any organization that is subject to Health Insurance Portability and Accountability Act

b. any organization that treats Medicare and Medicaid patients

48. Which of the following is not a traditional health record format?

a. integrated health record

b. problem-oriented health record

c. source-oriented health record

d. process-oriented health record

d. process-oriented health record

49. Which of the following is not an example of a data capture technology?

a. bar code readers

b. data dictionaries

c. optical character readers

d. continuous voice recognition

b. data dictionaries

50. What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?

a. certification

b. licensure

c. accreditation

d. deemed status

c. accreditation

51. Progress notes of physicians, nurses, therapists and authorized individuals would be found together in chronological sequence in a paper record.

a. integrated

b. source oriented

c. problem oriented

d. hybrid

a. integrated

52. Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek a medical attention as stated in that patient's own words?

a. present illness

b. social and personal history

c. past medical history

d. chief complaint

d. chief complaint

53. Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay?

a. physical examination

b. physician order

c. progress notes

d. medical history

c. progress notes

54. When correcting erroneous information in a health record, which of the following is not appropriate?

a. print "error" above the entry

b. enter the correction in chronological sequence

c. add the reason for the change

d. use black pen to obliterate the entry

d. use black pen to obliterate the entry

55. Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

a. a paper record

b. hybrid record

c. electronic record

d. problem oriented record

c. electronic record

56. What is the general name for Medicare standards impacting healthcare organizations?

a. Condition of participation

b. Regulations for licensure

c. Requirements for service

d. Terms of accreditation

a. Condition of participation

57. A nurse is responsible for which of the following types of acute care documentation?

a. operative report

b. medication record

c. radiology report

d. therapy assessment

b. medication record

58. Which of the following is an example of clinical data?

a. admitting diagnosis

b. date and time of admission

c. insurance information

d. health record number

a. admitting diagnosis

59. The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the _____.

a. anesthesia report

b. progress note

c. operative report

d. recovery room report

c. operative report

60. Which type of specialized record includes care provided prior to arrival at a healthcare settings and times and means of arrival?

a. ambulatory care record

b. emergency care record

c. ambulatory surgery record

d. pediatric record

b. emergency care record

61. Which of the following represents documentation of the patient's current and past health status?

a. physical exam

b. medical history

c. physician orders

d. patient consent

b. medical history

62. Which type of microfilm does not allow for a unit record to be maintained?

a. roll microfilm

b. jacket microfilm

c. microfiche

a. roll microfilm

63. "Loose" reports are health record forms that ____.

a. are maintained seperately from the health record

b. are not part of the legal health record

c. are received by the HIM department and added to the health record after it has been processed

d. are misfiled

c. are received by the HIM department and added to the health record after it has been processed

64. Which of the following is the key to the identification and location of a patient's health record?

a. disease index

b. outguide

c. deficiency slip

d. MPI (master patient index)

d. MPI (master patient index)

65. Which of the numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers?

a. unit

b. serial

c.. terminal-digit

d. alphabetic

b. serial

66. Which of the following is not true of good forms design for paper forms?

a. Every form should have a unique identification number

b. Every form should have a clear, concise title

c. Bright colors should be used to identify forms

d. Paper ranging from twenty to twenty-four pounds in weight

c. Bright colors should be used to identify forms

67. Which of the following is a request from a clinical area to charge out a health record?

a. outguide folder

b. requisition

c. MPI

d. patient registry

b. requisition

68. A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is reffered to as a...

a. prospective review

b. retrospective review

c. concurrent review

d. peer review

c. concurrent review

69. A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulation is called a/an ______.

a. suspended record

b. delinquent record

c. pending record

d. illegal record

b. delinquent record

70. Which database must  a healthcare facility query as part of a credentialing process when a physician initially applies for medical staff privileges?

a. UHDDS

b. MEDPAR

c. HEDIS

d. NPDB

d. NPDB (National Practitioner Data Bank)

71. When a hospital accredited by JCAHO is considered to be in compliance with Medicare's Conditions of Participation, this is called ______.

a. adjuvant accreditation

b. deemed status

c. conditional accreditation

d. dual accreditation

b. deemed status

72. Which of the typical HIM functions assist in monitoring and compliance of health care facility with JCAHO standards?

a. release of information

b. record processing

c. transcription

d. all of the above

d. all of the above

74. What component of the budget would include money for the purchase of an EHR?

a. revenue budget

b. expense budget

c. capital budget

d. cash budget

c. capital budget

74. The future role of the HIM professional is expected to change due to ____.

a. advances in technology

b. implementation of new clinical coding system

c. evolution of the EHR

d. all of the above

d. all of the above

75.  Specific performance expectation and/or structures and process information for each JCAHO standard are called _______.

a. elements of performance

b. fact sheets

c. ad hoc reports

d. registers

a. elements of performance

76. The services provided by HIM departments in acute care hospitals usually include all the follwing except _____.

a. medical transcription

b. medical billing

c. clinical coding

d. release of information

b. medical billing

77. The release of information function requires the HIM professional to have knowledge of _____.

a. clinical coding principals

b. database development

c. federal and state confidentiality laws

d. human resource management

c. federal and state confidentiality laws

78. In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare faility?

a. alphabetic filing system

b. serial numbering system

c. terminal numbering system

d. unit numbering system

b. serial numbering system

79. Which of the following should be taken into consideration when designing a health record?

a. assigning a unique identifying number to the form

b. using a concise title that identifies the form's purpose

c. including original and revised dates for tracking purposes

d. all of the above

d. all of the above

80. Which of the following statements describes alphabetical filing?

a. File the record alphabetically by first name, followed by the middle initial, and then the last name.

b. File the record alphabetically by last name, followed by the first name, and then the middle initial.

c. File the record alphabetically by the last name, followed by the middle initial, and then the first name.

d. File the record alphabetically by the last name only.

b. File the record alphabetically by last name, followed by the first name, and then the middle initial.

81. Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered ____ from the database.

a. data elements

b. information

c. informatics standards

d. data sets

b. information

82. A corporation is evaluating several health plans for its benefits package. The data set that provides comparison information about health plan performance is ______.

a. ORYX

b. HEDIS

c. UHDDS

d. MDS

b. HEDIS (Healthcare Effectiveness Data and Information Set)

83. Data collected to evaluate facility performance in designated core measure areas in order to achieve accreditation is ______.

a. HEDIS

b. ORYX

c. DEEDS

d. OASIS

b ORYX (The Joint Commission)

84. An example of data collection by the JCAHO for the ORYX initiatives is ______.

a. intrahospital mortality data

b. financial data

c. health plan performance data

d. patient demographic data

a. intrahospital mortality data

85. The _____ mandated the development of standards for electronic medical record.

a. Medicare and Medicaid Legislation of 1965.

b. Prospective Payment Act of 1983,

c. Health Insurance Portability and Accountability Act of 1996.

d. Balanced Budget Act of 1997.

c. Health Insurance Portability and Accountability Act of 1996.

86. Messaging standards for electronic data interchange in healthcare have been developed by _____.

a. HL7

b. IEE

c. JCAHO

d. CMS

a. HL7

87. AHIMA strongly opposes the use of which of the follwoing as a patient identifier in an electronic environment?

a. enterprise master patient index reord number

b. patient's full name

c. national healthcare identification number

d. social security number

d. social security number

88. The exchange of digitized images such as X-rays, CT scans, and MRIs us supported by _____.

a. UHDDS

b. DICOM

c. X12

d. NCPDP

b. DICOM (Digital Imaging and Communications In Medicine)

89. In which of the following systems does an individual receive a unique numerical identifier at the time of the first encounter with a healthcare facility and maintains that identifier for all subsequent encounters?

a. alphabetic filing system

b. serial numbering system

c. unit numbering system

d. none of the above

c. unit numbering system

90. Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of ____.

a. transaction standards

b. content and structure standards

c. vocabulary standards

d. security standards

c. vocabulary standards

91. According to the UHDDS definition, ethnicity should be recorded on a patient as ____.

a. Race of mother

b. Race of father

c. Hispanic, non-Hispanic, unknown

d. Free text descriptor as reported by patient

c. Hispanic, non-Hispanic, unknown

92. Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?

a. DEEDS

b. UACDS

c. MDS Version 2.0

d. OASIS

a. DEEDS (Data Elements for Emergency Department Systems)

93. While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on _____.

a. reason for admission

b. reason for encounter

c. discharge diagnosis

d. activities of daily living

b. reason for encounter

94. In long term care, the resident's care plan is based on data collected in the ______.

a. UHDDS

b. OASIS

c. MDS Version 2.0

d. HEDIS

a. MDS Version 2.0 (Minimum Data Set)

95. In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?

a. X12N

b. LOINC

c. IEEE 1073

d. DICOM

a. X12N

96. A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is ___.

a. X12N

b. LOINC

c. IEEE 1073

d. DICOM

d. DICOM (Digital Imaging and Communications in Medicine)

97. A core data set developed by ASTM to communicate a patient’s past and current health information as the patient’s transitions from one care setting to another is ___.

a. Continuity of Care Record

b. Minimum Data Set

c. Ambulatory Care Data Set

d. Uniform Hospital Discharge Data Set

a. Continuity of Care Record

98. Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?

a. X12N

b. LOINC

c. RxNorm

d. DICOM

b. LOINC (Logical Observation Identifiers Names and Codes)

99. The most prevalent trend in the collection of secondary data bases is _____.

a. The increased use of encryption technology

b. The increased use of enconders

c. The increased use of automated data entry

d. The widespread implementation of electronic health record

c. The increased use of automated data entry

100. Which of the following indexes and databases include patient-identifiable information?

a. MEDLINE

b. Clinical trials database

c. Master patient/population index

d. UMLS

c. Master patient/population index

101. Which of the following is an external user of data?

a. Public health department

b. Medical staff

c. Hospital administrator

d. Director of the clinical laboratory

a. Public health department

102. Review of disease indexes, pathology reportsm and radiation therapy reports is part of which function in the cancer registry?

a. case definition

b. case-finding

c. follow-up

d. reporting

b. case-finding

103. What is the information identifying the patient (such as name, health record number, address, and telephone number) called ?

a. accession data

b. indicator data

c. reference data

d. demographic data

d. demographic data

104. Cancer registries receive approval as part of the facility cancer program from which of the following agencies?

a. American Cancer Society

b. National Cancer Registrar's Association

c. National Cancer Institute

d. American College of Surgeons

d. American College of Surgeons

105. Which national databases includes data on all discharged patient regardless of payer?

a. Healthcare Cost and Utilization Project

b. Medicare Provider Analysis and Review file

c. Unified Medical Language System

d. Uniform Hospital Discharge Dataset

a. Healthcare Cost and Utilization Project

106. Two clerks are abstracting data for a registry. WHen their work is checked, discrepancies are found. Which data quality component is lacking?

a. completeness

b. validity

c. reliability

d. timeliness

c. reliability

107. What does an audit trail check for?

a. unauthorized access of a system

b. loss of data

c. presence ofa virus

d. successfull completion of a backup

a. unauthorized access of a system

108. Which law requires the reporting of deaths and severe complicaitons due to devices?

a. Medical Implantaion and Transplantation Act of 1986

b. Medical Devices Reporting Act of 1972

c. Food and Drug Modernization Act of 1997

d. Safe Medical Devices Act of 1990

d. Safe Medical Devices Act of 1990

109. Which of the following contains a list maintained in diagnosis code number order of patients discharged from a facility during a particular time period?

a. physician index

b. master patient index

c. disease index

d. operation index

c. disease index

110. Which of the following contains a list maintained in procedure code number order of patients discharged from a facility during a particular time period?

a. physician index

b.master patient index

c. disease index

d. operation index

d. operation index

111. Which of the following is a collection of secondary data related to patients with a specific diagnosis, conditions, or procedures?

a. Disease index

b. Disease registry

c. Master patient index

d. trauma registry

b. disease registry or a. disease index

112. Case finding is a method used to _____:

a. Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry.

b. define which cases are to be included in a registry

c. identify trends and changes in the incidence of disease

d. identify facility-based trends

113. In a cancer registry, the accession number _____.

a. identifies all the cases of cancer treated in a given year

b. is the number assigned to each case as it is entered into a cancer registry

c. identifies the pathologic diagnosis of an individual cancer

d. is the number assigned for the diagnosis of a cancer patient entered into the cancer registry

114. A population-based registry _____.

a. includes information from more than one facility in a particular geopolitical  area, such as a state or region

b. includes only cases for a particular facility such as a hospital or clinic

c. represents a computerized system that was developed for a particular facility

d. provides data for comparisons in survival rates and quality of life for patients with different treatments and at different stages of cancer

115. Which of the following is made up of claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities?

a. NPDB

b. MEDPAR

c. HIPDB

d. UHDDS

116. The Medicare Provider Analysis and Review file is made up of _____.

a. Medical malpractice payments and sanctions taken against providers

b. data collected from a sample of office-based physicians

c. medicare claims from acute care hospitals and skilled nursing facilities

d. data collected on births and deaths

117. Vital statistics include data on _____.

a. research projects in which new treatments and tests are investigated to determine whether they are safe and effective.

b. births, deaths, fetal deaths, marriages, and divorces

c. medicare claims

d. all of the above

118. Which database must a healthcare facility qyery as part of the credentialing process when a physician initially applies for medical staff privileges?

a. UHDDS

b. MEDPAR

c. HEDIS

d. NPDB

119. Data and Information mean the same thing.

True

False

120. Every health record system should allow record access 24 hours a day.

True

False

121. The first professional association for health information managers was established in:

a. 1900

b. 1905

c. 1928

d. 1970

122. The hospital standardization program was started by the American College of Surgeons in:

a. 1900

b. 1905

c. 1918

d. 1928

123. The formal approval process for academic programs in health information management is called:

a. accreditation

b. certification

c. registration

d. standardization

124. The formal process for conferring a health information management credential is called:

a. accreditation

b. certification

c. registration

d. standardization

125. Which of the following is a primary purpose of the health record?

a. to document patient care delivery

b. to assis caregives in patient care management

c. to aid in billing and reimburment functions

d. all of the above

126. which of the definitions below best describes the concept of confidentiality?

a. the right of individuals to control access to their personal health information

b. the protection of healthcare information from damage, loss, and unauthorized alteration

c. the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

d. the expectation that only individuals with the appropriate authority will be allowed to access healthcare information

c. the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

127. Which of the following statements does not pertain to paper-based health records?

a. they have a built-in access control mechanism.

b. they are kept in locked storage areas that are accessible only to authorized staff

c. they are logged out according to the organization's prescribed procedure

d. they are forwarded to the appropriate service area when needed for patient care purposes

128. Which of the following is an advantage offered by computer based clinical decision support tools?

a. they give physicians instant access to pharmaceutical formularies, referral databases, and reference literature

b. they review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends

c. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives

d. all of the above

129. Which of the following is a function of the health record?

a. planning and managing care

b. evaluating the adequacy and appropriateness of care

c. protecting the legal interests of both patient and healthcare provider

d. all of the above

130. Which of the following is not a function of the discharge summary?

a. providing information about the patient's insurance coverage

b. ensuring the continuity of future care

c. providing information to support the activities of the medical staff review committee

d. provide concise information that can be used to answer information request

131. In which of the following ways can the patient's consent to undergo treatment be expressed?

a. by his or her submission to treatment

b. by written agreement

c. by verbal agreement

d. all of the above

132. Whcih of the following would not be considered clinical data?

a. progress notes

b. physician orders

c. admission diagnosis

d. name of the insurance company

133. The name of the government agency that has led the development of basic data sets for health records and computer databases is the ____.

a. Centers for Medicare and Medicaid Services

b. John Hopkins University

c. American  National Standards Institute

d. National Committee on Vital and Health Statistics

134. The primary purpose of a minimum data set in healthcare is to ____.

a. recommend common data elements to be collected in health records

b. mandate all data that must be contained in a health record

c. define reportable data for federally funded programs

d. standardize medical vocabulary

135. Data that are collected on large populations of individuals and stored in databases are referred to as ____.

a. statistics

b. information

c. aggregate data

d. standards

136. The inpatient data  set that has been incorporated into federal law and is required for Medicare reporting is the ____.

a. Ambulatory Care Data Set

b. Uniform Hospital Discharge Data Set

c. Minimum Data Set for Long-Term Care

d. Health Plan Employer Data and Information Set

137. Removing health records from the storage area to allow space for more current records is called ____.

a. purging records

b. assembling records

c. logging records

d. cycling records 

138. Which system records the location of health records removed from the filing system and documents the return of the health records?

a. chart deficiency system

b. chart tracking system

c. abstracting system

d. none of the above

139. Which of the following is not true about document imaging?

a. allows random access for retrieval of documents

b. can be viewed by more than one person at a time

c. can be viewed from locations remote from the HIM department

d. is a paperless system

140. In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the _____.

a. incomplete record file

b. permanent file

c. temporary file

d. remote storage file