Spring HIM108 Comprehensive Final

The purpose of the HIPAA security rule is to

Dr. Blake is Susie’s attending physician. Who must sign the history and physical?

Document that informs health care providers of a patient’s wishes for life-sustaining treatment

Hillcrest Hospital wrote a retention policy for the HIM department. What index is permanent?

The JC requires the HX and PX exam be documented in patient record within ____ of InPT admit.

Ms. Smith is admitted to Sunny Valley Hospital wearing a diamond ring. Documented on:

Additional Dx that describe conditions that arise after beginning of hospital observation & Tx

Critical access hospitals are located at a distance of of miles from each other?

Standard classification of mental disorders published by American Psychiatric Association (APA)

Middle-digit filing uses the middle digit as the ____________________ number when filing.

Patient is transferred to a different level of care within the same hospital, a summary report:

Medical staff members are granted clinical privileges by the

Which of the following record formats links all documentation to a specific problem?

The use of charts, graphs, and tables to summarize data is called _________________________.

The exchange of data among multiple software products is known as _________________________

Hospital reimbursement based on retrospective payment system issues payment based daily charges

Medical staff membership category, Drs who deliver most of a hospital’s INPT medical services?

Newborn death rate is calculated by dividing number of newborn deaths by _____ and * by 100.

Which characteristic of electronic data interchange (EDI) below is incorrect?

The Joint Commission’s approach to accreditation is ______________ and data driven.

Which of the following describes alphabetic filing systems?

Data becomes this after it is given meaning

The professional association that sponsors the Coding Specialist for Payors certification

The name, address, and phone number of the third-party payer is considered

Civil law deals with the legal rights and responsibilities of private individuals and includes

Suzy job: coordinating PT care to ensure PT receive timely discharge or transfer. Her title is

The JC requires that a discharge summary be completed within ____ days of discharge

In 1948, Happy Hospital was able to secure federal grant funds to update its surgical units.

The Latin term that means “the thing speaks for itself” is

Early medical record automation efforts focused on the

PQRI established financial incentive 4 eligible Pro who participate voluntary quality reporting

The abbreviation NPO means

Patients that undergo procedures that can be performed on an outpatient basis are categorized

Health Care Finance Administration, "____" was created to manage Medicare & Medicaid programs

Voluntary compliance with standards is known as ____________________.

Which statement regarding the patient record is true?

Dr. Smith documents in a Pts record that the patient may be released from the recovery room.

Quaternary care is provided most commonly at ____________________ centers.

Nomenclature used for pathology laboratory, to gather information for staff pathologists.

Coding systems that a coding & reimbursement specialist will use include CPT, HCPCS, and

Ms. HIM files the following records: 223345, 223346, 223347, 223348, and 223349. Which system?

Developes a draft strategic plan for Hospitals, presents plans to board of trustees meeting

With alphabetic filing, which name is filed first?

Pre- and postanesthesia evaluations would be found in a(n) ____ record.

Which of the following is a disadvantage of automated systems?

The admissions clerk is entering patient registration into a computerized system-logs in:

Collection of cancer data from a variety of sources, reporting of cancer statistics, Credential

Generic term that refers to the various methods electronic document can authenticate _______

The Medicaid Integrity Program, a fraud and abuse detection program, was established by the

The process of advising a patient about treatment options is known as

A health care enrollee is known as a(n) ____________________.

Law passed by legislative body that can be amended, repealed, or expanded by legislative body

An admissions clerk enters “right lower abdominal pain” as the admission diagnosis

PT record with different care, DR, and facilities linked to form view, over time,PT health care

GINA is the abbreviation for ____________________

Which organization publishes CPT?

The use of signature stamps should be specified in the

Analyze PT record for deficiency & determine entry been authenticated w initials.

A durable medical equipment company would classify medical equipment using

MVA victim, told his DR that if he stops breathing, heart stops, he doesn't want to be revived.

To calculate the delinquent record rate, divide the total number of delinquent records by the

The purpose of the HIPAA security rule is to

Which of the following would not be documented on a medication administration record?

Tom was injured on the job. According to HIPAA who can access his PHI regarding that job injury

Funding for health care for the homeless was provided by the ____ Act.

PT born at Mercy in 1967 assign PT 57690. She was admitted 1974 for tonsillectomy assign 57690.

Security awareness & training programs include security reminders, log-in monitoring, and

Which of the following is an advantage of an automated system?

Which filing system should be used to distribute the records equally in the file area?

Links a patient’s medical record number with common identification data elements.

Home care record generated for Medicare Patient contains Home Care Certification & Plan of Care

The HIM department is responsible for generating reports & stats types of PTs treated facility.

Computer software must be purchased to manage a(n) ____________________ numbering system.

Each year the business office, ancillary departments, and HIM update the charges codes for all

Tom was admitted to drug rehabilitation facility. A friend calls the facility to speak with him

Which of the following is not documented as a part of a consultation report?

Which of the following will occur in an HIM department that has an electronic record system?

A form of authentication by an individual in addition to the signature by the original author

Hospitals use a ____________________ to record encounter data about ambulatory care

guidelines developed by hospitals to facilitate management & delivery of quality clinical care

HCPCS Level II or _________________________ codes classify DME, drugs, & services not in CPT.

Which of the following is an advantage of a manual record system?

Which of the following is a disadvantage of a manual record system?

______ was used late 1990s to describe systems based imaging & merging data stand-alone systems

The abbreviation q.h. means

The doctrine of respondeat superior would apply in which of the following situations?

The admission date and discharge date are considered

Indexes, registers, and registries are considered _____________ sources of patient information.

Progress notes should be written

In a(n) ____________________ system, views of patient records can be customized by users.

Patients have the right to ____________________ of PHI.

Sally is completing analysis of a pt’s record, finds an original incident report in the record.