HIM 102 Final Exam #1

These patients stay overnight for 24hr or more and are provided with room/board and nursing services

Intensive treatment program provided to pts who live in the community but come to the facility up to five days per week

Means something is self-evident or obvious; "the thing speaks for itself"

Administrative EHR application would include all of the following except

Used for Collection, storage, retrieval, analysis, & dissemination of info for pts with a specific disease/condition

Provides medically necessary care daily by skilled medical personnel

Records items patients bring with them to the hospital

Creation of policies, processes, and procedures that focus on the management of data and info that relates to pt care

Application feature that allows pts to communicate w/providers & access components of their own record

Which system allows easy training/record retrieval, but files don't expand at even rate & name changes require updates

Which is correct order for: 18-30-17, 14-31-17, 15-30-18, 15-36-19, 15-30-17 16-33-19; middle-digit is being used

Inventory to document subjective symptoms stated by the patient

Application that allows for ordering of tests, reporting test results such as CBC, urine cultures, and urinalysis (UA)

These patients undergo procedures on an outpatient basis; are treated and released the same day, without overnight stay

Automated process turning data into meaningful form by locating unknown or unnoticed relationships

Nurse administers too much/the incorrect medication; the hospital is responsible for nurses actions is an example of:

Results when a health care provider acts in an improper or negligentful manner & pt’s result is injury, damage, or loss

Which of the following joint state and federal programs assists with medical costs for low income & limited resource pts

____ is an entry that has been signed by the author and may only be signed by author.

Physically harming or unlawful touching

Submitted to state department of health or office of vital statistics within 5 days of event

Sets standards for all HIM educational programs

Obtained by the admissions office from the attending physician and is basis for patient care

Generated reports and statistics for the types of patients treated by a facility is known as

Those that work for federal government jobs have health insurance benefits and coverage through _____.

NDCs are managed by the

This promotes communication and continuity of care between health care providers

This facility provides X-rays, MRIs, CT scans, PET scans, and other radiographic services

Both inpatient and outpatient records the same; this helps save time during processing of discharged patient records

This hospital department would coordination post-hospital discharge services for patients.

Durable medical equipment would be found in which code set?

Ability of different info systems to access, exchange, integrate, and cooperatively use data in a coordinated manner

Oversees all policies that impact an individual's initial certification and ongoing recertification

This patient record format consists of database, problem list, initial plan, & progress notes

Coordinates communication, financial, HR, health info, insurance, marketing, & risk management of office

Allows for the collection and reporting of individual data elements

An incident report is completed if a patient falls/is injured in the hospital; this is filed in risk management office

Medicare CoP requires final diagnosis & medical records to be completed within _____ of discharge.

A defendant is an individual who initiates a civil complaint and has the burden of proof

This is synonymous with a case manager.

Formal recording of items, names, actions, or events

Organizes patient records throughout facility under the control of the department that creates and uses them

Describes actions that will be taken to evaluate, treat, and educate the patient

Threat or attempt to do bodily harm to another

Submitted to state department of health or office of vital statistics within 10 days of event

Patient’s description of medical condition, stated in the patient’s own words

Records are filed: 15-28-17, 14-30-17, 14-31-17, 15-32-18, 16-30-19; this filing system is being used

Process of advising a patient about treatment option

_____ report procedures, services, and supplies provided to patients by a physician

Preexisting condition that will, b/c of its presence with a specific diagnosis, cause an increase in the patient’s LOS

For example: documentation by nurses - located in nursing section, radiology reports - located in a radiology section

Responsibilities of this health care professional include timely discharge/transfer and coordination of care

Data stored in tables allows this to create relationships between different tables

This classification code set is published by the American Psychiatric Association for mental health disorders

Assigned to medical nomenclatures and reported to third-party payers for reimbursement

Index serves as a "key" to locate record such as, history of treatment in a facility, & must be retained permanently

Pseudonumbers are used to replace driver's license numbers.

The hospital uses family numbering; The family's number is 6598. The father is head of household, what is wife's #

The hospital uses family numbering; The family's number is 6598 and is father, mother, and children. What is 1st born #?

The goal of this organization was to advance the health of individuals/communities, hospitals, & health care networks

This established the Medicaid Integrity Program (MIP), which is a fraud and abuse detection program

This includes health maintenance and coordination of referrals

Upon discharge, most facilities will use this method of order filing; oldest info is filed first

Coordinates a program to ensure excellent pt care, improve pt outcomes, confirms compliance, & prepares for surveys

Encourages healthcare mistakes be reported to pt safety organizations & are protected from civil/criminal proceedings

An incident report should be filed in the patient's record for quick reference

Responsibilities include gathering info & recommending settlements for liability incidents

_____ report procedures, services, and supplies provided to patients by a hospital

This manager coordinates inpatient care for purposes of utilization of resources and timely discharge/transfer

Occurs when a dictated report has been signed prior to transcription and is not considered to be acceptable

Organizes patient records in one central location under the control of the facility’s health information department

Most facilities use this order of filing for inpatient hospitalizations; the most current/recent document is filed first

Ensures that there is adequate documentation to assign and support the assignment of diagnosis and procedure codes

Index organizes data by ICD-10-CM codes & could be used to run a report on # of pts in 30 days discharged with pneumonia

Reviews health-related claims to determine whether the costs are reasonable and medically necessary

Collect, monitor, and record patient physiological data

Short-term (usually fewer than 15 days) crisis intervention and treatment; patients receive 24-hour-a-day supervision

Located more than 35 miles from any hospital; inpatients in this hospital are restricted to 96-hr LOS

This numbering system assigns a new patient number each time he or she is admitted

Which of the following was established by the Health Care Quality Improvement Act?

Combination of housing and supportive services including personal care and household management for older adults

Type of programming language that allows users to access data & create tables; may be used instead of natural language

Matching individuals' needs with appropriate level and type of medical, psychological, health/social service is known as

These patients stay overnight for 24hr or more and are provided with room/board and nursing services

Indicates that several diagnoses are being considered as possible

Passed by a legislative body & may be amended, repealed, or expanded by the legislative body.

Utilization review committees ensure patient safety by analyzing trends of incidents in high-risk areas.

These patients are treated and released the same day, without overnight stay

This hospital category provides emergency care, general surgery, and admit patients for a range of health problems

The hospital uses family numbering; The family's number is 6598. The father is head of household, what is his #

Monitors standards of conduct, implements sanctions for noncompliance, & maintains a confidential integrity hotline

Global organization that is considered an industry leader in the management of health information

This coding system is used for diseases and injuries to clarify a patient's diagnosis(es)

This merges data from different data systems into one centralized database

24-hour medically directed evaluation and withdrawal management in an acute care inpatient setting for detoxification

As defined by AHIMA, these are the processes of translating data into information utilized for an application

This index organizes data by corresponding numbers assigned to providers

All of the following are advantages for terminal-digit filing except:

Inpatient LOS is typically >25 days and treats those with clinically complex conditions

Oversees development, implentation, maintenance/adherence to organizations polices/procedures with state & federal laws