michelle_aistearPlus
What is one of the four goals included in the Strategic Plan for the US Department of Health and Human Services
Advance communications among healthcare providers
True or False: The number of individuals who have health insurance continues to rise each year.
The medical care provided to individuals who are clinically complex and have multiple and chronic conditions requiring an average length of stay greater than 25 days in long-term care hospitals certified as acute-care hospitals are considered what category of healthcare services?
Long-term acute care
What federal agency is charged with improving the safety and quality of America's healthcare system?
A hybrid health record may be a combination of paper-based, electronic-based, and which other format?
Mobile Technology-based
The ONC published the Health IT Playbook that provided which of the following information?
Guidance on how to implement and use health IT to advance care information and delivery
True or False: The Office of the National Coordinator for Health Information Technology is governed by the Office of Civil Rights.
False - The ONC is in the US Department of Health and Human Services
Which of the following EHRs are free for patients to use?
Microsoft Health Vault (No longer available?)
True or False: Between 2009 and 2015, the number of healthcare records compromised for all reported breaches affecting 500 individuals or more has risen.
In 1965, What programs were developed making the US government the largest payer of healthcare services?
Which federal legislation requires US citizens to have health insurance coverage?
American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Health
True or False: In 2015, there was a rise in the number of individuals who have healthcare insurance
Which of the following facilities is considered solely an outpatient setting?
Hospitalists provide care to patients who are in the hospital. Which specialties may provide hospitalist services?
Surgical-based
The patient-centered medical home provides care for which of the following specialties?
What organization is one among others that accredit patient-centered medical home programs?
Accreditation Association for Ambulatory Health Care
Secondary care is provided by which of the following?
Specialty care offices
The ONC's Health IT Playbook includes answers to which of the following questions?
How can I activate and engage patients and their families
The PHR is maintained by whom?
Which of the following is an example that provides guidelines to ensure accurate and complete documentation?
Federal and State Statutes
True or False: The type of healthcare services provided does not impact the clinical documentation.
False - The content and style of clinical documentation depend on a combination of factors and the healthcare services. The type of healthcare services provided, such as routine screening, specific types of surgical procedures, or intensive care services, is one of the influences that impacts the clinical documentation.
Who is responsible for enforcing the HIPAA violations?
True or False: An example of reasonable cause is an individual selling other individuals' PHI for personal gain.
False - When the conscious and intentional action conducted, then this is an example of a willful neglect offense
Who are the main users of health records?
Clinicians responsible for direct patient care
True or False: PHRs are always considered part of the legal health record.
False - It is up to the facility, with its policies, to decide whether or not all or parts of the PHR. Organizational policy should address how personal health information provided by the patient will or will not be incorporated into the patient's health record.
What is the definition of derived data?
Factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients
True or False: All patient health record entries must be legible and complete, but authentication is optional.
False - According to CFR Title 42, Volume 4, Condition of Participation, rules should be set for prompt authentication of every entry in the health record by the author responsible for ordering, providing, or evaluating the service furnished. Health records must be accurately written, promptly completed, properly filed and retained, and accessible.
Which of the following is a code set adopted by HIPAA
CDT - Code on Dental Procedures and Nomenclature
True or False: The patient owns the information documented within the EHR.
The process of storing health information is called:
The abbreviation OCR stands for:
For criminal offenses, who handles the cases for disclosure of individually identifiable health information?
Which of the following HPAA offense are considered criminal offenses?
Willful neglect but the violation was corrected within required time period.
True or False: The legal health record only pertains to EHRs.
False - The legal health record may include documentation from a paper-base, electronic, or hybrid format.
CLIA is focused to which service line?
True or False: When a patient starts developing her own PHR and is gathering clinical information from a variety of sources, and authorization from the patient is required by the provider of service.
When should entries in the health record be documented?
As soon as possible after the service is performed.
Who is responsible for leading the health information exchange initiative?
Office of the National Coordinator for Health Information Technology
The acronym MACRA stands for:
Medicare Access and CHIP Reauthorization Act
True of False: The patient's social security number is the safest way to identify a patient.
False - With the increase in identity theft, facilities may assign a unique identifier with the intention of reducing identity theft
Which of the following are functions of the EHR?
Performs as an advanced decision support
What is the name of the current performance measures used by The Joint Commission?
ORYX Performance Measures
What is the process of obtaining, verifying, and assessing a practitioner's qualifications to provide care or services in or for a healthcare organization?
True or False: The process of accreditation of a healthcare organization is mandatory.
False - Accreditation is a voluntary process that a facility may elect to obtain to display best practices in certain areas, such as operations, quality of care, patient safety, and customer service.
True or False: Subpoenas and court orders are different names for the same document.
False - Court orders and subpoenas have two separate definitions and set of rules governing the proper process to receive and fulfill the requirement of each document.
The e-discovery amendments may be found in which of the following documents?
Federal Rules of Civil Procedure (FRCP)
True or False: The date that a valid authorization is signed has no effect on the validity of the authorization.
False - An authorization is considered invalid when the expiration date has passed or the expiration event is known by the covered entity to have occurred.
A certificate of destruction should include the following details:
A statement that the records were destroyed in the normal course of business.
True or False: HIM professionals are not involved with research assistance.
False - Providing research assistance to clinicians and medical staff committees is a HIM department function.
Which of the following information is not included in a clinical trial database?
The Food and Drug Adminitration's User Manual
True or False: Registries are a source of secondary data.
Which of the following serve as a purpose of the WONDER database?
To promote information-driven decision making by placing timely, useful facts in the hands of public health practitioners and researchers.
Which site is not included in the National Health Care Surveys?
Patient's home
Data elements included in the MPI should:
Accurately match patients being registered for care with their MPI records.
Which of the following are not considered biometric authentication?
Foot vein scanning
A transplant registry is defined as a registry that tracks:
The case of patients who need organ transplants
True or False: The NPDB has state agencies that monitor medical malpractice.
False - The NPDB provides an electronic information repository of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medical staff privileges) taken by healthcare entities.
The NCHS is involved with all of the following except?
Documenting the health status of individual patients
Who is primarily responsible for completing the discharge summary?
Which of these phases includes the distribution of the proposal?
Disposition phase
True or False: A cybersecurity attack does not have the potential to cease computer operations throughout an organization.
False - A cybersecurity attack can impact an entire organization depending upon the security measures that are in place
True or False: The Notice of Privacy Practices tells a patiet how health information is used by an organization.
Which of these organizations mandates accreditation standards for behavioral health organizations?
Commission on Accreditation of Rehabilitation Facilities
Special details surrounding the death of a patient would be shown in what document?
Which of the following documents contains information about pertinent laboratory, radiology, therapy, and consultations?
Discharge Summary
Which of these are a version of a handwritten signature?
The process of abstracting involves the following:
Extracting
True or False: The purpose of CDI is to increase reimbursement.
False - The purpose of CDI is to improve documentation, which supports many functions including reimbursement, quality measures, patient care through communication, reduce legal risk, and more.
True or False: The HHS OIG has determined the use of closed-ended queries is illegal.
False - AHIMA recommends open-ended queries; however closed-ended questions such as multiple choice and yes/no can be appropriate depending on the situation.
True or False: Clarification regarding a condition being present on admission or hospital acquired is an appropriate reason to initiate a query.
True or False: Queries should only be initiated when the clarifications would affect reimbursement.
True or False: Medical codes must match the recorded clinical documentation.
Modern EHR systems:
Offer options, tools, and templates to assist in the CDI process
Most successful CDI programs utilize this type of documentation review:
The physician champion or advisor's role is to:
Influence and educate peers regarding CDI
The most important outcome of a CDI program is:
Documentation that describes the patient's condition and treatment as accurately as possible
One component of a successful CDI program is:
Ongoing training for CDI staff and physicians
For an effective clinical tool/program to be successful, the following steps (in order) would need to be incorporated:
Analyzing the data
Interpreting the findings
Changing current practice
What is a Learning Health System?
Vision about leading healthcare and health to "big data" to empower all stakeholders in the healthcare to learn large
Adaptive leadership principles include:
Diagnose and ob serve the system they function within
Interpret what they are observing in the system
Intervene more effectively within the IG system informed by their observations and interpretations
To be able to conduct a successful IG program, which priorities were identified by IG leaders?
Educate members and stakeholders on IG
Collaborate and cooperate
Break down silos
Demonstrate the value, relevance, and importance of IG
Create IG resources
Grow the body of knowledge
Discuss the importance of IG
Part of the analytics framework includes the collection, compilation, an analysis of data. Data cleaning is an important first step in this process and some examples to look for in this process include:
Omissions, inconsistencies, missing values, incorrect values
Creating a data-cleaning plan would help with making sure the data is clean especially when dealing with large data sets
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