Deck 2: Health Data Structure, Collection, and Standards

Question 1

The staff of the ___________________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting.

A) information technology department
B) administrative offices
C) health information department
D) business office

Answer 1

health information department

Question 2

The date of birth on a patient's record is ___________________ data.

A) structured
B) unstructured

Answer 2

structured

Question 3

Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked primarily in which type of facility?

A) physicians' offices
B) long-term care facilities
C) hospitals
D) service providers (software vendors)

Answer 3

hospitals

Question 4

A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an

A) insurance record.
B) personal health record.
C) temporary record.
D) decision support record.

Question 5

Dr. Henderson wrote a progress note in the emergency room note of Lisa Ford. This is an example of _________________ data.

A) structured
B) unstructured

Question 6

The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health _______________________.

A) data
B) information

Question 7

The image above would be found in which format?

A) electronic health record
B) paper health record

Question 8

Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The ___________________ would be responsible for assessing the budgeting process, funding, and monitoring the monetary aspects of the project.

A) health information manager
B) chief executive officer
C) chief financial officer
D) billing manager

Question 9

Typically, paper health records are maintained how?

A) record kept by patient and taken to his/her medical appointments
B) filed on magnetic disks
C) filed in folders in numeric or alphabetic order
D) in dictated format

Question 10

Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health?

A) American Hospital Association
B) American Medical Technologists Association
C) American Health Information Management Association
D) American Association of Medical Assistants

Question 11

An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is ________________________ data.

A) structured
B) unstructured

Question 12

Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a

A) health information administrator.
B) chief nursing administrator.
C) human resources administrator.
D) health systems administrator.

Question 13

In a hospital setting, the management personnel and much of the staff of the department responsible for maintaining and retrieving data from health records are often certified through and members of which professional organization?

A) American Hospital Association (AHA)
B) American Academy of Professional Coders (AAPC)
C) American Health Information Management Association (AHIMA)
D) American Association of Medical Assistants (AAMA)

Question 14

Which of the following requires completion of a competency exam, but does not result in certification?

A) Registered Health Information Administrator
B) Practice Workflow & Information Management Redesign Specialist
C) Registered Medical Assistant
D) Registered Health Information Technician

Question 15

In a physician's practice, ________________ may be the title of the person who is responsible for the overall administrative management of the practice.

A) Health Information Manager
B) Office Administrator
C) Physician
D) Chief Medical Assistant

Question 16

Philip is a medical assistant who has been working for a medical practice with two physicians and one physician's assistant for three years. He recently applied for a supervisory position within the office, but was overlooked for the position. He is anxious to take his knowledge and experience to the next level, but never took a certifying exam, and to this point has not taken advantage of continuing education opportunities. What is the strategy for Philip to strengthen his chances of promotion in the future?

A) Speak with the office manager and let his career plans be known.
B) Join the American Health Information Management Association.
C) Begin studying for one of the medical assisting certifying exam and schedule a date to take it.
D) Look for other opportunities in other physicians' practices.

Question 17

A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, or compliance officer.

A) Certified Coding Associate (CCA)
B) Certified Medical Assistant (CMA)
C) Certified Health Care Facility Manager (CHFM)
D) Registered Health Information Administrator (RHIA)

Question 18

The health information manager and the ___________________ work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility?

A) Information Technology Manager/Officer
B) Chief Operating Officer
C) Chief Executive Officer
D) Chief Financial Officer

Question 19

A zip code would be an example of _______________ data.

A) structured
B) unstructured

Question 20

Roberta has an associate degree and holds RMA certification. She mainly performs administrative duties such as appointment scheduling, registering patients, and maintenance of health records in a large physician's practice. She occasionally performs clinical duties as well, as needed. Roberta is a

A) health information technologist.
B) nurse.
C) nurse practitioner.
D) medical assistant.

Question 21

A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the

A) care provider's social security number.
B) care provider's license number to practice medicine.
C) National Provider Identifier number.
D) care provider's policy number.

Question 22

The patient has a heart rate of 68 and a blood pressure of 110/65. These are known as:

A) past medical history
B) problem list
C) vital signs
D) social history

Question 23

What is the patient's marital status?

A) married
B) divorced
C) single
D) separated

Question 24

In a physician's office, the equivalent of a hospital's Master Patient Index is

A) a client index.
B) a customer list.
C) a patient list.
D) also referred to as a Master Patient Index in a physician's office.

Question 25

"A set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as

A) Health Insurance Portability and Accountability Act.
B) Office of the National Coordinator.
C) Health Information Technology for Economic and Clinical Health Act.
D) National Health Information Network.

Question 26

When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________.

A) paper
B) face-to-face communication
C) physician dictation
D) the keyboard

Question 27

Information that identifies the patient in any way is known as _________________.

A) electronic health information
B) practice management information
C) protected health information
D) administrative information

Question 28

How many surgeries has this patient undergone?

A) 2
B) 4
C) 3
D) 0

Question 29

From which medium is the image above taken?

A) electronic health record
B) paper health record

Question 30

The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the _______________________.

A) Health Insurance Portability and Accountability Act
B) Center for Medicare and Medicaid Services
C) Department of Health and Human Services
D) American Recovery and Reinvestment Act

Question 31

Of the following, which is not a core function of the EHR as defined by the Institute of Medicine?

A) reporting and population health
B) decision support
C) result management
D) filing of insurance claims

Question 32

What is the name of the screen that is open above? (note to vendor: Image is SPU from previous edition)

A) chart
B) registration
C) facesheet
D) schedule

Question 33

The capturing of data about a patient begins at what point?

A) when the patient arrives for an appointment or the hospital for care
B) when the insurance company agrees to pay for services
C) when the patient calls for an appointment or arrives at the hospital for care
D) when the patient completes the registration forms

Question 34

Entering data into a computer system is also known as ________________ data.

A) gathering
B) detailing
C) retrieving
D) capturing

Question 35

The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.

A) Health Insurance Portability and Accountability Act (HIPAA)
B) Electronic Health Record (EHR)
C) Health Information Exchange
D) Institute of Medicine

Question 36

In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?

A) version 3010
B) version 4010
C) version 5010
D) version 6010

Question 37

The hospital equivalent to practice management software used in the physician's practice is known as

A) Registration, Admission, Discharge, Transfer System (aka Admission, Discharge, Transfer System).
B) Electronic Health Records software.
C) Utilization Management Software.
D) Picture Archiving and Communication Systems.

Question 38

In a hospital setting, when the patient presents for care he/she is

A) registered.
B) scheduled.
C) discharged.
D) checked out.

Question 39

Which entity was founded in 2004 to certify electronic health records?

A) Regional Extension Centers
B) Certification Commission for Health Information Technology
C) National Health Information Network
D) Office of the National Coordinator

Question 40

The ________________________ is published by the federal government and includes all actions taken by any government entity on a given date.

A) Federal Review
B) Federal Register
C) Federal News Daily
D) Acts of Congress

Question 41

Define "information governance" and explain the role of health information professionals in, for instance, an acute care health setting.

Question 42

John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an

A) admission.
B) discharge.
C) transfer.
D) registration.

Question 43

The ___________ standards require healthcare organizations to include safeguards (administrative, physical, and technological) that ensure health information is protected, that it is kept private, and that it is retrievable in the event that the integrity of the electronic system is compromised.

Question 44

The acronym HITECH stands for _______.

Question 45

Physicians sometimes use media to describe a procedure or educate the patient about his or her care and treatment. Explain how this might be accomplished. What benefit does this have?

Question 46

A _________________________ includes healthcare organizations in a particular area or region that exchange patient information with the goal of improving patient care.

Question 47

A single fact, such as the race of a patient, is known as _______________.

Question 48

This position was created in 2004 by presidential order and was later mandated by HITECH legislation. The position is known as the _________________________________.

Question 49

Health information specialty areas are nondegree educational programs that require students to pass a/an ___________________ exam.

Question 50

What is meant by an "enterprise" system of healthcare, specifically as it relates to the EHR?

Question 51

A __________________ is a software program that allows care providers to view higher quality images of x-rays, ultrasounds, and other radiographic images from any location.

Question 52

A healthcare professional who typically holds an associate degree or certificate and may perform tasks such as prepping patients, taking patients' histories, answering phone, scheduling patients, filing insurance claims, and maintaining health records within a physician's office is known as a/an ____________.

Question 53

The acronym for the position created in 2004 by presidential order and later mandated by HITECH legislation is __________.

Question 54

_______________ is the acronym for the Act that increased the privacy and security of electronic health information.

Question 55

Name and describe six (6) professionals who work in the healthcare field.

Question 56

In 2017, an electronic health record will be required in every healthcare facility. This is due to the ____________________________________.

Question 57

Chief operating officer, chief financial officer, chief executive officer are all more specific terms for a healthcare ___________________.

Question 58

The free, open source software that supports the exchange of health information is called __________________.

Question 59

Name and describe the sources of data from which a patient's past medical history (PMH) are derived.

Question 60

Explain the HITECH Act.