Electronic Health Records
Exam Materials
Course Introduction
This course provides a comprehensive overview of Electronic Health Records (EHRs), exploring their fundamental concepts, benefits, and challenges within healthcare systems. Students will learn about the structure, functionality, and standards of EHRs, including data entry, storage, retrieval, and security. The course covers regulatory and ethical issues, interoperability, implementation strategies, and the impact of EHRs on patient care and clinical workflows. Through case studies and practical exercises, students will gain insights into current trends and best practices in EHR adoption and management.
Recommended Textbook
Health Information Technology 3rd Edition by Nadinia
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14 Chapters
874 Verified Questions
874 Flashcards
Source URL: https://quizplus.com/study-set/1089
Page 2
A. Davis
Chapter 1: Health Care Delivery Systems
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69 Verified Questions
69 Flashcards
Source URL: https://quizplus.com/quiz/21474
Sample Questions
Q1) The actual number of beds that a hospital has available for inpatients is called the
Answer: bed count
Q2) All of the following are ancillary services EXCEPT the _____ department.
A) Radiology
B) Laboratory
C) Emergency
D) Mammography
Answer: C
Q3) Community Care Center has 200 beds. It has an average length of stay of 2.5 years. Most of the patients are elderly, but there are some younger patients with serious chronic illnesses. Community Care Center is most likely a(n) _____ facility.
A) Acute care
B) Behavioral health
C) Long-term care
D) Rehabilitation
Answer: C
Q4) Health care professionals must adhere to their discipline's ____________.
Answer: code of ethics
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Chapter 2: Collecting Health Care Data
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74 Verified Questions
74 Flashcards
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Sample Questions
Q1) Another term for demographic data is:
A) Explanatory
B) Referral
C) Global
D) Indicative
Answer: D
Q2) All of the following are advantages to the use of Electronic Health Records EXCEPT which one?
A) Manage information timely and efficiently.
B) Use of computerized physician order entry (CPOE).
C) Ability to capture electronic signatures.
D) Unauthorized users may access patient information at any time.
Answer: D
Q3) The integrated record is organized by:
A) Source
B) Date
C) Alphabetical order
D) Numerical order
Answer: B
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Page 4
Chapter 3: Electronic Health Records
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67 Verified Questions
67 Flashcards
Source URL: https://quizplus.com/quiz/21476
Sample Questions
Q1) The interface which grants patients web-based access to their medical record is known as a patient ___________.
Answer: portal
Q2) Hospital B has a medical record that has computerized the progress notes, physician orders, ancillary reports, and nursing notes. The coders must review the record and enter abstracting data into the coding system. What type of record is being used at this facility?
A) Paper record
B) Hybrid record
C) Electronic record
D) All of the above
Answer: B
Q3) Use of a scanner or a fax machine to store the paper document electronically into a computer program or onto an optical disc is called ____________.
Answer: document imaging
Q4) Health care delivery that uses clinical research to make decisions in patient care is
Answer: evidence-based medicine
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Chapter 4: Acute Care Records
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.
Q2) If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be _________________ by the supervisor.
Q3) The first page, also known as the face sheet, in a paper record is usually the ___________.
Q4) Which of the following is an element of an acute care admission record?
A) Patient's previous operations
B) Type of dwelling in which the patient lives
C) Name of patient's employer
D) Patient's height and weight
Q5) In caring for a patient, an attending physician may request a(n) ___________ from another physician or health care professional who specializes in the patient's problem.
Q6) Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?
Q7) Name and describe the four scenarios that inpatient admissions correspond to.
Page 6
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Chapter 5: Health Information Management Processing
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69 Verified Questions
69 Flashcards
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Sample Questions
Q1) Which one of the following activities can be considered a preventive control?
A) Retrospective chart review
B) Concurrent chart review
C) Detective chart review
D) Documentation training review
Q2) List the forms that are present, in one way or another, in every acute care health record. What is the most useful way to organize those forms in a record while it is on the nursing unit? Postdischarge? Why do some organizations want the record to be organized differently predischarge and postdischarge?
Q3) TThe representation of diagnoses and procedures as alphanumerical values in order to capture them in the database is called ___________.
Q4) Is a computer-based record completely paperless? Why or why not?
Q5) ___________ procedures govern the storage of records, including duration, location, security, and access.
Q6) The postdischarge process begins with which of the following steps:
A) Assembling the patient chart
B) Analyzing the patient chart for deficiencies
C) Reviewing the discharge register
D) Requesting the physician's signature on deficient forms
Page 7
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Chapter 6: Code Sets
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48 Verified Questions
48 Flashcards
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Sample Questions
Q1) Because the patient record is a highly personal document, and therefore must be treated respectfully with regard to the coded data assigned, AHIMA has issued which of the following guidelines?
A) HIPAA Official Guidelines for Coding and Reporting
B) Standards of Ethical Coding
C) standards for code sets
D) Federal Register
Q2) How can coding assist health care facilities in analyzing their patient needs? Please list and discuss at least three reasons.
Q3) Current code sets under HIPAA include all of the following EXCEPT:
A) ICD-9-CM, Volumes I, II, and III
B) National Drug Codes
C) HCPCS and CPT-4
D) ICD-10-PCS
Q4) Coder can use the ________________ algorithm to assist in mapping SNOMED-CT codes to the more specific ICD-10-CM code set.
Q5) Can a health care facility choose to use only SNOMED instead of ICD-10-CM? Why or why not? How can these two data sets complement each other?
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Chapter 7: Reimbursement
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69 Verified Questions
69 Flashcards
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Sample Questions
Q1) How would someone use an unbilled list (DNFB)?
Q2) Payments calculated based on the number of days are called ____________.
Q3) One major difference between a PPO and an HMO is:
A) Under PPOs, patients can choose any health care provider without penalty
B) HMOs require co-pays
C) HMOs do not typically reimburse for out-of-network providers
D) PPOs require co-pays
Q4) Insurance policies that supplement Medicare coverage are called _________.
Q5) A hospital's case mix index is derived by:
A) Organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth
B) Adding all DRG relative weights together and then dividing by the total number of cases discharged in a given time period
C) Neither a nor b; case mix index is assigned by the federal government using special software
D) Both a and b
Q6) The type of insurance that assumes the payment for all or part of certain, specified services, but requires out-of-pocket deductibles and frequently caps total covered payments is called _____________.
Page 9
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Chapter 8: Health Information Management Issues in Other Care Settings
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53 Verified Questions
53 Flashcards
Source URL: https://quizplus.com/quiz/21481
Sample Questions
Q1) What unique length of stay issues apply to hospice care?
Q2) The minimum data set used for emergency room departments is also known as the: A) UHDDS
B) UACDS
C) DEEDS
D) RAI
Q3) The CMAT is a tool used by CMS for PPS in:
A) Behavioral health
B) Rehabilitation
C) Long-term care
D) Home health
Q4) A facility-based ambulatory care department that provides general or specialized services such as those provided in a physician's office is called a _______.
Q5) The minimum data set used for ambulatory care settings is also known as the: A) UHDDS
B) UACDS
C) MDS
D) RAI
Q7) Describe the unique data collection issues in radiology and laboratory services. Page 10
Q6) The mandated minimum data set for ambulatory care patients is the ________.
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Chapter 9: Managing Health Records
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58 Verified Questions
58 Flashcards
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Sample Questions
Q1) Health care records must be maintained for a specific number of years. What is the requirement in your state for retention of inpatient health care records? Do you recall how to determine the number of years a group of health care records must be maintained?
Q2) In a unit number filing system, the medical record number:
A) Changes with each new admission
B) Is not assigned to minor children
C) Is used for medical coding purposes
D) Remains the same for the life of the patient
Q3) A manual chart locater system must use ________ to hold the place of the original record.
A) Spacers
B) Outguides
C) Indexers
D) Blank files
Q4) A numerical patient record identification system, which gives the patient a new number for each visit, is called _________numbering.
Q5) What can be done when health records are lost or destroyed inadvertently?
Q6) A _____________is used to identify the location of records within a facility.
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Q7) The length of time that a record must be retained is called the ____________.
Chapter 10: Statistics
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) Diagnosis, physician, or procedure ________________ are used to organize and retrieve specific data from the HIM database.
Q2) In 2012, Comfort Community Hospital had 150 beds from January 1 through June 30. On July 1, the hospital increased its beds to 250 and the number remained at 250 through December 31. During the first 6 months, 27,912 inpatient days of service (IPSDs) were provided. During the last 6 months, 35,967 days of service were provided. What is the average daily census for the first 6 months in a non-leap year? The last 6 months? The whole year?
Q3) Which statement below requests aggregate health information?
A) Request for report on all DRG 127 for the month of June
B) Request for patient information, MR# 02-34-65, DRG 127
C) Request for first case of CHF for the third quarter
D) Request for record of patient #197808, under the care of Dr. S. S. Schoner
Q4) Named and identifiable pieces of data that can be queried and reported in a meaningful way are called ________________.
Q5) The length of stay for Patient H is _______________.
Q6) Explain the mean, median, and mode.
Q7) A measure of variance called the ______________ shows how closely the observations are distributed around the mean.
Page 13
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Chapter 11: Quality and Uses of Health Information
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67 Verified Questions
67 Flashcards
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Sample Questions
Q1) Compare and contrast Juran's and Crosby's quality management theories. How can health care facilities apply these theories?
Q2) A method used to effectively manage patients during their hospitalization is known as _______________.
Q3) Monitoring functions for compliance within set standards is called __________, which also requires action to correct noncompliance, and followup on the correction.
Q4) A predetermined course of treatment for a patient with a particular diagnosis is known as a ______________.
Q5) The predecessor of The Joint Commission was:
A) Hospital standardization
B) AHIMA
C) NCQA
D) ACS
Q6) Compare and contrast the difference between prevalence and incident. Why is it important to know both?
Q7) A quality improvement effort regarding scanning of loose reports would require an ___________ team.
Q8) What is the difference between mortality and morbidity?
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Chapter 12: Confidentiality and Compliance
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52 Verified Questions
52 Flashcards
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Sample Questions
Q1) A patient has been admitted to your facility for treatment of pneumonia. He gave insurance information to the patient registration department. During the course of treatment, the patient is found to have AIDS. After discharge, the patient's insurance company asks for a copy of the record. Can the insurance company obtain the record at this point? What are the issues?
Q2) A _____________ is the designated official in the health care organization who oversees privacy compliance and handles complaints.
Q3) An insurance company may obtain patient records by all of the following EXCEPT:
A) Prospective consent under the conditions of admission
B) By subpoena for disclosure of chemical dependency information
C) Prospective consent obtained when the patient became insured
D) Retrospective consent obtained after the patient is discharged
Q4) Under what circumstances will a release of information be denied? Name at least four.
Q5) Compare and contrast privacy, security, and confidentiality. Provide an example of each in a health care situation.
Q6) The period in which lawyers are preparing their case and obtaining documents and testimonies is called ______________.
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Chapter 13: Him Department Management
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62 Verified Questions
62 Flashcards
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Sample Questions
Q1) An HIM department budgets 3 full-time equivalents (FTEs) for coding. If a full-time employee usually works 40 hours a week, how many hours per week are available for coding?
A) 3 hours
B) 40 hours
C) 120 hours
D) 100 hours
Q2) All of the following administration chiefs are subordinate to the Chief Executive Officer EXCEPT the:
A) COO
B) CIO
C) CNO
D) CEO
Q3) In the HIM department Judy, the physician record clerk, is responsible to Deenie, the supervisor, and Michelle, the director. This violates the ______________ principle.
Q4) The ________________ is the group of processes that identify, record, and report the financial transactions that result from the facility's clinical relationship with a patient.
Q5) List and briefly explain the basic functions of an HIM department.
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Chapter 14: Training and Development
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49 Verified Questions
49 Flashcards
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Sample Questions
Q1) Although trainers do not need to know each employee individually, they do recognize that employees have different learning styles. In what ways can training sessions be formatted? Provide an example of these three training formats. Do all three training formats need to be used for the same session? Why or why not?
Q2) What subjects has AHIMA deemed core content for the HIM profession? Name at least five and detail how to obtain continuing education for these core content subjects.
Q3) List the topics covered during the HIM department orientation.
Q4) How is development different from training?
Q5) Explain three aspects of leadership and provide an example of how they can be accomplished.
Q6) ___________ provides documentation of the message intended for the recipient.
Q7) An employee's low ________ in a particular area can help a manager assess education needs.
Q8) What are the different methods of earning AHIMA-approved continuing education credits to maintain the credential?
Q9) All HIM professionals should recognize that their __________ are accompanied by a commitment to lifelong learning.
Page 17
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