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Health Information Management Technology 4th Edition by Sayles – 
Test Bank

 

 

 

 

Real-World Case Discussion Questions

 

  1. How is the EHR changing the roles of the HIM staff?

 

  1. Why are credentials important?

 

  1. What is your view of the HIM profession?

 

Application Exercises

 

  1. Visit the AHIMA website and research the qualifications for taking each certification examination and the continuing education requirements for maintaining each credential. What similarities and differences do you see?

 

  1. Visit the AHIMA website and make a list of the current national committees. What are the names of these committees and what is their purpose?

 

  1. Contact AHIMA via its website and determine how you can become a student member of AHIMA.

 

Review Quiz

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

 

  1. The first professional association for health information managers was established in:
    1. 1900
    2. 1905
    3. 1928
    4. 1970

 

  1. The hospital standardization program was started by the American College of Surgeons in:
    1. 1900
    2. 1905
    3. 1918
    4. 1928

 

  1. The formal approval process for academic programs in health information management is called:
    1. Accreditation
    2. Certification
    3. Registration
    4. Standardization

 

  1. The formal process for conferring a health information management credential is called:
    1. Accreditation
    2. Certification
    3. Registration
    4. Standardization

 

  1. Which of the following are elected to their positions by AHIMA members?
    1. AHIMA Board of Directors
    2. Members of the Council on Certification
    3. Members of the Commission on Accreditation for Health Informatics and Information Management Education
    4. All of the above

 

  1. Which of the following functions as the legislative body of AHIMA?
    1. AHIMA Board of Directors
    2. AHIMA Commission on Certification for Health Informatics and Information Management
    3. AHIMA House of Delegates
    4. AHIMA Foundation

 

  1. Which of the following make up a virtual network of AHIMA members?
    1. AHIMA Board of Directors
    2. AHIMA Council on Certification
    3. AHIMA Communities of Practice
    4. AHIMA House of Delegates

 

  1. Which of the following is an arm of AHIMA that promotes education and research in health information management?
    1. AHIMA Board of Directors
    2. AHIMA CAHIIM
    3. AHIMA Foundation
    4. AHIMA Commission on Certification for Health Informatics and Information Management

 

  1. Which of the following best describes the mission of the AHIMA?
    1. Community of professionals providing support to members and strengthening the industry and profession
    2. Community of professionals whose major purpose is lobbying Congress to change laws
    3. Community of credentialed members who monitor the credentialing process
    4. Community of credentialed members whose purpose is to ensure jobs for their members

 

  1. Which professional organization sponsors the CTR certification?
    1. AHIMA
    2. NCRA
    3. AAPC
    4. Community College Consortia

 

Test Bank

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

 

  1. The primary function of the American Health Information Management Association is to:
  2. Ensure that accurate and complete medical records are written for every hospital patient
  3. Standardize the content and format of the health records maintained by acute and emergency care facilities
  4. Promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting
  1. Provide support for two- and four-year health information management educational programs

 

  1. The primary goal of the Hospital Standardization Program was:
  2. Raise the standards of surgical practice
  3. Train physicians and nurses for American hospitals
  4. Standardize the educational curricula of American medical schools
  5. Force substandard hospitals to close

 

  1. Which of the following activities is not a traditional medical records function?
  2. Forms control
  3. Quantitative analysis
  4. Productivity monitoring
  5. Data administration

 

  1. The only requirements for professional certification through the AHIMA are graduating from an accredited two-year or four-year educational program.
  2. Yes
  3. No

 

  1. Which of the following is true about the AHIMA certification program?
  2. The eligibility requirements for all credentials are the same.
  3. Candidates must pass an examination before obtaining any of the credentials.
  4. Candidates must be college graduates before they can obtain any of the credentials.
  5. Candidates must have work experience and pass a certification exam before they can obtain any of the credentials.

 

  1. Which of the following classes of AHIMA membership requires that individuals hold an AHIMA credential?
  2. Active membership
  3. Associate membership
  4. Student membership
  5. Honorary membership

 

  1. Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA?
  2. House of Delegates
  3. Board of Directors
  4. Communities of Practice
  5. Component state associations

 

  1. The accreditation program of AHIMA is concerned with:
  2. Establishing standards for the content of college programs in HIT and HIM
  3. Making sure that AHIMA has good certification examinations
  4. Ensuring that AHIMA manages its property and affairs appropriately
  5. Establishing policies and procedures to be followed by the Communities of Practice

 

  1. The new opportunity for HIM professionals that deals with data repositories and data warehouses is:
  2. Health information manager
  3. Clinical data specialist
  4. Enterprise content and information manager
  5. Data resource administrator

 

  1. The _______makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA.
    1. Board of Directors
    2. Communities of Practice
    3. Commission on Certification for Health Informatics and Information Management
    4. House of Delegates

 

  1. Which of the following accredits academic programs in health information management?
    1. AHIMA Board of Directors
    2. CAHIIM
    3. CCHIIM
    4. House of Delegates

 

  1. Members of the AHIMA House of Delegates are:
    1. Appointed by the AHIMA Board of Directors
    2. Elected by the AHIMA Board of Directors
    3. Elected by members in state component organizations
    4. Elected by the AHIMA Nominating Committee

 

  1. Who is responsible for final approval of the AHIMA Code of Ethics?
  2. AHIMA Board of Directors
  3. AHIMA Commission on Certification for Health Informatics and Information Management
  4. AHIMA Ethics Committee
  5. AHIMA House of Delegates

 

  1. Which of the following actively promotes education and research in health information management?
    1. Commission on Certification for Health Informatics and Information Management
    2. CAHIIM
    3. AHIMA Foundation
    4. House of Delegates

 

  1. Which organization’s goal is centered on health information technology?
  2. HIMSS
  3. AHDI
  4. AHIMA
  5. AAPC

 

Instructor’s Manual

Chapter 2

Purpose and Function of the
Health Record

 

 

 

Project

Have students put together a trivia game. For this chapter, have students develop 10-15 cards on the purposes of the health record and quality characteristics of the health record.

 

Real-World Case Discussion #1 Questions

  1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR?

 

 

  1. How does copy/paste functionality affect reimbursement?

 

  1. What measures can a hospital take to improve data integrity in their EHR while still achieving their goal of streamlining the documentation process?

 

Real-World Case Discussion #2 Questions

 

  1. What impact can a hybrid record have on patient care?

 

 

  1. How might the hybrid record change health information management?

 

 

  1. How might a hospital overcome some of the issues created by the hybrid record?

 

 

Application Exercises

  1. Go to the AHIMA website (www.ahima.org) and search for articles related to data quality management, the AHIMA data quality improvement model, or the AHIMA data quality management model. Choose two articles that discuss the subject. Write a paragraph on the key points for HIM professionals to consider in the design of electronic data collection systems.

 

  1. Go to the AHIMA website (www.ahima.org) or another health-related site and search for articles related to functions of the electronic health record. Select two articles to read, and then write a paragraph about each that discusses the projected or achieved benefits of these functions to healthcare delivery.

 

  1. List and define the six attributes associated with storage of patient care documentation.

 

  1. Go to the AHIMA website or some other health-related site and search for articles related to the uses and users of health records. Select two articles to read and write a paragraph on each. Why did you select each article? What do you think is important about each article?

 

 

  1. Discuss the responsibilities of health information management professionals in the development and maintenance of health record systems. What are some new roles for HIM professionals in the future?

 

 

  1. Interview a HIM professional on the differences in working in a paper, hybrid, and/or electronic health record environment. Write a summary of your interview.

 

Review Quiz

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

 

  1. Which of the following is a secondary purpose of the health record?
  2. Document patient care delivery
  3. Assist caregivers in patient care management
  4. Aid in billing and reimbursement functions
  5. Generate a report to be used in performance improvement

 

  1. Which of the following is an institutional user of the health record?
  2. Patient care provider
  3. Third-party payer
  4. Coding and billing staff
  5. Government policy maker

 

  1. How do patient care managers and support staff use the data documented in the health record?
  2. Evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
  3. Communicate vital information among departments and across disciplines and settings
  4. Generate patient bills and/or third-party payer claims for reimbursement
  5. Determine the extent and effects of occupational hazards

 

  1. Which of the definitions below best describes the concept of confidentiality?
  2. The right of individuals to control access to their personal health information
  3. The protection of healthcare information from damage, loss, and unauthorized alteration
  4. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
  5. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

 

  1. Which of the following statements does not pertain to paper-based health records?
  2. They have a built-in access control mechanism.
  3. They are kept in locked storage areas that are accessible only to authorized staff.
  4. They are logged out according to the organization’s prescribed procedure.
  5. They are forwarded to the appropriate service area when needed for patient care purposes.

 

  1. Which of the following is an advantage offered by computer-based clinical decision support tools?
  2. They give physicians instant access to pharmaceutical formularies, referral databases, and reference literature.
  3. They review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends.
  4. They recall relevant diagnostic criteria and treatment options on the basis of data in the health record and thus support physicians as they consider diagnostic and treatment alternatives.
  5. All of the above

 

  1. The hospital where I work is transitioning to an EHR. In the meantime, we have part of

the health record electronic and part is still paper. This concept is known as:

  1. Integrated health record format
  2. A hybrid record
  3. A resident record
  4. Integrated health record format

 

  1. Critique this statement: Data and information mean the same thing.
  2. This is a true statement.
  3. This is false as data is used for administrative purposes and information is used                                for clinical purposes.
  4. This is a false statement as data is raw facts and figures and information is
    data converted into a meaningful format.
  5. This is a true statement as information is raw facts and figures and data is                              information converted into a meaningful format.

 

  1. Which of the following statements does not pertain to electronic health records (EHRs)?
  2. EHR technologies and systems must not intrude on the patient and provider relationship.
  3. EHRs are filed in paper folders.
  4. In the United States, a national health information infrastructure is being designed to support EHRs.
  5. Clinicians use computer keyboards when documenting in the EHR.

 

  1. Which of the following is a secondary purpose of the health record?
  2. Support for provider reimbursement
  3. Support for patient self-management activities
  4. Support for research
  5. Support for patient care delivery

 

  1. Use of the health record by a clinician to facilitate quality patient care is considered:
  2. A primary purpose of the health record
  3. Patient care support
  4. A secondary purpose of the health record
  5. Patient care effectiveness

 

  1. Use of the health record to monitor bioterrorism activity is considere:
  2. Primary purpose of the health record
  3. Secondary purpose of the health record
  4. Patient use of the health record
  5. Healthcare licensing agency function

 

  1. How do accreditation organizations use the health record?
  2. To serve as a source for case study information
  3. To determine whether the documentation supports the provider’s claim for reimbursement
  4. To provide healthcare services
  5. To determine whether standards of care are being met

 

  1. How do research organizations use the health record?
  2. To examine results of experimental protocols
  3. For reporting of communicable diseases
  4. To investigate domestic violence
  5. To manage disability insurance benefits

 

  1. Attorneys for healthcare organizations use the health record to
  2. Support claims for medical malpractice
  3. Protect the legal interests of the facility and its healthcare providers
  4. Plan and market services
  5. Locate missing persons

 

  1. Our record has all of the lab filed together, all of the progress notes filed together, and so on. What format are we using?
  2. Source-oriented health record
  3. Integrated health record
  4. Patient-oriented health record
  5. Problem-oriented health record

 

  1. Inaccurate data recorded in the health record could:
  2. Compromise quality patient care
  3. Contribute to incorrect assumptions by policy makers
  4. Invalidate research findings
  5. All of the above

 

  1. The term used to describe expected data values is
  2. Data definition
  3. Data currency
  4. Data precision
  5. Data relevancy

 

  1. Protection of healthcare information from damage, loss, and unauthorized alteration is also known as:
  2. Privacy
  3. Results management
  4. Security
  5. Data accuracy

 

  1. Since we implemented a new technology, we have eliminated lost orders and problems
    with legibility. What technology are we using?
  2. Computerized physician/provider order entry
  3. Electronic health record
  4. Results management
  5. Clinical decision support

 

  1. The paper-based health record format that organizes all forms in chronological order is known as the:
  2. Problem-oriented health record
  3. Integrated health record
  4. Patient-oriented health record
  5. Source-oriented health record

 

  1. Critique this statement: The health record documents services provided by allied health professionals and a patient’s family.
  2. This is a true statement.
  3. This is a false statement as the health record only document’s physician’s care.
  4. This is a false statement as the health record only documents care provided by patient families.
  5. This is a false statement as the health record documents the care provided by healthcare professionals.

 

  1. An individual’s right to control access to his or her personal information is known as:
  2. Security
  3. Confidentiality
  4. Privacy
  5. All of the above

 

  1. When all required data elements are included in the health record, the quality characteristic for ______ is met.
  2. Data security
  3. Data accessibility
  4. Data flexibility
  5. Data comprehensiveness

 

  1. Critique this statement: Patient care managers are individual users of health records.
  2. This is a true statement.
  3. This is a false statement as they do not require patient information to do their job.
  4. This is a false statement as they require patient information to do their job.
  5. This is a false statement as patient care managers are institutional users.

 

Test Bank

Instructions: For each item, complete the statement correctly or choose the most appropriate answer.

 

  1. Which of the following best describes the most important function of the health record?
  2. Communicating instructions between physicians and nurses
  3. Providing information to support reimbursement claims
  4. Storing patient care documentation
  5. Providing information to support managed care