WGU C468 Information Management
Questions and Answers with Complete
Solutions
International Classification of Disease (ICD-9/ICD-10) ✔✔System for classification of surgical,
diagnostic, and therapeutic procedures.
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WGU C468 Information Management
Questions and Answers with Complete
Solutions
International Classification of Disease (ICD-9/ICD-10) ✔✔System for classification of surgical,
diagnostic, and therapeutic procedures.
Electronic Signatures in Global and National Commerce Act (ESIGN) ✔✔Legislation that gives
electronic signatures the same legal status as hand-written signatures.
Electronic health record (EHR) ✔✔Digital version of patient data found in traditional paper
records. Increasingly used to refer to a longitudinal record ideally of all healthcare encounters.
Data mining ✔✔Technique that looks for hidden patterns and relationships in large groups of data
using software.
Data exchange standards ✔✔Set of agreed-on rules that permit the uniform capture and exchange
of data between information systems from different vendors and between different healthcare
providers.
Database administrator (DBA) ✔✔Person responsible for overseeing all activities related to
maintaining a database and optimizing its use.
Current Procedural Terminology (CPT) ✔✔Classification system that lists medical services and
procedures performed by physicians and is used for physician billing and payer reimbursement.
Continuity of care document (CCD) ✔✔Record comprised of contributions from many types of
caregivers, with each providing a summary of care provided for the purpose of improved continuity
of care when clients move between various points of care.
Computerized physician (or provider/prescriber) order entry (CPOE) ✔✔Process by which the
physician or provider directly enters orders for patient care into a hospital information system.
Computer-based training (CBT) ✔✔Educational format using the computer that is widely used to
train persons to use specific computer applications.
Computer-based patient record (CPR) ✔✔Automated patient record designed to enhance and
support patient care through availability of complete and accurate data as well as bodies of
knowledge and other aids to care providers.
Community Health Information Network (CHIN) ✔✔Organization that electronically links
providers; payers; and purchasers of care for the exchange of financial, clinical, and administrative
information via a wide area network in a particular geographic area. Precursor to RHIOs.
Commission on Accreditation of Rehabilitation Facilities (CARF) ✔✔Healthcare accrediting
body with a focus on the improvement of rehabilitative services to people with disabilities and
others in need of rehabilitation.
Clinical information systems (CIS) ✔✔Large computerized database management systems used
to access the patient data that are needed to plan, implement, and evaluate care. May also be known
as patient care information systems.
Clinical Care Classification System (CCC) ✔✔Nursing classification designed to document the
six steps of the nursing process across the care continuum. Consists of two interconnected
terminologies—the CCC of Nursing Diagnosis and Outcomes and the CCC of Nursing
Interventions.
Chief privacy officer (CPO) ✔✔Individual responsible for the protection of personal health
information of patients as required by federal law.
Chief information officer (CIO) ✔✔Person responsible for strategic planning, policy development,
budgeting, information security, recruitment and retention of information services staff, and
overall management of the enterprise's information systems. computer-related positions.
Barcode medication administration (BCMA) ✔✔Process or system used to ensure that the correct
patient receives the correct medication in the correct dosage via the correct route and at the correct
time. Patients and drugs both have barcode identification codes.
American Recovery and Reinvestment Act of 2009 (ARRA) ✔✔Legislation that included
provisions for health information technology and funding for the Office of the National
Coordinator of Health Information Technology (ONCHIT).
Logical Observation Identifiers, Names, and Codes (LOINC) ✔✔Terminology that includes
laboratory and clinical observations.
Medicare Improvements for Patients and Providers Act (MIPPA) ✔✔Legislation that called for
financial incentives for e-prescribing.
NANDA International (NANDA-I) ✔✔Terminology recognized by the American Nurses
Association. Represents Nursing Diagnoses as data elements within SNOMED CT.
National Health Information Network (NHIN) ✔✔Office of the National Coordinator (ONC) for
Health Information Technology (HIT) initiative to provide the standards, services, and policies
that enable secure health information exchange (HIE) over the Internet.
Nursing Interventions Classification (NIC) ✔✔Standardized classification of interventions that
describes the activities that nurses perform.
Nursing Minimum Data Set (NMDS) ✔✔Collection of data comprised of nursing diagnoses;
interventions; and outcomes that allows comparison of data across different healthcare settings in
order to project trends and stimulate research.
Nursing Outcomes Classification (NOC) ✔✔Cl
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