HIM CHAPTER 3,4,10
HL7 is working to develop standards that will aid the exchange of electronic data in and among health
care organizations by assuring __________ among computer systems. - ANS - Interoperability
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HIM CHAPTER 3,4,10
HL7 is working to develop standards that will aid the exchange of electronic data in and among health
care organizations by assuring __________ among computer systems. - ANS - Interoperability
A process that tracks the activity of users in the system, storing what the user accessed and when the
user accessed it, is: - ANS - Audit Trail
Which entity fosters collaboration of the public sector and private sector through the "Connecting for
Health" initiative to improve patient care by promoting standards for electronic medical information? -
ANS - Markle Foundation
The HIMSS definition of an electronic health record includes - ANS - Provides decision-making
capabilities
Collection of data
Real-time, point of care
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? - ANS - Hybrid Record
CPOE (Computerized Physician Order Entry) - ANS - A health information system in which physicians
enter orders electronically. Includes decision support and alerts.
HIE - ANS - the database of a network of health care providers.
ARRA - ANS - ...all so called the stimulus bill
HITECH - ANS - a subset of america recovery act.use of technology in health care.
patient registration form - ANS - Patient identity
Nurse/nursing staff - ANS - Vital signs
Maintained in system files - ANS - Health care facility identification number
Attending physician (or his or her designee) - ANS - Discharge summary
Examination of a patient using x-rays - ANS - Radiology tests
Analysis of body fluids - ANS - Laboratory tests
The nurse's evaluation of the patient - ANS - Nursing assessment
The physician's documentation of the examination of the patient, particularly at the initial visit - ANS -
Physical examination
Record of all drugs given to a patient during the hospitalization - ANS - Medication sheet
Acronym that describes the medical decision-making process. It also refers to the way physicians
organize their progress notes - ANS - SOAP format
The physician's documentation of a surgical procedure, usually dictated and transcribed - ANS -
Operative report
The physician's record of each visit with the patient - ANS - Progress notes
The process of systematically eliminating potential diagnoses. Also refers to the list of potential
diagnoses - ANS - Rule out
The diagnostic, therapeutic, or palliative measures that will be taken to investigate or treat the patient's
condition or disease - ANS - Plan of treatment
One or more surgical procedures performed at the same time - ANS - Operation
The physician's directions regarding the patient's care. Also refers to the data collection device on which
these elements are captured - ANS - Physician's orders
The physician's operative report must be completed: - ANS - during the procedure.
The best place to look to determine what medications a patient has received is the: - ANS - nursing
medication administration record.
the Centers for Medicare and Medicaid (CMS) allows some patients to stay in the hospital up to 48
hours for monitoring without being admitted. This is called _____________ status. - ANS - observation
What is one distinguishing factor between emergent and urgent care? - ANS - Patient presents with lifethreatening condition
Obstetrical records differ from other types of acute care records because: - ANS - prenatal care data is
collected earlier and transferred to the hospital.
A cardiology consultation is typically requested by: - ANS - attending physician.
Which of the following is an element of an acute care admission record? - ANS - Name of patient's
employer
Clinical decision-making systems can assist in the patient care process by all of the following, EXCEPT
- ANS - patient compliance.
The greatest obstacle to convert to an EHR system is: - ANS - start-up costs.
Which is a career opportunity for health information management (HIM) professionals in information
technology - ANS - All of the above
Health Level Seven (HL7) is a: - ANS - standards development organization whose domain is clinical
and administrative data.
Interoperability means: - ANS - the ability of software and hardware on different machines from
different vendors to share data.
Heritage Hospital's health information department uses EHR for its laboratory department, but uses
paper health records for the emergency department. This hospital is currently using which type of
Medical Record System - ANS - Hybrid
The following are examples of security measures, EXCEPT: - ANS - e-PHI.
Sam, the HIM Director at Providence Hospital, suspects that some of his employees have been viewing
patient files that they are not authorized to view. What can Sam do to investigate? - ANS - Perform an
audit trail.
Sapphire Medical Center is ready to implement an EHR system. Currently its clinical laboratory and
radiology department have an electronic system that is well established and interfaces very well. What
may be Sapphire Medical Center's biggest obstacle? - ANS - The interoperability of the new EHR
system with the current clinical laboratory and radiology department EHR system
The Office of the National Coordinator for Health Information Technology's (ONC's) strategic plan has
how many goals? - ANS -
Which goal of the ONC includes unified public health surveillance architectures and accelerated
research and dissemination of evidence? - ANS - Improve population health.
The Healthcare Information and Management Systems Society (HIMSS) definition of an EHR includes:
- ANS - all of the above.
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