CHIMA NCE Data & EHR Questions &
Answers, 100% Accurate, rated A+
An organization's legal health record definition must identify the following regarding individually
identifiable data:
a. Sources
b. Medium
c. Loc
...
CHIMA NCE Data & EHR Questions &
Answers, 100% Accurate, rated A+
An organization's legal health record definition must identify the following regarding individually
identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - ✔✔-d
It is best practice to establish a ____ when defining the legal health record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - ✔✔-d
The legal health record can only be comprised of documentation that physically exists in an electronic
system.
True/False - ✔✔-False
Which function is the first step in the creation of a patient's medical record and initiates the flow of
patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - ✔✔-b
Which of the following processes includes deficiency analysis and chart completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - ✔✔-d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - ✔✔-a
In a negligence case, a physician will be held to a standard of providing care that reflects what is called
_____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - ✔✔-d
A physician who fails to treat a patient who is brought to him or her for care is guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
d. Malpractice - ✔✔-c
A physician who performs a surgical procedure without patient consent may be prosecuted for _____.
a. Assault
b. Battery
c. Negligence
d. Malfeasance - ✔✔-b
Defaming another person in writing is called _____.
a. Libel
b. Slander
c. Invasion of privacy
d. Fraud - ✔✔-a
To successfully prosecute an individual for slander, the plaintiff must prove that:
a. Actual harm occurred
b. There was harmful intent
c. There was dissension between the parties involved
d. Lost wages resulted from the slander - ✔✔-a
Information systems which help with treatment choices, advance care planning and palliative care are
issues that result for those dealing with _____.
a. End of life
b. Integrated
c. Managed
d. Quality - ✔✔-a
Problems with verifying admissions to a facility and children's protective services are ethical issues for
those working with ______ information:
a. Drug, alcohol, sexual, and behavioral
b. Genetic
c. Managed care
d. Public health - ✔✔-a
Promoting the values of autonomy for each individual is ethical behavior for the following Code of Ethics
principle:
a. Facilitate interdisciplinary collaboration
b. Put service before self-interest
c. Put service before self-interest
d. Respect the dignity and worth of every person - ✔✔-d
Protection of information, providing service to those who seek access to information, and preserving
and securing health information reflect professional obligations to _____.
a. An employer
b. Oneself, peers and professional associations
c. Patients and the healthcare team
d. The public - ✔✔-d
Which of the following represents the broadest aspect of a subject?
a. Classification
b. Nomenclature
c. Terminology
d. Code set - ✔✔-a
The original goal of the International Classification of Diseases (ICD) was to describe ________.
a. Morbidity
b. Prevalence of disease
c. Mortality
d. Incidence of disease - ✔✔-c
Cancer registries often use the _______ classification system.
a. SNOMED
b. ICD-O
c. CPT
d. DSM-IV-TR - ✔✔-b
DSM-IV-TR is used most frequently in what type of care setting?
a. Nursing homes
b. Ambulatory surgery centers
c. Behavioral health centers
d. Home health agencies - ✔✔-c
A classification/terminology that provides only very broad and general terms would be described as
more granular that a classification/ terminology that provides an extensive number of very specific
concepts.
True/False - ✔✔-False
Canadian laws and regulations regarding health information have evolved closer on the spectrum to the
European Union's approach than to the United States.
True/False - ✔✔-True
What is the last group to be involved in health information, unless there is court action?
a. Physicians
b. Lawyers
c. Hospital administration
d. Patients - ✔✔-b
The terms "clinical classifications," "nomenclatures", and "terminologies" may be used interchangeably.
True/False - ✔✔-False
An individual may request access to his or her health information in order to make appropriate health
care decisions, provide consent for treatment or to request changes to the documentation. True/False -
✔✔-True
A vital sign, some aspect of a person's health that can be measured (ex: blood pressure, weight,
temperature) is called a:
a. Demographic
b. Biomedical
c. Infomatic
d. Biosignal - ✔✔-d
Using technology to provide distance health care to a patient from their home, or a local clinic/health
facility:
a. Evidence-based Medicine
b. Computerized Provider Order Entry
c. Telehealth
d. Electronic Health Records - ✔✔-c
In the project implementation process, the decision to move onto the next step in the process, delay the
next step, or cancelling the project is the responsibility of the:
a. Project Manager
b. Champion
c. Subject Matter Expert
d. Gatekeeper - ✔✔-d
The final phase of the Request for Proposal (RFP) process is negotiating the contract with the selected
vendor.
True/False - ✔✔-True
Data is error free
a. Relevancy
b. Precision
c. Accuracy
d. Comprehensiveness - ✔✔-c
The data remains relevant and understood over a period of time:
a. Accessibility
b. Timeliness
c. Relevancy
d. Currency - ✔✔-d
Data is at basic level; cannot be further divi
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