HIM 1000 FINAL STUDY GUIDE QUESTIONS
AND ANSWERS ALL CORRECT
Which of the following is an argument against the use of the copy and paste function in
the EHR? - Answer- inability to identify the author
What is the general name for Medicare standards impacting healthcare organizations? -
Answer- conditions of participation
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - Answer- Joint Commission
When correcting erroneous information in a paper health record, which of the following
is appropriate? - Answer- Print "addendum: above the entry
An RAI/MDS and care plan are found in records of patients in what setting? - Answer-
long-term care
Which of the following represents the attending physician's assessment of the patient's
current health status? - Answer- physical examination
What is the function of a consultation report? - Answer- Documents opinions about the
patient's condition from the perspective of a physician not previously involved in the
patient's care
Which of the following represents documentation of the patient's current and past health
status? - Answer- medical history
Which of the following contains the physician's findings based on an examination of the
patient? - Answer- physical exam
Which of the following is usually a component of acute care patient records? - Answer-
progress notes
Which of the following is true of many electronic health records? - Answer- They are
interoperable
Patient Account Information includes: - Answer- patient gender
, In what part of the health record would the social and personal history be found? -
Answer- medical history
The overall goal of documentation standards is to _____________. - Answer- Ensure
what is documented in the health record is complete and accurately reflects the
treatment provided to the patient
The SNOMED CT _________ includes the semantic tag. - Answer- Fully specified
name
Category I CPT includes which of the following? - Answer- surgery
ICD-10-PCS is a classification of _________. - Answer- inpatient procedures
A classification provides clinical data to ______________. - Answer- allows collections
ad reporting of healthcare statistics
An accumulation of numeric or alphanumeric representations or codes for exchanging
or storing information is a ___________. - Answer- code system
Which of the following is the standard for clinical lab test results under the Meaningful
Use program? - Answer- LONIC
HCPCS is made up of which code systems? - Answer- CPT & HCPCS Level II
Home health agency process and improvement outcome measures are based on data
from the _____. - Answer- OASIS
(Outcomes and Assessment Information Set)
The standardized HEDIS data elements are collected by _________. - Answer- acute-
care hospitals
The UHDDS's core data elements were incorporated into the ___________ prospective
payment system. - Answer- acute inpatient
Which of the following datasets was created to collect uniform data across the United
States for inpatient patient stays? - Answer- UHDDS
Which of the following is a collection of data that is organized in a manner to be
accessed, managed, reported, and updated electronically? - Answer- database
Which of the following is the process of execution, implementation, and management of
databases within healthcare? - Answer- database life cycle
The first professional association for health information managers was established in
what year? - Answer- 1928
AND ANSWERS ALL CORRECT
Which of the following is an argument against the use of the copy and paste function in
the EHR? - Answer- inability to identify the author
What is the general name for Medicare standards impacting healthcare organizations? -
Answer- conditions of participation
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - Answer- Joint Commission
When correcting erroneous information in a paper health record, which of the following
is appropriate? - Answer- Print "addendum: above the entry
An RAI/MDS and care plan are found in records of patients in what setting? - Answer-
long-term care
Which of the following represents the attending physician's assessment of the patient's
current health status? - Answer- physical examination
What is the function of a consultation report? - Answer- Documents opinions about the
patient's condition from the perspective of a physician not previously involved in the
patient's care
Which of the following represents documentation of the patient's current and past health
status? - Answer- medical history
Which of the following contains the physician's findings based on an examination of the
patient? - Answer- physical exam
Which of the following is usually a component of acute care patient records? - Answer-
progress notes
Which of the following is true of many electronic health records? - Answer- They are
interoperable
Patient Account Information includes: - Answer- patient gender
, In what part of the health record would the social and personal history be found? -
Answer- medical history
The overall goal of documentation standards is to _____________. - Answer- Ensure
what is documented in the health record is complete and accurately reflects the
treatment provided to the patient
The SNOMED CT _________ includes the semantic tag. - Answer- Fully specified
name
Category I CPT includes which of the following? - Answer- surgery
ICD-10-PCS is a classification of _________. - Answer- inpatient procedures
A classification provides clinical data to ______________. - Answer- allows collections
ad reporting of healthcare statistics
An accumulation of numeric or alphanumeric representations or codes for exchanging
or storing information is a ___________. - Answer- code system
Which of the following is the standard for clinical lab test results under the Meaningful
Use program? - Answer- LONIC
HCPCS is made up of which code systems? - Answer- CPT & HCPCS Level II
Home health agency process and improvement outcome measures are based on data
from the _____. - Answer- OASIS
(Outcomes and Assessment Information Set)
The standardized HEDIS data elements are collected by _________. - Answer- acute-
care hospitals
The UHDDS's core data elements were incorporated into the ___________ prospective
payment system. - Answer- acute inpatient
Which of the following datasets was created to collect uniform data across the United
States for inpatient patient stays? - Answer- UHDDS
Which of the following is a collection of data that is organized in a manner to be
accessed, managed, reported, and updated electronically? - Answer- database
Which of the following is the process of execution, implementation, and management of
databases within healthcare? - Answer- database life cycle
The first professional association for health information managers was established in
what year? - Answer- 1928
