HIM Final Exam 2023 with verified questions and answers

Three required Ahima credentials? CCA (certifed coding assistant) CCS (Certified coding specialist) CHDA ( Certified health data analyst) Medicaid Includes services for who? Poor children Disabled Pregnant women Very poor adults Hospital based ambulatory care services ... Long term care? Skilled nursing facilities Nursing homes Hospice Programs Managed Care Term for healthcare reimbursement system that manages cost, quality, and access services Healthy People 2020 Promote quality of life, healthy development, longer lives free of preventable diseases Master Patient Index Permanent record of all patients treated at facility. Chief executive officer ... Registry Database on specific diseases and procedures Release of information The process of disclosing patient-identifiable information from the health record to another party Voice recogniton technology Computer converts what is said directly into text and no transcriptionist is needed Quantitative Analysis Review of the health record to determine if there are any missing reports. Qualitative Analysis Monitoring the quality of the documentation. Hybrid health record Combination of the paper record and the EHR Medical staff bylaws Standards governing the practice of medical staff members Subject Objective Assessment Plan (SOAP) Method used to construct physician progress notes Authorization Permission given to an individual Health Information Exchange (HIE) When health information is electronically between providers and others with the same level of interoperability UMLS (Unified Medical Language System. electronic resource containing various medical terms Data Set A list of recommended data elements with uniform definitions that are relevant for a particular use. Disease Index A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use Oasis Home healthcare setting. Data Governance Ensures control and accountability for enterprise data through the establishment of decision rights Clinical documentation Manual or electronic notation made by a physician related to a patients medical condition treatment Accuracy Focuses on the data being free of errors. Cancer Registry Tracks new cases of cancer Implant Registries Tracks Performance of implants such as complications and death Diabetes registries Collects cases of patients with diabetes. Medicare Provider Analysis and Review (MEDPAR) File Acute care hospital and skilled nursing facility claims data for all medicare claims. Confidentiality Similar to privacy, but shares MEDPAR consists of: Data on the provider Total charges Demographic data on the patient Protocol List of rules and procedures to be followed The American Recovery and Investment Provides funding for health information technology and other fundings. Workforce members Employees, volunteers, trainees, and other persons under direct control of the covered entity. Treatment, Payment and Operations (TPO) Conditions under which protected health information can be released without consent from the patient Data Integrity Means that data is complete, accurate, consistent and up to date. Data Availability Means making sure the organization can depend on the information system to perform as expected. Security Breaches unauthorized data or system access, by people from both inside and outside the organization Access control Restriction of access to information resources Access safeguards Fundamental se Data Security Protecting the privacy of data Chief Security Officer (CSO) Responsible for ensuring the security of IT systems Physical Safeguards Physical protection of information resources. Trigger events Review of access logs, audit trails, failed logins, and other reports generated to monitor compliance with the policies and procedures Court Order Document issued by a judge Components of a security program Employee Awareness Access Safeguards Risk Management Program Disaster Planning And Recovery compels a person to bring records to a desposition or trial Subpoena duces tecum