SNHP 405 - Informatics and Data Management » Spring 2023 » Test 2

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Question #1
Coding is best described as which of the following?
A.   It is the process by which a numeric code listed in a classification system is assigned to data found in the health record.
B.   It is a recognized system of preferred clinical or medical terminology.
C.   It is a grouping of several items that have one or more common denominators.
D.   It is a systematic listing of proper names for concepts, items, actions, and other aspects of a particular area of interest or knowledge.
Question #2
Which of the following coding schemes are most commonly used in the United States today?
A.   SNOP and ABC
B.   ICD-10-CM and MS-DRG
C.   ICD-10-CM and CPT
D.   SNDO and SNOMED
Question #3
What are the four concepts directly relating to the content of the health record?
A.   Authorship, authentication, timeliness, and completeness
B.   Authorship, authentication, accuracy, and completeness
C.   Authentication, accuracy, timeliness, and completeness
Question #4
President George W. Bush focused the attention on the importance of advancing health information technology as a means to do what?
A.   Combat fraud and abuse in health care
B.   Improve the quality of care
C.   Increase healthcare revenue
D.   Increase jobs in the IT field
Question #5
A health care provider administers the incorrect dose to a patient. The correct form to complete regarding this error is a(an) _____.
A.   incident report
B.   negligence report
C.   daily report
Question #6
Match the word with the best description. a recognized system of preferred clinical or medical terminology
A.   nomenclature
B.   medical language
C.   clinical terminology
D.   clinical vocabulary
Question #7
Match the word with the best description. a vocabulary that specializes in words or phrases of a clinical or medical nature
A.   clinical terminology
B.   medical language
C.   clinical vocabulary
D.   eponyms
Question #8
Match the word with the best description. also referred to as terminology
A.   eponyms
B.   vocabulary
C.   nomenclature
D.   medical language
Question #9
Match the word with the best description. words based on the personal names of people
A.   nomenclature
B.   vocabulary
C.   eponyms
D.   medical language
Question #10
Match the word with the best description. the words, their pronunciation, and the methods of combining them that has been established by long usage and understood by the medical profession
A.   eponyms
B.   clinical terminology
C.   clinical vocabulary
D.   medical language
Question #11
Match the word with the best description. a chosen set of words, usually arranged in alphabetical order, understood and accepted by a community
A.   nomenclature
B.   medical language
C.   vocabulary
D.   eponyms
Question #12
How long must HIPAA compliance records be retained?
A.   3 years
B.   6 years
C.   5 years
D.   2 years
Question #13
A written signature or computer generated signature are examples of which of the following?
A.   Authorship
B.   Authentication
C.   Completeness
D.   Information
Question #14
The ICD-10-CM has ___ volumes.
A.   3
B.   2
C.   4
D.   5
Question #15
Performance improvement is improvement of the processes involved in the delivery of health care.,,
A.   True
B.   False
Question #16
What is another name for a health record?
A.   All of these
B.   Clinical record
C.   Hospital chart
D.   Medical record
Question #17
Who is responsible for maintaining a personal health record?
A.   The insurance company
B.   The hospital
C.   The primary care physician
D.   The patient
Question #18
What is the term for a chosen set of words, usually arranged in alphabetical order, that are understood and accepted by a community?
A.   Clinical vocabulary
B.   Medical language
C.   Vocabulary
D.   Clinical terminology
Question #19
SNOMED is an example of which of the following?
A.   Clinical vocabulary
B.   Terminology
C.   Nomenclature
D.   Clinical terminology
Question #20
When did ICD begin to be used in American hospitals?
A.   1940s and 1950s
B.   1960s and 1970s
C.   1980s and 1990s
D.   1920s and 1930s
Question #21
Which of the following has been identified as the leading cause for hospitalization or extending the length of stay?
A.   Heart attacks
B.   Chronic alcoholism
C.   Pregnancy and delivery
D.   Acute accidents
Question #22
When using the CPT system, the coder should evaluate the following three components: , ____________________, and ______________________________.
A.   history, examination, medical decision making
B.   history, laboratory, medical decision making
C.   family background, examination, medical decision making
Question #23
Nosocomial infections are frequently seen in which of the following?
A.   Viral infections
B.   Urinary tract infections
C.   Central-line bloodstream infections
D.   Class II wound infections
Question #24
When was HIPAA was signed into law?
A.   2003
B.   1988
C.   2006
D.   1996
Question #25
Which of the following is not a component of a records management system?
A.   Destruction
B.   Retention
C.   Advance directives
D.   Data storage
Question #26
How are delinquent records defined?
A.   Records that are not completed within thirty days following discharge
B.   The provider’s medical staff bylaws, rules, and regulations outline are what define a delinquent record.
C.   Third party payer guidelines define delinquent records. 
D.   The Centers for Medicare and Medicaid Services define delinquent records.
Question #27
The main mission of the Agency for Healthcare Research and Quality (AHRQ) is what?
A.   To ensure health care coding quality
B.   To develop scientific evidence that enables health care decision makers to reach more informed health care choices
C.   To accredit health care facilities that meet very stringent criteria that demonstrate they are meeting or exceeding the standards of care
D.   To serve on a consulting basis to health care facilities to assist in improving the quality of care
Question #28
Who developed and popularized the problem-oriented health record?
A.   Lawrence Green
B.   Lawrence Reed
C.   Lawrence Weed
Question #29
What is the process of linking terminology between two different schemes, a target and a source, for a given purpose called?
A.   Encoding
B.   Data mapping
C.   Clinical data representation
D.   Case mix
Question #30
What are the three key components of evaluation and management coding?
A.   History, exam, and complexity
B.   Chief complaint, exam, and medical decision making
C.   History, exam, and medical decision making
D.   History, review of systems, and exam
Question #31
Which is the best definition of quality circles?
A.   A recognition program for the highest performers in the organization. This group then meets on a regular basis to analyze and solve work-related problems and to recommend solutions to other departments.
B.   A small group of workers from various departments who meet monthly to analyze and solve work-related problems and to recommend solutions to management.
C.   A small group of workers who perform similar work and who meet regularly to analyze and solve work-related problems and to recommend solutions to management.
D.   A group of high performers with recognized skills in quality management who meet to analyze and solve work-related problems and to recommend solutions to other departments.
Question #32
Quality assurance is when every aspect of health care quality may be subject to managerial oversight,,
A.   False
B.   True
Question #33
Which of the following terms refers to raw facts and figures?
A.   Statistical
B.   Numerical
C.   Data
Question #34
The Security Rule (HIPAA) standards require the documents related to risk analysis be kept for how many years?
A.   2 years
B.   3 years
C.   7 years
D.   6 years
Question #35
The National Committee for Quality Assurance was established in what year?
A.   1993
B.   1990
C.   1989
D.   1991
Question #36
A patient requests to see her health care record, but the facility declines the patient’s request. Which of the following statements best applies to this scenario?
A.   Paper-based charts must be reproduced for the patient, but electronic data is exempt from this ruling.
B.   Declining the request may violate the HIPAA Privacy Rule.
C.   The health care record belongs to the facility, and it cannot be mandated to produce the records.
Question #37
Within how many days of a sentinel event should facilities report to JC?
A.   30
B.   45
C.   15
D.   60
Question #38
An employee who focuses on how to reduce medical, financial, and legal risk to an organization would probably be from what department?
A.   Risk management
B.   Administration management
C.   Coding
D.   Accounting
Question #39
What surgeon pioneered the practice of monitoring surgical outcomes in patients and documenting physician errors concerning specific patients?
A.   A. E. Codman
B.   W. Edwards Deming
C.   Philip Crosby
Question #40
A patient is given the wrong blood transfusion, resulting in a severe reaction from which the patient nearly died. This is an example of which of the following?
A.   Root-cause analysis
B.   Sentinel event
C.   Serious incident
D.   Enterprise risk management
Question #41
Which of the following is an example of clinical data?
A.   Lab results
B.   Consents for treatment
C.   Financial data
D.   Advance directive
Question #42
The movement of data through a system and to those in need of it is referred to as what?
A.   Multidirectional data flow
B.   Data flow
C.   Bidirectional data flow
D.   Unidirectional data flow
Question #43
Which of the following refers to the high grade, superiority, or excellence of data?
A.   Data control
B.   Data quantity
C.   Quality assurance
D.   Data quality
Question #44
The report, Crossing the Quality Chasm: A New Health System for the 21st Century, reported which of the following findings?
A.   There is a shift from care of chronic illnesses to care of acute illnesses.
B.   Current health care systems are more devoted to dealing with acute, episodic conditions.
C.   It is necessary to implement a specific “blueprint” or standard for the future
D.   Current health care systems are well organized to meet the challenges of continuity of care.
Question #45
What is the term for measurement of quality to a level of near perfection or without defects?
A.   FOCUS PDCA
B.   Six Sigma
C.   PDSA
Question #46
  
A.   Unified Medical Language System
B.   RxNorm
C.   Lexicon
D.   Semantic Network
Question #47
Which of the following is a tool used by many health plans to measure performance of care and service?
A.   HEDIS
B.   OASIS
C.   NCQA
D.   ORYX
Question #48
Process improvement is improvement of the processes involved in the delivery of health care
A.   True
B.   False
Question #49
Which of the following is true of deliberate miscoding of diagnoses and procedures?
A.   Nothing will happen
B.   It is easily done
C.   It is considered fraud and abuse
D.   It is permissible in certain circumstances
Question #50
You have been asked to design a new form for a paper-based system. The two concepts that you should keep in mind as you develop the form in order to ensure both the flexibility and ease of use of the form are ____________ and ____________________.
A.   simplicity, accessibility
B.   uniformity, simplicity
C.   clarity, complexity

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