Classification Systems & Secondary Data Sources
Health Data Content & Standards
Medical Science
Organization & Management
Information Retention & Access
100
This is a system of preferred terminology for naming disease processes
What is medical nomenclature
100
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. This document type is what you would give to this form
What is pathology report
100
The cause, set of causes, or matter of causation of a disease or condition
What is etiology
100
This is the management function that must first be engaged in order to be in the best position to organize the work effectively
What is planning
100
This is the technology that works best with automated record-tracking systems to speed the data entry process
What are bar codes
200
This is the setting in which the DSM-IV-TR is used most frequently
What is behavioral health center
200
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. This is where the manager would most likely find this information
What is the incident report
200
Many bacterial diseases are transmitted from person to person. This disease is transmitted by way of a tick vector
What is Lyme disease
200
You are the Coding Supervisor and wish to know the amount of time spent on coding by 8 employees this month. Below is the productivity log. What percentage of time was spent on coding? Productivity Log September Number of employees: 8 Charts coded: 725 Standard: 12 minutes per chart Hours worked: 1,280
What is 11.3%. Calculations: (Remember to convert the hours to minutes). 1280 hours * 60 minutes = 76800 minutes. 725 charts * 12 minutes per chart = 8700. (8700 minutes on coding * 100) / 76800 minutes worked = 11.3%.
200
Color coding record files are used to assist in the control of these
What are misfiles
300
Type of registry which collects data on recipients of pacemakers and heart valves
What is implant registry
300
This data element would be expected to be collected in the MDS but not in the UHDDS
What is cognitive patterns
300
These are cells that produce antibodies
What are plasma cells
300
This is the type of identification system in which the patient is issued a different number for each admission or encounter for care and the records of past episodes of care are brought forward to be filed under the last number issued
What is serial-unit number system
300
This is how the name Jill Thomas-Jones would be filed in the Master Patient Index *Hint* MPI is filed by last name
What is Thomasjones, jill
400
You reviewed a patient record and entered the required elements into a data base. This process is called
What is abstracting
400
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on documentation found in this
What is problem list
400
This is a hereditary disease of the cerebral cortex that includes progressive muscle spasticity and mental impairment leading to dementia
What is Huntington's disease
400
Calculate the minimum number of FTE's needed for the following volume: Average number of lines transcribed per month is 142,500. Daily production standard is 950 lines per day. 20 workdays in the month.
What is 7.5 FTE's. Calculations: 950 * 20 = 19000. 142500 / 19000 = 7.5
400
Health Record Retention Requirements Your state: 7 years Federal Law: 5 years The minimum retention period for health records in your facility should be?
What is 7 years
500
This is an encoder that prompts the coder to answer a series of questions & choices based on the documentation in the medical record
What is a logic-based encoder
500
Using the SOAP method of recording progress notes, this entry would most likely include a differential diagnosis
What is assessment
500
This is a disease that is a malignancy of the lymphatic system
What is Hodgkin's disease
500
The standard for record retrieval is 200 work units per month. Based on the information below, what is the variance from standard for the month of July? July Productivity Report – Chart Retrieval Week 1: 30 Week 2: 40 Week 3: 25 Week 4: 35
What is 65%. Calculations: (30+40+25+35) * 100 = 13000. 13000/200 = 65%. Formula: total actual work units * 100 / standard work units = variance percent.
500
There is more than one patient with the identical last name, first name and middle initial. This is how the MPI arranges entries next
What is date of birth
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