Information Governance
Health Insurance Portability and Accountability Act (HIPAA) Of 1996
What refers to the digital version of a patient's paper chart?
What is the system of assigning alphanumeric codes to diagnoses, procedures, and services for billing purposes?
Medical coding
What is the name of the that organization sets the standards for health information management practices in the United States?
American Health Information Management Association (AHIMA)
What is a form of authentication of a record used by physicians?
Handwritten signatures, e-signatures, code/password, biometric identifiers, digital image of a signature.
What is the number of individuals affected by a breach that requires media notification?
500
What is the process of electronic exchange of patient-specific information between two separate healthcare organizations?
Health Information Exchange
What is the coding system used for inpatient hospital procedures and services in the United States?
ICD-10-PCS
What is the title of the person responsible for ensuring compliance with privacy and security regulations within a healthcare organization?
Privacy Officer
What is often referred to as data about data?
Metadata
Stringent
What technology enables different EHR systems to communicate and share information?
Interoperability
What system assigns codes to medical procedures and services for outpatient settings?
CPT (Current Procedural Terminology)
What is the title of the person who accounts for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements, and complications?
Medical Coder
What is a permanent database including every patient who has ever been admitted or treated by the facility?
Master patient index
True or False: HIPAA defines the workforce as only those paid by a covered entity.
False
What is the aspect of EHRs ensures that only authorized users have access to patient information?
Access Controls
What is an example of a government-sponsored healthcare program?
Medicare, CHIP, Medicaid, Tricare, Workers compensation, CHAMPVA
Who is responsible for implementing processes and systems to ensure accurate and complete medical record documentation
HIM Director
Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness
What is an example of a technical safeguard according to the Security Rule?
Automatic log-off, passwords, unique user identification, and access controls.
What organization oversees the development and implementation of HIE initiatives in the United States?
Office of the National Coordinator for Health Information Technology (ONC)
What is clinical documentation improvement?
Hospitals, physician offices, insurance companies, legal offices, pharmaceutical companies, skilled nursing facilities, home health agencies, and consulting firms.