C802 Foundations in Healthcare Information Management
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Free C802 Foundations in Healthcare Information Management Questions
1. Which term best describes providing clinicians and staff with knowledge and person-specific information at appropriate times to enhance their healthcare.
- Clinical decisions support
- Clinical evidence support
- Health information exchange
- Clinical health support
Explanation
Clinical decision support refers to systems and tools that provide healthcare professionals with patient-specific information and evidence-based knowledge at the right time to improve decision-making and patient outcomes. These systems integrate data from electronic health records and other sources to deliver alerts, reminders, clinical guidelines, and diagnostic support. The goal is to enhance the quality, efficiency, and safety of healthcare delivery by ensuring that clinicians have the most relevant information during the care process.
2. What is the correct sequence of data flow for processing a hospital outpatient visit?
- Patient check-in > services rendered > charges captured > coding completed
- Patient check-in > coding completed > services rendered > charges captured
- Services rendered > charges captured > patient check-in > coding completed
- Coding completed > patient check-in > services rendered > charges captured
Explanation
The correct data flow in processing a hospital outpatient visit follows a logical order based on patient encounter and billing workflow. It begins with patient check-in, where demographic and insurance information is verified. Next, services are rendered by clinical staff or providers. After services are provided, charges are captured to record what procedures or services were performed. Finally, coding is completed to assign appropriate ICD-10-CM and CPT/HCPCS codes for billing and data reporting. This sequence ensures accuracy in documentation, billing, and compliance with reimbursement guidelines.
3. What is the minimum retention period for health records as mandated by the Medicare Conditions of Participation?
- Two years
- Five years
- Ten years
- Permanently
Explanation
The Medicare Conditions of Participation require that health records be retained for a minimum of five years from the date of creation or the patient’s discharge. This ensures that records are available for audits, legal inquiries, quality reviews, and continuity of care. Shorter retention periods could compromise compliance and access to vital patient information, while longer retention may be institution-specific but is not the mandated minimum.
4. What term describes the framework of policies, procedures, and technologies that guide the management of information to ensure compliance, risk mitigation, and alignment with organizational goals?
- Data governance
- Information stewardship
- Information management
- Information governance
Explanation
Information governance refers to the overarching framework that establishes accountability, standards, and control mechanisms for managing information throughout its lifecycle. It integrates policies, procedures, and technologies to ensure that data handling aligns with legal, regulatory, and ethical requirements while supporting organizational objectives. Information governance also encompasses data quality, privacy, and security management, making it a critical element for compliance and risk reduction in healthcare organizations.
5. HIPAA has specific guidelines for the destruction of records. They include all of the following EXCEPT:
- the method used to destroy the records
- the length of time between acquisition of records and destruction
- a list of preferred business associates
- how the facility intends to safeguard against breach of confidentiality
Explanation
HIPAA’s privacy and security rules require covered entities to establish procedures for the safe and secure destruction of protected health information (PHI). These guidelines include specifying how records are destroyed, documenting the method used, and ensuring confidentiality during the destruction process. However, HIPAA does not require maintaining or using a “list of preferred business associates” for record destruction. While business associates may be contracted to perform destruction services, HIPAA focuses on compliance, method, and security, not preferred vendor listings.
6. The primary structure used to store data in a(n) ________ is a table that organizes information into rows and columns, allowing for efficient data retrieval and management.
- Object-oriented database
- Relational database
- Hierarchical database
- Network database
Explanation
A relational database organizes data into tables composed of rows (records) and columns (fields), making it one of the most efficient and widely used data structures in healthcare information systems. This structure allows for the establishment of relationships between tables using keys, enabling complex queries and flexible data retrieval. Relational databases are used in many health information systems, including EHRs, due to their scalability, ease of management, and structured query capabilities through SQL.
7. A lithotripsy was performed as an outpatient for kidney stones. This is considered to be which root operation?
- Fragmentation
- Destruction
- Removal
- Extirpation
Explanation
In ICD-10-PCS, fragmentation is the root operation used when a procedure breaks solid matter in a body part into smaller pieces, without removing the material from the body. Lithotripsy involves using shock waves or other methods to break kidney stones into smaller fragments so they can pass naturally or be removed later. Since the procedure does not remove the stones entirely at the time of treatment, it is classified as fragmentation rather than removal, extirpation, or destruction.
8. This functionality can result in confusion from incessant repetition of irrelevant clinical data.
- Change
- Amendment
- Copy and paste
- Deletion
Explanation
Copy and paste functionality in electronic health records allows clinicians to duplicate text from previous notes into new documentation. While this can save time, it can also lead to confusion when irrelevant or outdated information is repeatedly carried forward, potentially affecting patient safety and the accuracy of records. Unlike amendments, deletions, or changes, the problem specifically arises from the uncritical repetition inherent in copying and pasting.
9. Which function in the cancer registry involves the evaluation of treatment outcomes and patient status after initial diagnosis?
- Case definition
- Case finding
- Follow-up
- Reporting
Explanation
Follow-up in a cancer registry refers to the ongoing evaluation of a patient’s treatment outcomes and current health status after their initial diagnosis. This function is critical for assessing the effectiveness of treatments, monitoring survival rates, and maintaining accurate longitudinal records. Other functions, such as case definition and case finding, focus on identifying and defining patients to include in the registry, while reporting involves communicating data to public health authorities or research bodies.
10. Patient A presents for a ventral hernia repair. A review of the H&P indicates HIV disease and GERD. The diagnosis code assignment is:
- K43.9, B20, K21.9
- B20, K43.9, K21.9
- Z21 K43.9, K21.9
- K43.9, Z21, K21.9
Explanation
For a patient with HIV disease (B20) and other conditions such as GERD (K21.9) and ventral hernia (K43.9), the principal diagnosis is generally the condition that prompted the encounter—in this case, the ventral hernia repair, coded as K43.9. HIV disease is coded as a secondary diagnosis, followed by GERD as another secondary diagnosis. Using B20 as the first code would incorrectly prioritize the HIV over the reason for the encounter. Codes like Z21 are used for asymptomatic HIV status and are not appropriate here since the patient has documented HIV disease.
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