Health Information Management Flashcards
6 cards from real Certified Coding Associate Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Information Management flashcards as text
Which of the following best defines a hybrid health record?
Answer: A record with a combination of paper and electronic components
A hybrid health record contains both paper and electronic components, common during transitions from paper to fully electronic records.
What is the purpose of an advance directive?
Answer: To document a patient's wishes regarding healthcare decisions if they become incapacitated
An advance directive is a legal document in which patients specify their healthcare wishes in the event they are unable to make decisions themselves.
The term 'concurrent review' in health information management refers to:
Answer: Review of records and care while the patient is still admitted
Concurrent review is conducted while the patient is still admitted to assess the ongoing appropriateness and quality of care.
Which of the following is the best example of secondary data in health information management?
Answer: Data in a disease registry compiled from multiple patient records
Secondary data is derived from primary health records and compiled into databases, registries, or indexes for broader analysis and reporting.
What is the primary role of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule?
Answer: To establish national standards for the protection of individual health information
The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and personal health information.
Which document in the health record provides a physician's assessment of a patient's condition at the end of a hospitalization?
Answer: Discharge summary
The discharge summary provides a comprehensive overview of the patient's hospital stay, including diagnoses, treatment, and follow-up instructions.