A coder needs to locate electronic health records for a patient across a health information exchange
(HIE). What tool(s) should the coder use?
a. Certification
b. Identity-matching algorithm and record locator service
c. Interoperability and certification
d. Meaningful use - Correct Answer: B
...
AHIMA CCA: Exam 1 / Revised Questions and
Answers / Sure A+
A coder needs to locate electronic health records for a patient across a health information exchange
(HIE). What tool(s) should the coder use?
a. Certification
b. Identity-matching algorithm and record locator service
c. Interoperability and certification
d. Meaningful use - Correct Answer: B
An HIE organization requires an identity-matching algorithm and record locator service (RLS). An identity-
matching algorithm must be used by the HIE to identify any patient for whom data are to be exchanged.
This algorithm uses sophisticated probability equations to identify patients. The RLS, then, is a process
that seeks information about where a patient may have a health record available to the HIE organization
(Johns 2011, 151).
A hospital HIM department wants to purchase an electronic system that records the location of health
records removed from the filing system and documents the date of their return to the HIM department.
Which of the following electronic systems would fulfill this purpose?
a. Chart deficiency system
b. Chart tracking system
c. Chart abstracting system
d. Chart encoder - Correct Answer: B
,With an automated tracking system, it is easy to track how many records are charged out of the system,
their location, and whether they have been returned on the due dates indicated (Johns 2011, 402).
A software interface is a:
a. Device to enter data
b. Protocol for describing data
c. Program to exchange data
d. Standard vocabulary - Correct Answer: C
A software interface is a computer program that allows different applications to communicate and
exchange data (Johns 2011, 137).
A system that provides alerts and reminders to clinicians is a(n):
a. Clinical decision support system
b. Electronic data interchange
c. Point of care charting system
d. Knowledge database - Correct Answer: A Clinical decision support includes providing
documentation of clinical findings and procedures, active reminders about medication administration,
suggestions for prescribing less expensive but equally effective drugs, protocols for certain health
maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-
making aids for all stakeholders in the care process (Johns 2011, 138).
, According to the Joint Commission Accreditation Standards, which document must be placed in the
patient's record before a surgical procedure may be performed?
a. Admission record
b. Physician's order
c. Report of history and physical examination
d. Discharge summary - Correct Answer: C
According to the Joint Commission, except in emergency situations, every surgical patient's chart must
include a report of a complete history and physical conducted no more than seven days before the
surgery is to be performed (Odom-Wesley et al. 2009, 150).
All documentation entered in the medical record relating to the patient's diagnosis and treatment is
considered this type of data:
a. Clinical
b. Identification
c. Secondary
d. Financial - Correct Answer: A
Clinical information is data related to the patient's diagnosis or treatment in a healthcare facility (Odom-
Wesley et al. 2009, 55).
An individual designated as an inpatient coder may have access to an electronic medical record to code
the record. Under what access security mechanism is the coder allowed access to the system?
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