WGU D033 HEALTH INFORMATION SYSTEMS
UPDATED FINAL EXAM ALL QUESTIONS AND
ANSWERS SURE A+
✔✔Audit log - ✔✔Or audit trail, an electronic footprint of the actions that occurred in a
particular file in an information system or that were performed by a specific individual
✔✔Audit trails - ✔✔The record of information system activities, such as log-in, log-out,
unsuccessful log-ins, print, query, and other actions
✔✔Audit-reduction tools - ✔✔Tools that review the audit trail and compare it to criteria
specified by the CE, which eliminates routine entries such as the periodic backups
✔✔Authorship - ✔✔The origination or creation of recorded information attributed to a
specific individual or entity acting at a particular time
✔✔Automated codebook encoder - ✔✔An encoder that lists diagnoses and procedures
in alphabetic order much like the alphabetic index
✔✔Back-end speech recognition (BESR) - ✔✔A speech recognition technology in
which the physician dictates in the traditional manner and an editor listens to the audio
and reviews the document created
,✔✔Backscanning - ✔✔The process of scanning past health records into the DMS so
there is an existing database of patient information, making the DMS valuable to the
user from the first day of implementation
✔✔Backward map - ✔✔A map that links the two coding systems in the opposite
direction, moving from ICD-10 to ICD-9
✔✔Barcode medication administration record (BC-MAR) - ✔✔See Electronic medication
administration record (EMAR)
✔✔Best of breed - ✔✔Choosing the ISs based on functionality rather than by vendor
313 314 Glossary
✔✔Best of fit - ✔✔The decision to purchase software from a single vendor
✔✔Beta sites - ✔✔The healthcare facilities who subsequently implement the
information system
✔✔Bidder's conference - ✔✔A meeting for vendors to come to the healthcare facility to
ask questions about the request for proposal, the healthcare facility, and other important
points
✔✔Biomedical device - ✔✔An article, instrument, apparatus, or machine that is used in
the prevention, diagnosis, or treatment of illness or disease, or for detecting, measuring,
restoring, correcting, or modifying the structure or function of the body for some health
purpose
✔✔Birth certificate information system - ✔✔A state-approved system in which the birth
certificate data are entered, after the HIM staff interviews the mother or other parents or
guardians and reviews the health record. This software reports births occurring in the
healthcare facility to the state health agency
✔✔Blue Button - ✔✔A campaign that was established by The Office of the National
Coordinator for Health IT (ONC). It is a consumer-motivated method to improve
healthcare by having the patient or caretaker actively involved in decisions and planning
by having direct access to personal health information
✔✔Bots - ✔✔Perform automated tasks, such as gathering information and instant
messaging, thus relieving a person the responsibility of doing it
✔✔Bring your own device (BYOD) - ✔✔Healthcare practitioners using their personal
smartphones or other devices rather than devices provided by the HCO, the personal
device must meet specific encryption and other security protocols to protect PHI as
required by the HCO
, ✔✔Cancer registry information system - ✔✔An information system that tracks
information (including very detailed information regarding diagnosis and treatment)
about the patient's cancer from the time of diagnosis to the patient's death
✔✔Certified EHR technology - ✔✔An EHR that has been evaluated by a member of the
Office of the National Coordinator-Authorized Certification Bodies (ONC-ACBs) and
verified that it meets the criteria set by the MU incentive programs
✔✔Certified health data analyst (CHDA) - ✔✔Advanced certification sponsored by
AHIMA that covers data management, data analytics, and data reporting
✔✔Certified in healthcare privacy and security (CHPS) - ✔✔Credential that
demonstrates advanced privacy and security skills. These advanced privacy and
security skills exceed those in the RHIA or RHIT examinations. It is sponsored by
AHIMA
✔✔Certified information security manager (CISM) - ✔✔Sponsored by ISACA; an
international examination that is designed for leaders in security who oversee the
security programs of organizations
✔✔Certified information systems security professional (CISSP) - ✔✔Certification
sponsored by the International Information Systems Security Certification Consortium. It
is a generic security certification and therefore is not healthcare specific
✔✔Change management - ✔✔The formal process of introducing change, getting it
adopted, and diffusing it throughout the healthcare facility
✔✔Chargemaster - ✔✔A financial management form or software that contains
information about the healthcare facility's charges for the services it provides to patients
(also called a charge description master [CDM]); it automates the coding process for
routine procedures
✔✔Chart deficiency system - ✔✔A system that track and record documentation
omission due to deficiency in the health record that comes to the HIM department.
Deficiencies can be in paper, imaged, or electronic records depending on the
information system used
✔✔Chart locator system - ✔✔A system is designed to identify the current location of the
paper health record. This tracking is important because paper records are moved from
place to place for patient care, quality reviews, coding, and many other purposes
✔✔Chart tracking system - ✔✔See Chart locator system
✔✔Clinical data repository (CDR) - ✔✔A centralized data repository
UPDATED FINAL EXAM ALL QUESTIONS AND
ANSWERS SURE A+
✔✔Audit log - ✔✔Or audit trail, an electronic footprint of the actions that occurred in a
particular file in an information system or that were performed by a specific individual
✔✔Audit trails - ✔✔The record of information system activities, such as log-in, log-out,
unsuccessful log-ins, print, query, and other actions
✔✔Audit-reduction tools - ✔✔Tools that review the audit trail and compare it to criteria
specified by the CE, which eliminates routine entries such as the periodic backups
✔✔Authorship - ✔✔The origination or creation of recorded information attributed to a
specific individual or entity acting at a particular time
✔✔Automated codebook encoder - ✔✔An encoder that lists diagnoses and procedures
in alphabetic order much like the alphabetic index
✔✔Back-end speech recognition (BESR) - ✔✔A speech recognition technology in
which the physician dictates in the traditional manner and an editor listens to the audio
and reviews the document created
,✔✔Backscanning - ✔✔The process of scanning past health records into the DMS so
there is an existing database of patient information, making the DMS valuable to the
user from the first day of implementation
✔✔Backward map - ✔✔A map that links the two coding systems in the opposite
direction, moving from ICD-10 to ICD-9
✔✔Barcode medication administration record (BC-MAR) - ✔✔See Electronic medication
administration record (EMAR)
✔✔Best of breed - ✔✔Choosing the ISs based on functionality rather than by vendor
313 314 Glossary
✔✔Best of fit - ✔✔The decision to purchase software from a single vendor
✔✔Beta sites - ✔✔The healthcare facilities who subsequently implement the
information system
✔✔Bidder's conference - ✔✔A meeting for vendors to come to the healthcare facility to
ask questions about the request for proposal, the healthcare facility, and other important
points
✔✔Biomedical device - ✔✔An article, instrument, apparatus, or machine that is used in
the prevention, diagnosis, or treatment of illness or disease, or for detecting, measuring,
restoring, correcting, or modifying the structure or function of the body for some health
purpose
✔✔Birth certificate information system - ✔✔A state-approved system in which the birth
certificate data are entered, after the HIM staff interviews the mother or other parents or
guardians and reviews the health record. This software reports births occurring in the
healthcare facility to the state health agency
✔✔Blue Button - ✔✔A campaign that was established by The Office of the National
Coordinator for Health IT (ONC). It is a consumer-motivated method to improve
healthcare by having the patient or caretaker actively involved in decisions and planning
by having direct access to personal health information
✔✔Bots - ✔✔Perform automated tasks, such as gathering information and instant
messaging, thus relieving a person the responsibility of doing it
✔✔Bring your own device (BYOD) - ✔✔Healthcare practitioners using their personal
smartphones or other devices rather than devices provided by the HCO, the personal
device must meet specific encryption and other security protocols to protect PHI as
required by the HCO
, ✔✔Cancer registry information system - ✔✔An information system that tracks
information (including very detailed information regarding diagnosis and treatment)
about the patient's cancer from the time of diagnosis to the patient's death
✔✔Certified EHR technology - ✔✔An EHR that has been evaluated by a member of the
Office of the National Coordinator-Authorized Certification Bodies (ONC-ACBs) and
verified that it meets the criteria set by the MU incentive programs
✔✔Certified health data analyst (CHDA) - ✔✔Advanced certification sponsored by
AHIMA that covers data management, data analytics, and data reporting
✔✔Certified in healthcare privacy and security (CHPS) - ✔✔Credential that
demonstrates advanced privacy and security skills. These advanced privacy and
security skills exceed those in the RHIA or RHIT examinations. It is sponsored by
AHIMA
✔✔Certified information security manager (CISM) - ✔✔Sponsored by ISACA; an
international examination that is designed for leaders in security who oversee the
security programs of organizations
✔✔Certified information systems security professional (CISSP) - ✔✔Certification
sponsored by the International Information Systems Security Certification Consortium. It
is a generic security certification and therefore is not healthcare specific
✔✔Change management - ✔✔The formal process of introducing change, getting it
adopted, and diffusing it throughout the healthcare facility
✔✔Chargemaster - ✔✔A financial management form or software that contains
information about the healthcare facility's charges for the services it provides to patients
(also called a charge description master [CDM]); it automates the coding process for
routine procedures
✔✔Chart deficiency system - ✔✔A system that track and record documentation
omission due to deficiency in the health record that comes to the HIM department.
Deficiencies can be in paper, imaged, or electronic records depending on the
information system used
✔✔Chart locator system - ✔✔A system is designed to identify the current location of the
paper health record. This tracking is important because paper records are moved from
place to place for patient care, quality reviews, coding, and many other purposes
✔✔Chart tracking system - ✔✔See Chart locator system
✔✔Clinical data repository (CDR) - ✔✔A centralized data repository
