Domain 1 (Exam 1, pg. 2) ANSWERS ONLY

The patient registration department assists the HIM department in what way?

assigning the health record number

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?

Conditions of Participation

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Outcome and Assessment Information Set

An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?

UACDS

A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharged data elements for Medicare and Medicaid inpatients in an acute-care hospital?

UHDDS

Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:

by the hospital

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would best first step in trying to rectify the current situation?

consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report?

consultation

Which of the following is a risk of copy and pasting?

copying the note in the wrong patient's record

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:

data consistency

The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a:

data map

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n):

delinquent record

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?

develop a list of statues, regulations, rules, and guidelines that contain requirements affecting the release of health records

In designing an input screen for an EHR, which of the following would be best to capture structured data?

drop-down menus

The advent of the EHR has increased the amount of documentation largely due to:

ease of entry

Patient care managers use the data documented in the health record to:

evaluate patterns and trends of patient care

A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?

identify data content requirements for all areas of the organization

Which of the following is characteristic of the legal health record?

it is the record disclosed upon request

The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data?

laboratory

Before healthcare organizations can provide services, they usually must obtain ___ by government entities such as the state or country in which they are located.

licensure

Which of the following is considered the authoritative key in locating a health record?

master patient index

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family history?

medical history

A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?

medication administration record and clinical laboratory reports

Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching?

obliterating or deleting errors

Two patients' records were filed together by mistake. This is an example of:

overlay

The forms design committee:

provides oversight for the development, review, and control of forms and computer screens

To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?

review each patient's health record concurrently to make sure that history and physicals are present

Which of the terms below represents fixed rules that must be followed?

standard

Which of the following is a secondary purpose of the health record?

support for research

Which of the following is true regarding the reporting of communicable diseases?

the diseases to be reported are established by state law

Which of the following is a true statement about the consent of the legal health record?

the legal health record may contain metadata

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if:

the template was defined

How do accreditation organizations such as the Joint Commission use the health record?

to determine whether standards of care are being met

Which of the following is a key characteristic of the problem-oriented health record?

uses itemized list of the patient's past and present health problems

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information?

vital signs record

Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:

vocabulary standards