Practice RHIT Exam -- Compliance (CENGAGE)

You recommend that the staff at your home health agency routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every

60 days

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

DEEDS

A website, available to the general public, permits anyone to review specific measures of quality care for a particular hospital, is called ___________

Hospital Compare

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the

MDS

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the

MDS

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the

National Practitioner Data Bank

Referring to the information in the table and the delinquent record rate, would the facility be out of compliance with Joint Commission standards? SPRINGFIELD HOSPITAL QUARTERLY STATISTICS Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 Delinquent Records Rate = 32.4% Calculation: Based on this data, the delinquent record rate would be 32% [(590x100) divided by 1,820]. The Joint Commission standard states that hospitals are to keep their general delinquent record rate below 50%. A rate of 32% indicates that the hospital is in compliance with this standard.

No

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency.

ONC

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the

Office for Civil Rights

An organization that reviews the facility's provision of health care services, respond to Medicare beneficiary complaints that have been filed, and take action by implementing quality of care improvements is known as a(n) ______________

Quality Improvement Organization (QIO)

A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be

check sheet

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be

cognitive patterns

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) _________ will be added to his health record.

consultation report

Jane believes new equipment will make her staff more efficient. The board has asked for an analysis of the cost of the equipment to be compared with the benefit to the facility. This mathematical process is known as a ________

cost-benefit analysis

There are times when good staff members can burn out. As a manager, a _________ program can help the organization retain these quality workers while providing the staff member with something new to do.

cross-training

During a risk management strategy session, the HIM director states that policies and procedures must be created to prevent specific opportunities for an adverse outcome, as well as those that will function to diminish any that might not be preventable. This type of strategy is known as a _____________

proactive strategy

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing?

qualitative review

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

recorded by persons authorized by hospital regulations and procedures.

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee-for-Service program. You will need to develop a professional relationship with

recovery audit contractors

As the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with

recovery audit contractors

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to

reduce clinical denials for medical necessity

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

24 hours after admission or prior to surgery

Referring to the data below, determine the delinquent record rate for Springfield Hospital. SPRINGFIELD HOSPITAL QUARTERLY STATISTICS Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 CALCULATION: Using the basic rate formula, calculate as follows: Delinquent records × 100 divided by average monthly discharges, or (590 x 100) divided by (1,820) = 32.4%

32%

A quarterly review reveals the following data for Springfield Hospital: SPRINGFIELD HOSPITAL QUARTERLY STATISTICS Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 What is the percentage of incomplete records during this quarter? Calculation: Using the basic rate formula, calculate as follows: Incomplete records × 100 divided by average monthly discharges, or (1,002 x 100) divided by (1,820) = 55.1%

55%

As the compliance officer for a large physician practice group, you are interested in researching the original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You begin by googling

HITECH Act

According to the following table, the most serious record delinquency problem occurred in which of the following months? Record Delinquency for Second Quarter April May June Percentage incomplete records 70% 88% 79% Percentage delinquent records 51% 43% 61% Percentage delinquent due to missing H&P 3% 1.4% 0.5% CALCULATION: A recommendation for improvement from Joint Commission is indicated if the number of delinquent records is greater than 50% or if the percentage of records with delinquent records due to missing H&Ps exceeds 2% of the average monthly discharges. In the month of April, both of these delinquency problems are reflected. The percentage of incomplete records is not relevant.

April

Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for

Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission.

An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done?

Both patients can be treated under implied consent.

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Federal Register

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process?

Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.

Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the

UHDDS

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

Uniform Hospital Discharge Data Set

In an acute care hospital, a complete history and physical may not be required for a new admission when

a legible copy of a current H&P performed in the attending physician's office is available.

The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered

an inappropriate use of hospital resources.

A clinical documentation specialist performs many duties. These include reviewing the data and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)

analyst

Your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model shown above. The team asks if you see anything missing from the model. You tell them they (See WORD document)

are missing a step requiring ongoing monitoring and reassessment

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

attending physician

The comparing of one facility's outcomes to another, similar facility, or to national standards is known as ______________

benchmarking

What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft?

disaster

Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record?

discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist

A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the medical staff as well as to administration the powerful impact that precise documentation has on the internal and external data reporting. In this role, he/she is acting as a(n)

educator

The high cost of staff turnover is eating away at the department's budget, so Thomas is creating a(n) __________ program to increase staff satisfaction.

employee retention

All of these are quality improvement strategies EXCEPT

error-based penalites

Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that

evidence cannot be provided that the physician actually reviewed and approved each report.

Sally wants to motivate her staff members to earn and submit their required continuing education credits by the deadline, so she is offering a $25 gift card to the first one to complete their requirements. Sally is using _____ motivation techniques.

extrinsic

In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to

facilities with superior performance.

When you and your team have identified a problem and must determine the cause or causes of that situation, completing a(n) ________ can help.

fishbone diagram

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

hospital bylaws, rules, and regulations

The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information, you will consult the

hospital bylaws, rules, and regulations.

Which of the following reports would normally be considered a consultation?

impressions of a cardiologist asked to determine whether patient is a good surgical risk

You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to

improve your department's processes.

Joint Commission requires the attending physician to countersign health record documentation that is entered by

interns or medical students

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for

marking the surgical site.

One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with

meaningful use requirements

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show

missing operative reports

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates

noncompliance with Joint Commission standards

A portion of a deficiency slip is reproduced below. This patient was discharged yesterday. Your greatest concern regarding deficiencies on this record would be the missing (See WORD document)

operative report

A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of

respondeat superior.

When managers work to keep staff members feeling appreciated and valued for their contributions to the job and the organization, this is known as __________.

staff satisfaction

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that

the H&P copy is acceptable as long as she documents any interval changes.

The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that

the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues.

Both patients can be treated under implied consent.

the Recovery Audit Contractor.

After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because (See WORD document)

the results appear to violate the Pareto principle

What quality indicator would prove useful in tracking customer satisfaction in the correspondence/release of information function?

the turnaround time from the date a request is received to the date the information is provided to the requester

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the

time and means of arrival

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the

use of prohibited or "dangerous" abbreviations

Review 5. Compliance Your Score: 43.5% 30 Correct out of 69 Question 14 of 69 Resources that produce little-to-no value to the organization, such as non-utilized talent, inventory miscalculations, and staff members waiting for information so they can do their jobs, is known as _______, which must be reduced, if not eliminated, in a lean managed organization.

waste

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to dsclose proof of immunication to a school without

written authorization of the parent

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

yes, prior to surgery