RHIT Practice Exam 1
Community Hospital has 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. the hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2? 240 242 280 320
242
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? 30 31.5 32 35
31.5
A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578: Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580: Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36582: Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access 36597: Repositioning of previous placed central venous catheter under fluoroscopic guidance 36578 36580 36582, 36597 36582
36582
A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? 49320: Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662: Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670: Laparoscopy, surgical; with fulguration of oviducts (with or without transaction) 58671: Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Fallopian ring) 49320, 58662 58670 58671 49320
58670
Based on this output table, what is the average coding test score for the beginner coder? Coding Test Score Coder Status/Mean/N/Standard Deviation Advanced/93.0000/3/5.00000 Intermediate/89.5000/2/.70711 Beginner/73.3333/3/6.42910 Total/84.7500/8/10.51190 93 6.4 73 90
73
A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used? Fixed percentage Random Sample Audit Example Coder/Work Output/ Records for 5% audit A/500/_____ B/480/_____ C/300/_____ D/360/_____ 82 156 820 1,550
82
Community Hospital's HIM department conducted a random sample of 200 inpatient health records to determine the timeliness of the history and physicals completion. Nine records were found to be out of compliance with the 24-hour requirement. Which of the following percentages represents the H&P timeliness rate at Community Hospital? 4.5% 21.2% 66.7% 95.5%
95.5%
Which of the following individuals may authorize the release of health information? An 86-year-old patient with a diagnosis of advanced dementia A married 15-year-old father A 15-year-old minor The parents of an 18-year-old minor
A married 15-year-old father
To use a data element for aggregation and reporting, that data element must be: Abstracted or indexed Searched Subject to case finding Registered
Abstracted or indexed
An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? Access controls Audit controls Contingency controls Security incident controls
Access controls
Data elements collected on large populations of individuals and stored in databases are referred to as: Statistics Information Aggregate data Standard
Aggregate data
Which of the following is true regarding the development of health record destruction policies? All applicable laws must be considered The organization must find a way not to destroy any health records Health records involved in pending or ongoing litigation may be destroyed Only state laws must be considered
All applicable laws must be considered.
Community Hospital wants to compare its hospital-acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. Of these individuals, 200,000 were admitted with a principal diagnosis of UTI; another 300,000 were admitted with a principal diagnosis of infectious disease, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital? All individuals in the MEDPAR database All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease All individuals in the MEDPAR database except those admitted with a diagnosis of hypertension
All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease.
How is the patient registration department assisted by the HIM department? Assigns the health record number Processes the healthcare claim Implements the information systems used by the HIM department Maintains the information systems used by the HIM department
Assigns the health record number
A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): Audit trail Facility access control Forensic scan Security management plan
Audit trail
Which of the following is an example of how an internal user utilizes secondary data? State infectious disease reporting Birth certificates Death certificates Benchmarking with other facilities
Benchmarking with other facilities
Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: By the hospital By the patient By the attending and consulting physician Jointly by the hospital, physician, and patient.
By the hospital
After the types of cases to be included in a cancer registry have been determined, what is the next step in data acquisition? Case registration Case definition Case abstracting Case finding
Case finding
Continuing coding education is required for: Certified coders Inpatient coders All coders Inpatient and ambulatory surgery coders
Certified coders
A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter? Code skin lesion Code benign skin lesion Code basal cell carcinoma Query the dermatologist
Code skin lesion
What formatting problem is found in the following table? Community hospital admissions by Gender, 20XX Male/3,546/42.4 Female/4,825/57.6 Total/8,371/100 Column headings are missing Title of the table is missing Column totals are inaccurate Variable names are missing
Column headings are missing
An alternative to the retrospective coding model is the _______ _______ coding model in which records are coded while the patient is still an inpatient. Concurrent Analytical Prospective Auxillary
Concurrent
Valley High, a skilled nursing facilities, 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? Minimum Data Set National Commission on Correctional Health Care Conditions of participation Outcomes and Assessment Information Set
Conditions of Participation
Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? Determine that a formal letter of termination meets HIPAA requirements and no further action is required. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned. Inform the CFO that business associate agreements cannot be terminated.
Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned.
The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? Call the Joint Commission and notify them of non-compliant physicians Consult with the m epically director who has authority over the on-call physicians for suggestions on how to improve response to the current notices Post the hospital policy in the emergency department Routinely send out a fourth notice to remind each physician of his or her documentation obligations
Consult with the medical director who has authority over the on-call physicians 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. in what type of report would the physician specialist record findings, impressions, and recommendations? Consultation Medical history Physical examination Progress notes
Consultation
For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it: Contains only Medicare data is used to determine pay for performance Contains data on all payer types Contains bibliographic listings from medical journals
Contains data on all payer types
An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: American Health Information Management Association American Medical Association Centers for Medicare and Medicaid Services Cooperating Parties
Cooperating Parties
Which of the following is a risk of copy and pasting documentation in the electronic health record? Reduction in the time required to document System may not save data Copying the note in the wrong patient's record System thinking that the information belongs to the patient from whom the content is being copied.
Copying the note in the wrong patient's record
When coding a benign neoplasm of the skin of the left upper eyelid, which of the following codes should be used? D23.12: Other benign neoplasm of skin of left eyelid, including canthus D17.0: Benign lipomatous neoplasm of skin D23.121: Other benign neoplasm of skin of left upper eyelid, including canthus D23.122: Other benign neoplasm of skin of left lower eyelid, including canthus
D23.121
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 comprehensiveness Data consistency Data currency Data granularity
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 charge master report Data dictionary Database Management system Data map
Data map
When data has been lost in an EHR, which action is taken to remedy this problem? Build a firewall Data recovery Review the audit trail Develop data integrity plan
Data recovery
A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis? Dehydration Chemotherapy Liver carcinoma Complication of chemotherapy
Dehydration
A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): Suspended record Delinquent record Pending record Illegal record
Delinquent record
What is data collected that consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? Original Source Protected Derived
Derived
On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? Reprimand the employee Terminate the employee Determine what information was printed and why Revoke the employee's access privileges
Determine what information was printed and why
A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? Alert the Joint Commission that the hospital has not met its quality goal Determine whether there was a medical or other reason why patients were not given aspirin Institute an in-service training program for clinical staff on the importance of administering aspirin within 24 hours Determine which physicians did not order aspirin
Determine whether there was a medical or other reason why patients were not given aspirin
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 all data elements referencing patients that are included in both paper and electronic systems of practice. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records. Perform a quality check on all health record systems in the practice Develop a listing and categorize all information requests for health information over the past two years.
Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records.
In designing an in put screen for an EHR, which of the following would be best to capture structured data? Speech recognition Drop-down menus Natural language processing Document imaging
Drop-down menus
Patient care managers use the data documented in the health record to: Determine the extent and effects of occupational hazards Evaluate patterns and trends of patient care Generate patient bills and third-party payer claims for reimbursement Provide direct patient care
Evaluate patterns and trends of patient care
The release of information function requires the HIM professional to have knowledge of: Clinical coding principles. Database development Federal and state confidentiality laws human resource management
Federal and state confidentiality laws
What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? Risk management analysis Qualitative analysis Gap analysis Documentation management analysis
Gap analysis
What types of covered entity health records are subject to the HIPAA privacy regulations? Health records in any format Only health records in electronic format Only health records from hospitals Only health records in paper format
Health records in any format
Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? Identification of the record as the one subpoenaed The care provided to the patient The qualifications to the treating physician Identification of the standard of care used to treat the patient.
Identification of the record as the one subpoenaed
A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which fo the following should be the HIM director's first step in carrying out this responsibility? Call the EHR vendor and ask to review the system's data dictionary Identify data content requirements for all areas of the organization Schedule a meeting with all department directors to get their input Contact CMS to determine what data sets are required to be collected
Identify data content requirements for all areas of the organization
Which of the following is a function of the outpatient code editor? Validate the patient's age on a claim Validate the patient's encounter number Identify unbundling of codes Identify cases that don't meet medical necessity
Identify unbundling of codes
The accounts not selected for the billing report is a daily report used to track accounts that are: Awaiting payment in accounts receivable Paid at different rates In bill hold or in error and awaiting billing Pulled for quality review
In bill hold or in error and awaiting billing
Which of the following statements is true regarding HIPAA security? All institutions must implement the same security measures. Institutions are allowed flexibility in the way they implement HIPAA standards. All institutions must implement all HIPAA specifications. A security risk assessment must be performed every year.
Institutions are allowed flexibility in the way they implement HIPAA standards.
Which of the following is characteristic of the legal health record? It must be electronic It includes the designated record set It is the record disclosed upon request It includes a patient's personal health record
It is the record disclosed upon request.
Which of the following is the first step in analyzing data? Knowing your objectives or purpose of the data analysis Starting with basic types of data analysis and work up to more sophisticated analysis Utilizing a statistician to analyze the data Presenting your findings to administration
Knowing your objectives or purpose of the data analysis
The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? Laboratory Radiology Quality Management Registration
Laboratory
Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: Legitimate need for access Password to access the EHR Report development program Signed confidentiality agreement
Legitimate need for access
Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located. Accreditation Certification Licensure Permission
Licensure
Which of the following is an example of a physical safeguard that should be provided for in a data security program? Using password protection Prohibiting the sharing of passwords Locking computer rooms Annual employee training
Locking computer rooms
Which of the following is considered the authoritative resource in locating a health record? Disease index Master patient index Patient directory Patient registry
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 conditions? Problem list Medical history Physical examination Clinical observation
Medical history
Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? Payer/Charges/Payments/Adjustment/Charges/Payments/Adjustments BC/BS/$450,000/$360,000/$90,000/23%/31%/12% Commercial/$250,000/$200,000/$50,000/13%/17%/6% Medicaid/$350,000/$75,000/$275,000/18%/6%/36% Medicare/$750,000/$495,000/$255,000/39%/42%/33% TRICARE/$150,000/$50,000/$100,000/7%/4%/13% Total/$1,950,000/$1,180,000/$770,000/100%/100%/100% BC/BS Commercial TRICARE Medicare
Medicare
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 dat analyst need to consult in order to prepare this report? Physician progress notes and medication record Nursing and physician progress notes Medication administration record and clinical laboratory reports Physician orders and clinical laboratory reports
Medication administration record and clinical laboratory reports
The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond? Notice of privacy practices is required on the first provision of service. Notice of privacy practices is required every time the patient is provided with service. Notice of privacy practices is only required for inpatient admissions. Notice of privacy practices is required on the first inpatient admission but for every outpatient encounter.
Notice of privacy practices is required on the first provision of service.
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 Leaving existing entries intact Labeling late entries as being late Ensuring the legal signature of an individual making a correction accompanies the correction
Obliterating or deleting errors
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? Two CPT codes, one for each laceration One CPT code for the largest laceration One CPT code for the most complex closure One CPT code, adding the lengths of the lacerations together
One CPT code, adding the lengths of the lacerations together
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? Minimum data set for long-term care Outcomes and Assessment Information Set Patient assessment instrument Resident assessment protocol
Outcomes and Assessment Information Set
An HIM technician was alerted by registration that the system has a record for John Smith with two different birthdates. After an investigation the technician determined the documentation was for two different patients, both named John Smith, who have the same health record number in the EHR. This is an example of: Overlap Overlay Duplicate Purge
Overlay
Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request? PHI related to treatment, payment, and operations PHI provided to meet national security or intelligence requirements PHI sent to a physician who has not treated Sally PHI released to Sally's attorney upon her request
PHI sent to a physician who has not treated Sally
Which of the following best represents the definition of the term data? Patient's laboratory value is 50. Patient's SGOT is higher than 50 and outside of normal limits. Patient's resting heartbeat is 70, which is within normal range. Patient's laboratory value is consistent with liver disease.
Patient's laboratory value is 50.
A patient had a placenta Previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be: Normal delivery Placenta Previa Twin gestation Vaginal hemorrhage
Placenta previa
Sometimes data do not follow a normal distribution and are pulled toward the tails of the curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus making a long tail when the distribution is skewed. When the tail is pulled toward the right side, it is called a _______. Negatively skewed distribution Positively skewed distribution Bimodal distribution Normal distribution
Positively skewed distribution
Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? Wait until Susan is 18 years old Present an authorization signed by the court that granted the adoption. Present an authorization signed by Susan's natural (birth) parents Present an authorization that at least one of them (Ted or Mary) has signed
Present an authorization that at least one of them (Ted or Mary) has signed
The first step in an inpatient record review is to verify correct assignment of the: Record sample Coding procedures Principal diagnosis MS-DRG
Principal diagnosis
The right of an individual to keep personal health information from being disclosed to anyone is a definition of: Confidentiality Integrity Privacy Security
Privacy
The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performances Procedure 1: 900+ Procedure 2: 200-400 Procedure 3: 200-400 Procedure 4: 900+ Procedure 5: 200-400 Procedure 6: 200- Procedure 7: 200- Procedure 8: 200-400 Procedures 1, 4 Procedures 2, 3, 5 Procedures 6, 7 Procedures 1, 4, 6, 7
Procedures 1, 4, 6, 7
A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations? Provide copies of the records within 15 days Provide copies of the records within 30 days Provide copies of the records within 45 days Provide copies of the records within 60 days
Provide copies of the records within 30 days
A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond? Provide the records in paper format only Scan the paper documents so that all records can be sent electronically Provide the patient with both paper and electronic copies of the record Inform the patient that PHI cannot be sent electronically.
Provide the records in paper format only.
The clinical forms committee: Provides oversight for the development, review, and control of forms and computer screens Is responsible for the EHR implementation and maintenance Is always a subcommittee of the quality improvement committee Is an optional function for the HIM department
Provides oversight for the development, review, and control of forms and computer screens
Carolyn works as an inpatient coder in a hospital HIM department. She views a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? Assign a code for the staph infection Put a note in the chart Query the physician Tell her supervisor
Query the physician
A patient was seen in the emergency department of richest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is: K21.9, Gastro-esophageal reflux disease without esophagitis R07.9, Chest pain, unspecified R10.11, Right upper quadrant pain Z03.89, Encounter for observation for other suspected diseases and conditions ruled out
R07.9, Chest pain, unspecified
Which of the following is true about health information retention? Retention depends only on accreditation requirements Retention periods differ among healthcare facilities The operational needs of a healthcare facility cannot be considered Retention periods are frequently shorter for health information about minors
Retention periods differ among healthcare facilities
To comply with the Joint Commission standards, the HIM director wants to ensure the 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? Establish a process to review health records immediately on discharge Review each patient's health record concurrently to ensure the history and physicals are present Retrospectively review each patient's health record to ensure the history and physicals are present Write a memorandum to all physicians relating the Joint Commission requirements for documenting history and physical examinations
Review each patient's health records concurrently to ensure the history and physicals are present.
A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? Review the subpoena to determine what documents must be produced Review the subpoena and notify the hospital administrator Review the subpoena and appear at the time and place supplied to give testimony Review the subpoena and alert the hospital's risk management department
Review the subpoena and appear at the time and place supplied to give testimony
Which tool is used to display performance data over time? Status process control chart Run chart Benchmark Time ladder
Run chart
Which of the following is a secondary purpose of the health record? Support for provider reimbursement Support for patient self-management activities Support for research Support for patient care delivery
Support for research
What factor is medical necessity based on? The beneficial effects of a service for the patient's physical needs and quality of life The cost of a service compared with the beneficial effects on the patient's health The availability of a service at the factory The reimbursement available for a given service
The beneficial effects of a service for the patient's physical needs and quality of life
Which of the following is true regarding the reporting of communicable diseases? They must be reported by the patient to the health department. The diseases to be reported are established by state law The diseases to be reported are established by HIPAA They are never reported because it would violate the patient's privacy.
The diseases to be reported are established by state law
An employee views a patient's electronic health record. It is a trigger event if: The employee and the patient have the same last name The patient was admitted through the emergency department The patient is over 89 years old A dietitian views a patient's nutrition care plan
The employee and the patient have the same last name
Which of the following definitions best describes the concept of confidentiality? The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose The protection of healthcare information from damage, loss, and unauthorized alteration The right of individuals to control access to their personal health information The expectation that only individuals with the appropriate authority will be allowed to access healthcare information
The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose.
Which of the following is a true statement about the content of the legal health record? The legal health record contains only clinical data The legal health record may contain metadata The legal health record should not include e-mail The legal health record should not include diagnostic images
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 The data type was numeric The field was not required The field length was longer
The template was defined
The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advice the committee? HIPAA does not allow a patient's name to be announced in a waiting room. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice. HIPAA allows only the use of the patient's first name HIPAA requires that patient's be given numbers and only the number be announced.
There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice.
An external security threat can be caused by which of the following? Employees who steal data during work hours A facility's water pipes bursting Tornadoes The failure of a facility's software
Tornadoes
The primary goals of ______ are to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. The National Health Information Network The National Committee on Vital and Health Statistics Health Level Seven (HL7) International The EHR Collaborative
the National Health Information Network
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 discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? CARF DEEDS UACDS UHDDS
UHDDS
Which of the following is true about a primary key in a database table? Changes in value Is dependent on the data in the table Uniquely identifies each row in a table
Uniquely identifies each row in a table
Copies of personal health records (PHRs) are considered part of the legal health record when: Consulted by the provider to gain information on a consumer's health history Used by the organization to provide treatment Used by the provider to obtain information on a consumer's prescription history Used by the organization to determine a consumer's DNR status
Used by the organization to provide treatment
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 Initial nursing assessment record Physician progress notes Admission record
Vital signs record
Recently, a local professional athlete was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine: Whether access by employees is appropriate If the patient is satisfied with their stay If it is necessary to order prescriptions for the patient Whether the care to the patient meets quality standards
Whether access by employees is appropriate
As part of your job responsibilities, you are responsible for reviewing audit trails of access to patient information. The following are all types of activities that you would monitor except: Every access to every data element or document type Whether the person viewed, created, updated, or deleted the information Physical location on the network where the access occurred Whether the patient setup an account in the patient portal
Whether the patient setup an account in the patient portal
How do accreditation organizations such as the Joint Commission use the health record? To serve as a source for case study information To determine whether the documentation supports the provider's claim for reimbursement To provide healthcare services To determine whether standards of care are being met
to determine whether standards of care are being met
Which of the following is a key characteristic of the problem-oriented health record? Allows all providers to document in the health record Uses laboratory reports and other diagnostic tools to determine health problems Provides electronic documentation in the health record Uses an itemized list of the patient's past and present health problems
uses an itemized list of the patient's past and present health problems
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of: Content and structure standards Security standard Transaction standards Vocabulary standards
vocabulary standards