Final Quiz Health Data Content and Standards 1.1 (RHIA & RHIT)

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 12 hours after admission or prior to surgery. 24 hours after admission or prior to surgery. 12 hours after admission. 24 hours after admission.

24 hours after admission or prior to surgery.

A data item to include on a qualitative review checklist of newborn inpatient health records that need NOT be included on adult records would be APGAR score. condition on discharge. chief complaint. time and means of arrival.

APGAR score.

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. Baby Boy Hiltz, born 1/5/2018, maintained normal status, discharged 1/7/2018. Patient admitted with COPD 1/4/2018 and discharged 1/7/2018. Baby Boy Doe admitted 1/3/2018, died 1/4/2018. Baby Boy Hiltz's mother admitted 1/5/2018, C-section delivery, and discharged 1/7/2018.

Baby Boy Hiltz, born 1/5/2018, maintained normal status, discharged 1/7/2018.

The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the CARF manual. Medical Staff Bylaws, Rules, and Regulations. Conditions of Participation for Rehabilitation Facilities. Joint Commission manual.

CARF manual.

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. Review the medical records and/or imaging studies. Confirm the patient's true identity. Mark the surgical site.

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

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. Health Care Quality Improvement Act. HIPAA. EMTALA.

HITECH Act.

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 Uniform Ambulatory Core Data. MDS. UHDDS. Uniform Clinical Data Set.

MDS.

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the FBI. Office for Civil Rights. Department of Recovery Audit Coordinators. Office of Inspector General.

Office for Civil Rights.

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's expert system. CPOE. RHIO. EDMS system.

RHIO.

As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use follow-up files. accession register. patient abstracts. patient index.

accession register.

For inpatients, the first data item collected of a clinical nature is usually expected payer. principal diagnosis. review of systems. admitting diagnosis.

admitting diagnosis.

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to bar code placement. signature line for authentication. use of box design. placement of hospital logo.

bar code placement.

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical quality indicator for patients with pneumonia might be beta blocker at discharge. discharged on antithrombotic. blood culture before first antibiotic received. early administration of aspirin.

blood culture before first antibiotic received.

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data comprehensiveness. accuracy. security. timeliness.

comprehensiveness.

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain standing orders. discharge order. telephone orders. stop orders.

discharge order.

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient. admission note clinical laboratory report discharge summary physical exam

discharge summary

Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? X-ray report charted on the wrong record discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist missing discharge summary need for physician authentication of two verbal orders

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

Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? pediatric census sheet procedure index disease index patient register

disease index

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's number control index. disease index. patient index. physicians' index.

disease index.

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. reviewer. ambassador. manager.

educator.

Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that electronic signatures are not acceptable in every state. tampering too often occurs with this method of authentication. it is too easy to delegate use of computer passwords. evidence cannot be provided that the physician actually reviewed and approved each report.

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

As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the facility's data dictionary. glossary of health care terms. MDS. UHDDS.

facility's data dictionary.

In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the chief complaint. subjective review of systems. family history as related by the patient. general appearance as assessed by the physician.

general appearance as assessed by the physician.

An example of a primary data source for health care statistics is the disease index. health record. MPI. accession register.

health record.

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. policy and procedure manual. Federal Register. consolidated manual for hospitals.

hospital bylaws, rules, and regulations.

The foundation for communicating all patient care goals in long-term care settings is the cognitive assessment. Uniform Hospital Discharge Data Set. legal assessment. interdisciplinary plan of care.

interdisciplinary plan of care.

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. apprising the patient of all complications that might occur. including the primary caregiver in surgery consults. including the surgeon in the preanesthesia assessment.

marking the surgical site

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 absence of SOAP format in progress notes. missing operative reports. missing discharge summaries. missing signatures on progress notes.

missing operative reports.

In creating a new form or computer view, the designer should be most driven by needs of the users. medical staff bylaws. QIO standards. flow of data on the page or screen.

needs of the users.

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. compliance with Joint Commission standards. compliance with Medicare regulations. compliance with Joint Commission standards for nonsurgical patients.

noncompliance with Joint Commission standards.

The best example of point-of-care service and documentation is doctors using voice recognition systems to dictate radiology reports. using an automated tracking system to locate a record. nurses using bedside terminals to record vital signs. using occurrence screens to identify adverse events.

nurses using bedside terminals to record vital signs.

One record documentation requirement shared by both acute care and emergency departments is advance directive. patient's condition on discharge. problem list. time and means of arrival.

patient's condition on discharge.

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? physical exam emergency record medical consultation pharmacy consultation

pharmacy consultation

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? The patient is alert and in no acute distress. Initial vital signs: T 98, P 102 and regular, R 20 and BP 120/69... social history physical exam past medical history chief complaint

physical exam

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? problem list initial plan progress notes database

problem list

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? legal review utilization review quantitative review qualitative review

qualitative review

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of quantitative review. legal analysis. qualitative review. peer review.

qualitative review.

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 the OIG. QIO physicians. MEDPAR representatives. recovery audit contractors.

recovery audit contractors.

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a continuum of care. data retrieval portal group. regional health information organization. data warehouse.

regional health information organization.

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data timeliness. validity. reliability. precision.

reliability.

The minimum length of time for retaining original medical records is primarily governed by medical staff. Joint Commission. state law. readmission rates.

state law.

In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from generic screens used by record abstractors. the disease index. the indicator monitoring program. the R-ADT system.

the R-ADT system.

While data governance focuses primarily on managing data as it is being created within a healthcare system, information governance focuses instead on managing data currency the output of those systems data accuracy the granularity of healthcare systems

the output of those systems

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. whether the severity of illness and/or intensity of service warranted acute level care. the quality of follow-up care. whether a postoperative infection occurred and how it was treated.

the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

An effective information governance system should include all of the following principles except one: the principle of disposition the principle of availability the principle of retention the principle of interoperability

the principle of interoperability

A primary focus of screen format design in a health record computer application should be to ensure that programmers develop standard screen formats for all hospitals. the user is capturing essential data elements. data fields can be randomly accessed. paper forms are easily converted to computer forms.

the user is capturing essential data elements.

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 physical findings. time and means of arrival. lab and diagnostic test results. instructions for follow-up care.

time and means of arrival.

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the problem list. discharge summary. transfer record. interdisciplinary patient care plan.

transfer record.

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 flagrant use of specialty-specific abbreviations. use of abbreviations in the final diagnosis. prohibited use of any abbreviations. use of prohibited or "dangerous" abbreviations.

use of prohibited or "dangerous" abbreviations.

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 documentation of any kind any communication with the parent written authorization of the parent written authorization by the child

written authorization of the parent