Practice Exam01

When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following? a. Performance measurement b. Workforce planning c. Work observation study d. Variance analysis

*Correct Answer: D* Reported performance data are regularly analyzed for variance. Variance—where actual performance does not meet, varies, or is significantly different from the standard—should be further assessed (Prater 2016, 588).

When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected? a. There is no impact. b. The person making the entry in the health record may not be called as a witness in trial. c. The incident report likely becomes discoverable because it is mentioned in a discoverable document. d. The incident report cannot be discovered even though it is mentioned in a discoverable document.

*Correct Answer: C* Hospitals strive to keep incident reports confidential, and in some states, incident reports are protected under statutes protecting quality improvement studies and activities. Incident reports themselves should not be considered a part of the health record. Because the staff member mentioned in the record that an incident report was completed, *it will likely be discoverable as the health record is already a discoverable document* (Carter and Palmer 2016, 522).

An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard? a. 45.6 pages b. 68.4 pages c. 76 pages d. 190 pages

*Correct Answer: C* Productivity standards should be based on both accuracy and volume. In this situation, 114 / 0.60 = 190; 190 − 114 = 76 more pages will need to be indexed to meet the productivity standard (Schraffenberger and Kuehn 2011, 76).

After the types of cases to be included in a registry have been determined, what is the next step in data acquisition? a. Case registration b. Case definition c. Case abstracting d. Case finding

*Correct Answer: D* After the cases to be included have been determined, the next step is usually case finding. Case finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry (Sharp 2016, 175).

From the information provided in this table, what percentage will the facility be paid for procedure 25500? Billing Number Status Indicator CPT/HCPCS APC 998323 V 99285-25 0612 998323 T 25500 0044 998323 X 72050 0261 998323 S 72128 0283 998323 S 70450 0283 a. 0% b. 50% c. 75% d. 100%

*Correct Answer: D* Procedure 22550 has a "T" status indicator, which indicates that it is a significant procedure and multiple procedure reductions will apply. In this case, there is only one CPT procedure code that is a status "T" indicator, so 100 percent of the fee-based APC will be paid (Casto and Forrestal 2015, 175).

The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments

*Correct Answer: A* The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance (Foltz et al. 2016, 462).

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? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist

*Correct Answer: A* In the outpatient setting, do not code a diagnosis documented as "probable." Rather, code the conditions to the highest degree of certainty for the encounter (Schraffenberger and Palkie 2017, 102).

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all of the designated records in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically

*Correct Answer: A* The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be provided in that format (Thomason 2013, 102).

45. Cancer registries are maintained by hospitals: a. By federal law or state law b. Voluntarily or by state law c. Voluntarily or by federal law d. By mandate from the American College of Surgeons

*Correct Answer: B* Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central state-wide registry or incidence surveillance program who in turn reports the data to the Centers for Disease Control (CDC) (Sharp 2016, 175-177).

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit

*Correct Answer: B* Focused selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-risk areas or other areas of specific concern, such as a focused audit of cases with no CC/MCC to determine why the case-mix is dropped (Foltz et al. 2016, 459).

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits

*Correct Answer: B* Local coverage determination (LCD) is used to determine coverage on a Medicare Administrative Contractor-wide, intermediary-wide, or carrier-wide basis (rather than nationwide, as with a NCD). LCDs are educational materials that assist facilities and providers with correct billing and claims processing. Within the LCD is a listing of ICD-10-CM codes that indicate what is covered and what is not covered. For example, a procedure may be covered by Medicare, but is not reimbursed by Medicare because it does not meet medical necessity (Casto and Forrestal 2015, 268).

In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis and complaints b. Chargemaster description c. Clinical laboratory results d. Radiology orders

*Correct Answer: B* One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description for accuracy (Foltz et al. 2016, 458-459).

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? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records c. Perform a quality check on all health record systems in the practice d. Develop a listing and categorize all information requests for health information over the past two years

*Correct Answer: B* The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record as the first step in determining the components of the legal health records (Rinehart-Thompson 2017b, 171-172).

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is *now* removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation

*Correct Answer: B* The root operation extirpation is defined as taking or cutting out solid material from a body part. The matter may have been broken into pieces during the lithotripsy previous to this encounter, but at this time the pieces of the calculus are being removed (Kuehn and Jorwic 2017, 86).

A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by *incision*. What is the correct ICD-10-PCS code for this procedure? a. 0QB60ZZ b. 0Q860ZZ c. 0SB90ZZ d. 0SN90ZZ

*Correct Answer: B* The root operation performed was *division—cutting into a body part without drawing fluids and/or gases from the body part in order to separate or transect a body part*. The intent of the operation was to separate the femur; 0Q860ZZ is the correct code. The Section is Medical and Surgical—character 0; Body System is Lower Bones—character Q; Root Operation is Division—character 8; Body Part is Femur, Right—character 6; Approach is Open— character 0; No Device—character Z; and No Qualifier —character Z (Kuehn and Jorwic 2017, 21-23, 99).

OASIS-C data are used to assess the ________ of home health services. a. Core measure b. Financial performance c. Outcome d. Utilization

*Correct Answer: C* The Outcomes and Assessment Information Set (OASIS-C) consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement (White 2013, 565-566; Giannangelo 2015, 254).

What is the first step an organization should take when developing a data dictionary? a. Develop an approvals process b. Integrate common data elements c. Design a plan d. Ensure consistency

*Correct Answer: C* The data dictionary should be designed to accommodate changes resulting from clinical or technical advances and regulatory changes. There should be a plan for future expansion, such as expanding a data field from one element to multiple elements. This becomes problematic when comparing data across time if the meaning of a particular element has changed while its name or representation has not (Russo 2013b, 322).

The advent of the EHR has increased the amount of documentation largely due to: a. Storage capabilities b. Joint Commission requirements c. Ease of entry d. Reporting

Correct Answer: C The advent of the electronic health record (EHR) came with improvements as well as challenges related to clinical documentation. Overall, the EHR has increased the amount of documentation based largely on the ease of entry (Hess 2015, 124).

Managing an organization's data and those who enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following? a. Data dictionary b. Data warehouse c. Data mapping d. Data set

Correct Answer: A A data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology (Brinda 2016, 141).

In a database the LAST_NAME column in a table would be considered a: a. Data element b. Record c. Primary key d. Row

Correct Answer: A A data element is an individual fact or measurement that is the smallest unique subset of a database (Brinda 2016, 141).

he act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called: a. Accreditation b. Licensure c. Acceptance d. Approval

Correct Answer: A Accreditation is the act of granting approval to a healthcare organization. The approval is based on whether the organization has met a set of voluntary standards that were developed by the accreditation agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or certification. The Joint Commission is an example of an accreditation agency (Shaw and Carter 2015, 406).

Specific performance expectations and structures and processes that provide detailed information for each of the Joint Commission standards are called: a. Elements of performance b. Fact sheets c. Ad hoc reports d. Registers

Correct Answer: A Elements of performance (EPs) are the Joint Commission's specific performance expectations and structures or processes that must be in place for an organization to provide safe, high-quality care, treatment, and services. Knowledge of EPs pertaining directly to the health record and documentation in the record are critical for HIM professionals working in an accredited facility (Rossiter 2013, 486).

In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: a. Provide uniform data definitions b. Guide efforts toward computerization c. Determine statistical formulas d. Provide a research database

Correct Answer: A Healthcare data sets have two purposes. The first is to identify the data elements that should be collected for each patient. The second is to provide uniform definitions for common terms. The use of uniform definitions ensures that data collected from a variety of healthcare settings will share a standard definition. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities (Brinda 2016, 142).

48. In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. Because of unexpected complications, however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case? a. Request that the physician dictate an addendum to the discharge summary b. Have the record analyst note the date discrepancy c. Request that the physician dictate another discharge summary d. File the record as complete because the discharge summary includes all of the pertinent patient information

Correct Answer: A If during record analysis, missing or incomplete information is identified, HIM personnel can issue deficiency notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a supplement to a signed report that provides additional health information within the health record. In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident (Sayles 2016b, 64-65).

The primary purpose of a *minimum data set* in healthcare is to: a. Recommend common data elements to be collected in health records b. Mandate all data that must be contained in a health record c. Define reportable data for federally funded programs d. Standardize medical vocabulary

Correct Answer: A In 1969, a conference on hospital discharge abstract systems was sponsored jointly by NCHS, the National Center for Health Services Research and Development, and Johns Hopkins University. Conference participants *recommended* that all short-term general hospitals in the United States collect a minimum set of patient-specific data elements. They also recommended that these data elements be included in all databases compiled from hospital discharge abstract systems (Brinda 2016, 142).

Which of the following is an institutional user of the health record? a. A third-party payer b. Patient c. Physician d. Employer

Correct Answer: A Institutional users of the health record are organizations that need access to health records in order to accomplish their mission. These institutional users include *healthcare delivery organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, and policy-making bodies* (Sayles 2016b, 54-55).

40. Activities of daily living (ADL) are components of: a. OASIS-C b. UHDDS c. UACDS d. ORYX and RAPs

Correct Answer: A Outcomes and Assessment Information Set (OASIS-C) is a standardized data set of more than 30 data elements designed to gather data about Medicare beneficiaries who are receiving services from a home health agency (White 2013, 557-560).

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission

Correct Answer: A The Commission on Accreditation of Rehabilitation Facilities (CARF) is a private, not-for-profit organization committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. CARF accreditation is based on an organization's commitment to continually enhance the quality of its services and programs and to focus on customer satisfaction (Shaw and Carter 2015, 408).

The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: a. Master patient index (MPI) b. Audit trail c. Case-mix management d. Electronic document management system (EMDS)

Correct Answer: A The MPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility (Sayles 2016b, 56).

The HIM director has put together a group of department employees to develop *coding benchmarks* for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team? a. Insufficient knowledge of team members b. Too many team members c. Unspecific team charge d. Too few team members

Correct Answer: A Whether selecting a permanent staff team or members of a team for a short-term project, making the right choice is fundamental to the team's success. Putting together a team involves understanding the challenges to be faced and considering all of the perspectives, experience, and knowledge that will be needed. The members of the team should be selected for what they can contribute to the team. Member selection should not be based purely on job title; rather, team members should be selected for the tasks that they actually can perform and the responsibilities they can carry out (Kellogg 2016b, 487).

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? a. Notice of privacy practices is required on the first provision of service. b. Notice of privacy practices is required every time the patient is provided service. c. Notice of privacy practices is only required for inpatient admissions. d. Notice of privacy practices is required on the first inpatient admission but for every outpatient encounter.

Correct Answer: A A patient has a right to a notice of privacy practices as defined in the HIPAA Privacy Rule. A healthcare provider has to provide the notice no later than the first service delivery. After that first provision of service, there is no requirement to provide a notice every time a patient receives service (Thomason 2013, 113).

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: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer

Correct Answer: A A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry (Brinda 2016, 141; Sayles and Gordon 2016, 675).

The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas? a. Operative and other invasive procedures, medication management, and blood and blood product use b. Blood and blood product use, medication management, and appointment to the board of directors c. Medication management, marketing strategy, and blood use d. Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use

Correct Answer: A Appointments to the Board of Directors is important information, but the Joint Commission requires detailed information on the responsibilities and actions of the Board, not necessarily its composition. The Joint Commission requires healthcare organizations to collect data on each of these areas: *medication management, blood and blood product use, restraint and seclusion use, behavior management and treatment, operative and other invasive procedures, and resuscitation and its outcomes* (Shaw and Carter 2015, 378, 382).

Which of the following definitions best describes the concept of *confidentiality*? a. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The right of individuals to control access to their personal health information d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

Correct Answer: A Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose (Rinehart-Thompson 2016b, 214).

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? Costs Associated with Each IT Help Desk Call to Resolve Password Issues Personnel Cost User's time—30 minutes $15 Telephone cost—30 minutes $2 Call Desk time—30 minutes $16 Call Desk IS facilities time $17 Total $50 a. Training will provide $146,000 savings in help desk support and can be justified. b. The results of training will provide $365,000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.

Correct Answer: A Current cost: $50 × 40 calls per day = $2,000 per day × 365 days = $730,000. Cost with reduced number of help desk calls: $50 × (40 × 0.80) calls per day = $1,600 per day × 365 days = $584,000, or a savings of $146,000. Training costs of $100,000 will be recouped and a savings of $46,000 realized (Gordon and Gordon 2016b, 548). $50*40*365*0.2=$146,000

A coder's misrepresentation of the patient's clinical picture through *intentional* incorrect coding or the omission of diagnosis or procedure codes would be an example of: a. Healthcare fraud b. Payment optimization c. Payment reduction d. Healthcare creativity

Correct Answer: A Healthcare fraud is an intended and deliberate deception or misrepresentation by a provider, or by representative of a provider, that results in a false or fictitious claim. These false claims then result in an inappropriate payment by Medicare or other insurers (Foltz et al. 2016, 448).

Which of the terms below represents fixed rules that must be followed? a. Standard b. Guidelines c. Forms control program d. Policy

Correct Answer: A Standards are fixed rules that must be followed (Sayles 2016b, 66).

17. A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. b. Yes; this is hospital policy for which HIPAA has no control. c. No; the records from the previous hospital are not included in the designated record set but should be released anyway. d. Yes; HIPAA only requires that current records be produced for the patient.

Correct Answer: A When other healthcare providers provide records, it is done to ensure the continuity of care for the individual. Many covered entities either include the whole file or copies of the file as part of the covered entity's record, with the assumption that the treating physician has used some or all of the records to decide how to treat the patient. Any copies that are included with the records of the individual are, therefore, considered part of the individual's designated record set and should be released (Thomason 2013, 99).

Which of the following is not a characteristic of the common healthcare data sets such as UHDDS and UACDS? a. They define minimum data elements to be collected. b. They provide a complete and exhaustive list of data elements that must be collected. c. They provide a framework for data collection to which an individual facility can add data items. d. The federal government recommends, but does not mandate, implementation of most of the data sets.

Correct Answer: B A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. The contents of data sets vary by their purpose. However, data sets are not meant to limit the number of data elements that can be collected. Most healthcare organizations collect additional data elements that have meaning for their specific administrative and clinical operations. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities. A number of data reporting requirements come from federal initiatives (Brinda 2016, 142).

An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: a. Consistency b. Granularity c. Comprehensiveness d. Relevancy

Correct Answer: B Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data (Brinda 2016, 158).

Which of the following documentation must be included in a patient's health record prior to performing a surgical procedure? a. Consent for operative procedure, anesthesia report, surgical report b. Consent for operative procedure, history, physical examination c. History, physical examination, anesthesia report d. Problem list, history, physical examination

Correct Answer: B Documentation of health history, consents, and the physical examination must be available in the patient's record before any surgical procedures may be performed (Russo 2013a, 203-207).

The ability to electronically send data from one EHR to another while maintaining the original meaning is called: a. Data comparability b. Interoperability c. National data exchange d. Data architecture

Correct Answer: B Interoperability refers to the use of standard protocols to enable two different computer systems to share data with each other (Brinda 2016, 153).

Which of the following is a true statement about the content of the legal health record? a. The legal health record contains only clinical data b. The legal health record may contain metadata c. The legal health record should not include e-mail d. The legal health record should not include diagnostic images

Correct Answer: B Organizations should develop and maintain an inventory of all documents and data that could comprise the legal health record, considering all locations in the organization (for example, separate departments or servers) where such information could be housed. Organizations should also carefully consider whether to include data such as pop-up reminders, alerts, and metadata. Metadata are data about data and include information that track actions such as when and by whom a document was accessed or changed (Rinehart-Thompson 2016a, 206).

What type of standards provide clear descriptors of data elements to be included in computer-based patient record systems? a. Vocabulary b. Structure and content c. Transaction d. Security

Correct Answer: B Structure and content standards establish and provide clear and uniform definitions of the data elements to be included in EHR systems. They specify the type of data to be collected in each data field and the attributes and values of each data field, all of which are captured in data dictionaries (Sayles and Trawick 2014, 32-33).

How many times each year are healthcare facilities required to practice emergency preparedness plans? a. Once b. Twice c. Three times d. Never

Correct Answer: B The emergency operations plan is practiced twice a year in response either to an actual disaster or to a planned drill. Exercises should stress the limits of the organization's emergency management system to assess preparedness capabilities and performance when systems are stressed (Shaw and Carter 2015, 310).

On the problem list in a problem-oriented health record, problems are organized: a. In alphabetical order b. In numeric order c. In alphabetical order by body system d. By date of onset

Correct Answer: B The problem-oriented health record is better suited to serve the patient and the end user of the patient information. The key characteristic of this format is an *itemized list* of the patient's past and present social, psychological, and health problems. Each problem is *indexed with a unique number* (Russo 2013b, 303).

Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures? a. Reliability b. Validity c. Completeness d. Timeliness

Correct Answer: B Validity is the degree to which codes accurately reflect the patient's diagnoses and procedures (Prater 2016, 573).

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? a. Problem list b. Medical history c. Physical examination d. Clinical observation

Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician (Brickner 2016, 90).

Two patients' records were filed together by mistake. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge

Correct Answer: B Another problem with the question of the quality of the MPI is an overlay, where a patient is erroneously assigned another person's health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient as well (Sayles 2016b, 58).

Which of the following is not a characteristic of high-quality healthcare data? a. Data relevancy b. Data currency c. Data consistency d. Data accountability

Correct Answer: D The data quality model applies the following quality characteristics: data accuracy, data accessibility, data comprehensiveness, data consistency, data currency, data definition, data granularity, data precision, data relevancy, and data timeliness (Brinda 2016, 156-159).

15. 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? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to get their input d. Contact CMS to determine what data sets are required to be collected

Correct Answer: B Data content standards allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes. The HIM director should identify data content requirements for all areas of the organization to ensure the data content standards are met (Sayles and Trawick 2014, 170).

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 transection) 58671 Laparoscopy, surgical; with occlusions of oviducts *by device (e.g., band, clip, or Falope ring)* a. 49320, 58662 b. 58670 c. 58671 d. 49320

Correct Answer: B No mention is made of biopsy, excision of lesion, or occlusion, so following proper steps for coding in CPT, the correct code is 58670 (Kuehn 2017, 22, 24).

HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into? a. Reasonable cause b. Reasonable diligence c. Willful neglect d. Abuse

Correct Answer: B Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements (Foltz et al. 2016, 451).

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital? a. $40,300 b. $39,375 c. $26,250 d. $13,125

Correct Answer: B Unbundling is the practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure code. In this situation, the penalty is the overpayment of the $75 for all 175 claims overpaid as well as *3 times the total amount of the overpayment* (175 × $75 = $13,125 then; $13,125 × 3 = $39,375) (Foltz et al. 2016, 450)

Two health information professionals are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking? a. Completeness b. Validity c. Reliability d. Timeliness

Correct Answer: C Reliability refers to the degree to which a selection test produces consistent scores on a test and retest. Reliability is frequently checked by having more than one person abstract data for the same case. The results are then compared to identify any discrepancies (Prater 2016, 573).

Correct Answer: C Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. For example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results—or in the collection of demographic data, data elements should be defined appropriately to determine the differences in outcomes of care among various populations (Brinda 2016, 158).

Correct Answer: C *Data granularity* requires that the attributes and values of data be defined at the *correct level of detail* for the intended use of the data. For example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results—or in the collection of demographic data, data elements should be defined appropriately to determine the differences in outcomes of care among various populations (Brinda 2016, 158).

17. 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? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set

Correct Answer: C Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Participation (Brickner 2016, 84, 102).

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data

Correct Answer: C Administrative describes patient identification, diagnosis, procedures, and insurance. Patient registration information would be considered administrative data as would patient account information. A significant portion of administrative data is demographic data (Brickner 2016, 90, 97).

49. The hospital is revising its policy on health record documentation. Currently, all entries in the health record must be legible, complete, dated, and signed. The committee chairperson wants to add that all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest? a. Suggest that only hospital clock time be noted in clinical documentation b. Suggest that only electronic documentation have time noted c. Inform the committee that according to the Conditions of Participation, all documentation must include date and time d. Inform the committee that according to the Conditions of Participation, only medication orders must include date and time

Correct Answer: C All patient health record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures (Russo 2013a, 200-201; CMS Conditions of Participation 482.24(c)(1) ).

What is the key piece of data needed to link a patient who is seen in a variety of care settings? a. Facility medical record number b. Facility identification number c. Identity matching algorithm d. Patient birth date

Correct Answer: C Because the United States does not have a national patient identifier, an identity matching algorithm process must be used by organizations to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients (Amatayakul 2016, 306-307).

In which of the following examples does the gender of the patient constitute information rather than a data element? a. As an entry to be completed on the face sheet of the health record b. In the note "50-year-old white male" in the patient history c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females d. In a study of the age distribution of lung cancer patients

Correct Answer: C Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combined to produce value) and enhance that information with experience and trial-and-error that produces knowledge. In this example, the gender is tied to race in the data collection that constitutes information and not a data element (Fahrenholz 2013a, 73).

Which of the following is not true of good electronic forms design? a. Minimizes keystrokes by using pop-up menus b. Performs completeness check for all required data c. Uses radio buttons to select multiple items from a set of options d. Uses text boxes to enter text

Correct Answer: C Good forms design is needed within an EHR to create ease of use. The use of a selection box allows the user to select a value from a predefined list. *Check boxes are used for multiple selections and radio buttons are used for single selections* (Sayles 2016b, 70-71).

The utilization manager's role is essential to: a. Analyze the estimate of benefits (EOBs) received b. Capture all relevant charges for the patient's account c. Prevent denials for inappropriate levels of service d. Verify the patient actually has insurance

Correct Answer: C *Front-end utilization management (UM) is essential to the prevention of denials for inappropriate levels of care*. UM staff work with the physician to ensure that the requested services meet *medical necessity* requirements and are provided in the most appropriate setting. When the insurer denies the claim, an appeal may be possible (Gordon and Gordon 2016a, 438).

The organization that you work for just concluded an investigation of a USB thumb drive that was lost and contained a file with the information of 765 patients on it, including name, address, telephone number, and social security number. As the privacy officer, you are required to manage the notification process for the data breach. All of the following would need to be notified of this data breach within 60 days of the discovery except: a. Individual patients b. Local media c. Attending physicians of the patients d. Department of Health and Human Services

Correct Answer: C All individuals whose information has been breached must be notified without unreasonable delay, and not more than *60 days*, by first-class mail or a faster method such as by telephone if there is the potential for imminent misuse. If *500 or more* individuals are affected they must be *individually notified immediately and media* outlets must be used as a notification mechanism as well. The *Secretary of HHS* must specifically be notified of the breach. The attending physicians of the patients do not need to be notified of the breach (Rinehart-Thompson 2016b, 240).

30. Data elements collected on large populations of individuals and stored in databases are referred to as: a. Statistics b. Information c. Aggregate data d. Standard

Correct Answer: C Data about patients can be extracted from individual health records and combined as aggregate data. Aggregate data are used to develop information about groups of patients. For example, data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database (Sharp 2016, 173).

13. The *right of an individual* to keep personal health information from being disclosed to anyone is a definition of: a. Confidentiality b. Integrity c. Privacy d. Security

Correct Answer: C In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information (Rinehart-Thompson 2016b, 214).

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? a. PHI related to treatment, payment, and operations b. PHI provided to meet national security or intelligence requirements c. PHI sent to a physician who has not treated Sally d. PHI released to Sally's attorney upon her request

Correct Answer: C Maintaining some type of accounting procedure for monitoring and tracking PHI disclosures has been a common practice in departments that manage health information. However, the Privacy Rule has a specific standard with respect to such record keeping. Disclosures for which an accounting is not required and which are therefore exempt include some of the following examples: TPO disclosures, pursuant to an authorization, and to meet national security or intelligence requirements. PHI sent to a physician that has not treated the patient would need to be accounted for (Rinehart-Thompson 2017d, 247-248).

Which of the following is the approved method for implementing an organization's formal position? a. Hierarchy chart b. Organizational chart c. Policy and procedure d. Mission statement

Correct Answer: C Policies and procedures also can be considered organizational tools. Policies are written descriptions of the organization's formal positions. Procedures are the approved methods for implementing those positions. Together, they spell out what the organization expects employees to do and how they are expected to do it (Gordon and Gordon 2016b, 537-538).

David works for an organization that utilizes health record data to prove or disprove the efficacy of a healthcare treatment. What type of organization does David work for? a. Educational b. Policy-making c. Research d. Third-party payer

Correct Answer: C Research organizations conduct medical research and include state disease registries such as the cancer registry, research centers, and others who explore diseases and their treatments (Sayles 2016b, 54-55).

In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited? a. Drop-down menus b. Point and click fields c. Speech recognition d. Structured templates

Correct Answer: C Speech recognition can be very effective in certain situations when data entry is fairly repetitive and the vocabulary used is fairly limited. As speech recognition improves, it is becoming a replacement for other forms of dictation. In some cases, the user reviews the speech as it is being converted to type and makes any needed corrections; in other cases, the speech is sent to a special device where it generates type for another individual to review and edit (Sayles and Trawick 2014, 189-191).

9. 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? a. All individuals in the MEDPAR database b. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease d. All individuals in the MEDPAR database except those admitted with a diagnosis of hypertension

Correct Answer: C The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients. Community Hospital is excluding MEDPAR data of those patients with a principal diagnosis of *UTI or infectious disease* because these would not represent a hospital acquired condition (HAC) because the patients were admitted with those diagnoses. Community Hospital is looking for comparative secondary diagnosis data of Medicare patients from the MEDPAR file to compare their HAC rate for UTIs to the national average from the MEDPAR data (Gordon and Gordon 2016a, 437; Sharp 2016, 185).

The accounts not selected for the billing report is used to track accounts that are: a. Awaiting payment in accounts receivable b. Paid at different rates c. In bill hold or in error and awaiting billing d. Pulled for quality review

Correct Answer: C The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the *discharged not final billed (DNFB)* report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list. Some accounts are held because the patient has not signed the consents and authorizations required by the insurer. Still others are not billed because the primary and secondary insurance benefits have not been confirmed (Schraffenberger and Kuehn 2011, 436; AHIMA 2014, 48).

Which of the following is a function of the *outpatient code editor*? a. Validate the patient's age on a claim b. Validate the patient's encounter number c. Identify unbundling of codes d. Identify cases that don't meet medical necessity

Correct Answer: C The latest version of the Medicare integrated outpatient code editor (OCE) should be installed to review claims prior to releasing billed data to the Medicare program. OCE software contains the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT). The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to control improper coding leading to inappropriate payment and unbundling on the Part B claims. They also identify component codes that were used instead of the appropriate comprehensive code, as well as other types of coding errors (Foltz et al. 2016, 450; AHIMA 2014, 110)

Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request d. It includes a patient's personal health record

Correct Answer: C The legal health record distinction is important for several reasons. First, it is important to an organization's business and legal processes. Second, because the legal health record is the record that is produced upon request, including legal requests, it becomes important to ensure that the legal health record is legally sound and defensible as a valid document in legal situations (Rinehart-Thompson 2016a, 206).

How many identifiers must be removed for a data to be considered deidentified under the Safe Harbor Method? a. 12 b. 15 c. 18 d. 20

Correct Answer: C The safe harbor method of deidentification requires the removal of 18 specific identifiers from the protect health information (Marc and Sandefer 2016, 22).

A critical early step in designing an EHR is to develop a(n) ________ in which the characteristics of each data element are defined. a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary

Correct Answer: D A data dictionary improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing. A critical early step in implementing the EHR is to develop a data dictionary (Brinda 2016, 141-142).

Which of the following are components of AHIMA's principles of information governance? a. Accountability and accessibility b. Integrity and safeguards c. Safeguards and accessibility d. Accountability and integrity

Correct Answer: D AHIMA defined the following principles to support proper information governance across an organization: accountability, transparency, integrity, protection, compliance, availability, disposition, and retention (Brinda 2016, 150-151).

What is the information identifying the patient (such as name, health record number, address, and telephone number) called? a. Accession data b. Indicator data c. Reference data d. Demographic data

Correct Answer: D Demographic data is used to identify an individual, such as name, address, gender, age, and other information linked to a specific person (Gordon and Gordon 2016a, 422).

Cancer registries receive approval as part of the facility cancer program from which of the following agencies? a. American Cancer Society b. National Cancer Registrar's Association c. National Cancer Institute d. American College of Surgeons

Correct Answer: D Several organizations have developed standards or approval processes for cancer programs. The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program (Sharp 2016, 177).

Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records? a. Current Procedural Terminology b. Healthcare Common Procedure Coding System c. International Classification of Diseases, Tenth Revision, Clinical Modification d. Systematized Nomenclature of Medicine Clinical Terminology

Correct Answer: D Standardized vocabulary is needed to facilitate the indexing, storage, and retrieval of patient information in an electronic health record (EHR). Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) creates a standardized vocabulary. The Computerbased Patient Record Institute (CPRI) has studied the ability of current nomenclatures to capture information for EHRs. The institute has determined that SNOMED CT is the most comprehensive controlled vocabulary for coding the contents of the health record and facilitating the development of computerized records (Giannangelo 2016a, 116-117).

The data set designed to organize data for public release about the outcomes of care is: a. UHDDS b. DEEDS c. MDS d. HEDIS

Correct Answer: D The *Healthcare Effectiveness Data and Information Set (HEDIS)* is sponsored by the National Committee for Quality Assurance (NCQA). HEDIS is a set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of managed healthcare plans (Shaw and Carter 2015, 179).

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage? a. Media control b. Audit controls c. Mitigation d. Integrity

Correct Answer: D The goals of the HIPAA security rule are to ensure the *confidentiality, integrity, and availability* of electronically created protected health information (PHI). Integrity is ensuring that data are not altered either during transmission across a network or during storage. e-PHI must be available when needed for patient care and other uses (Sayles and Trawick 2014, 206-207).

42. Which of the following should be avoided when designing forms for an electronic document management system (EDMS)? a. Color borders around the edge of a form b. Mnemonic descriptor used for nonbarcode recognition engine c. Quarter-inch border on each side of document without bar code d. Shading of bars or lines that contain text

Correct Answer: D The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images (Sayles 2016b, 65).

An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: a. American Health Information Management Association b. American Medical Association c. Centers for Medicare and Medicaid Services d. Cooperating Parties

Correct Answer: D Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the Cooperating Parties and any other official coding rules and guidelines established for use with mandated standard code sets (Casto and Forrestal 2015, 30-31).

One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following? a. Serial work division b. Job sharing c. Job rotation d. Parallel work division

Correct Answer: D In parallel work division, the same tasks are handled simultaneously by several workers; each completes all steps in the process from beginning to end, working independently of the other employees (Prater 2016, 584).

If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment *from the patient*: a. For the balance due after Medicare has paid b. Only if both Medicare and any supplemental insurance have been billed and settled c. Never—providers may not bill Medicare patients for amounts unpaid by Medicare d. Only if a properly executed ABN was obtained before the service was provided

Correct Answer: D Medicare does have a provision that a patient may be billed for a test that is not medically necessary if he or she receives an *advance beneficiary notice (ABN)* before the test is performed. Therefore, not only must the registration staff determine whether the sign or symptom is sufficient, they also may contact the patient's physician to obtain a new order or, if a new order is not provided, to issue an ABN. Success in the patient registration process involves a thoroughly educated staff with the tools to determine medical necessity, the processes in place to clarify orders, and the ability to obtain signatures on ABNs (Schraffenberger and Kuehn 2011, 467-468).

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? a. Provide copies of the records within 15 days b. Provide copies of the records within 30 days c. Provide copies of the records within 45 days d. Provide copies of the records within 60 days

Correct Answer: D The HIPAA Privacy Rule requires that records be produced within 30 days to a patient or their personal representative, with a one-time extension of an additional 30 days if necessary. If such an additional 30 days is needed, the covered entity must notify the patient in writing of the need for additional time (Thomason 2013, 98).

As part of your job duties, you are responsible for reviewing audit trails of access to patient information. All of the following are types of activity that you would monitor except: a. Every access to every data element or document type b. Whether the person viewed, created, updated, or deleted the information c. Physical location on the network where the access occurred d. Whether the patient setup an account in the patient portal

Correct Answer: D The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. Often they record: time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred. Creation of an account through the patient portal by the patient is appropriate use (Thomason 2013, 177).

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system

Correct Answer: D The database management system is the best option to collect, store, manipulate, and retrieve data for this situation. Paper and word-processing documents cannot sort and store the data in a meaningful way for this purpose. Spreadsheets should be used for accounting-type functions and not for data storage (Brinda 2016, 146).

The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following? a. Reporting of claims, initial investigation of claims, protection of primary and secondary health records, negotiation of settlements, management of litigations, and use of information for claim's resolution in performance management activities b. Risk acceptance, risk avoidance, risk reduction or minimization, and risk transfer c. Safety management, security management, claims management, technology management, and facilities management d. Risk identification and analysis, loss prevention and reduction, and claims management

Correct Answer: D The purpose of the risk management program is to link *risk management* functions to related processes of quality assessment and PI. The basic functions of healthcare risk management programs are similar for most organizations and include: risk identification and analysis, loss prevention and reduction, and claims management (Carter and Palmer 2016, 522).

Accountability

Willingness to take credit and blame for actions.

Privacy

The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the *right of a patient* to control disclosure of protected health information

Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided? a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission

The Joint Commission has been the most visible organization responsible for accrediting healthcare organizations since the mid-1950s. The primary focus of the Joint Commission at this time is to determine whether organizations seeking accreditation are continually monitoring the quality of the care they provide. The Joint Commission requires that this continual improvement process be in place throughout the entire organization, from the governing body down, as well as across all department lines (Shaw and Carter 2015, 406).

Multiple users entering data may have different definitions or perceptions about what goes into a data field, thereby confounding the data. For example, one department may use the term "PATIENT" while another department my use the term "CLIENT" to define the same entity. Which of the following would be used to provide standardization? a. Data dictionary b. Data mining c. Data model d. Database

The data dictionary is a central building block that supports communication across business processes. It improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing. For example, the data element "PATIENT" would have the same field length and definition across all applications in the organization (Brinda 2016, 141).

The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear? a. Admission note b. Dietary note c. Physician progress note d. Social service note

This documentation would typically be found in social service notes (Fahrenholz 2013c, 660).

Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users? a. Controlled vocabulary b. Data exchange standards c. Encoded vocabulary d. Proprietary standards

What is the key piece of data needed to link a patient who is seen in a variety of care settings? a. Facility medical record number b. Facility identification number c. Identity matching algorithm d. Patient birth date

Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an EHR? a. Make admission date a required field b. Provide a template for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data

correct Answer: B *Template*s are a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date (Brinda 2016, 159-160).

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written? a. Assessment b. Objective c. Plan d. Subjective

orrect Answer: A Some providers also use a SOAP format for their problem-oriented progress notes. Professional conclusions reached from evaluation of the subjective or objective information make up the assessment (A) (Brickner 2016, 106).

What is the function of a consultation report? a. Provides a chronological summary of the patient's medical history and illness b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care c. Concisely summarizes the patient's treatment and stay in the hospital d. Documents the physician's instructions to other parties involved in providing care to a patient

orrect Answer: B The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The consultation is requested by the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record (Brickner 2016, 96).

Confidentiality

the act of holding information in confidence, not to be released to *unauthorized individuals* 1. A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from *unauthorized* use or disclosure 2. As amended by HITECH, the practice that data or information is not made available or disclosed to unauthorized persons or processes (45 CFR 164.304 2013)