RHIA
Agreements that are reached in a participant agreement or vendor contract should be developed into: a. Operational policies b. Strategy plans c. Admit, discharge, transfer notifications d. Long-term vision for technical interoperability
A
Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information? a. It can exist in separate and multiple paper-based or electronic systems. b. The record is incomplete. c. Numerous physicians have not given consent to release the record. d. Risk management will not allow the legal health record to be released.
A
Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors according to which of the following Code of Ethics principles? a. Advocate and uphold the right to privacy b. Respect the inherent dignity and worth of every person c. Represent the profession accurately to the public d. Put service before self-interest
D
An accrediting agency's published rules, which serve as the basis for comparative assessment during the review or survey process, are called: a. Accreditation controls b. Accreditation guides c. Accreditation policies d. Accreditation standards
D
In order for health information exchange (HIE) participants to search for health records on eachof the other systems using patient indexing and identification software, the systems must belinked by a(n): a. Primary key interface (PKI) b. Application programming interface (API) c. Continuity of care record (CCR) d. Record locator service (RLS)
D
Joan is educating the physicians in her hospital about the Medicare Hospital Value-Based Purchasing (VBP) Program. As part of this education she explains to her audience that the HCAHPS survey results are a part of the ________ domain in the Medicare VBP program. a. Safety b. Clinical Care c. Efficiency and Cost Reduction d. Person/Community Engagement
D
An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s). a. A list of newborns to the local newspaper for publication in the birth announcements section b. Data about cancer patients to the state health department cancer surveillance program c. Birth information to the country registrar d. Information about patients with sexually transmitted infections to the county health department
A
When a physician office acquires a new EHR in place of its old EHR, the old EHR data will require: a. Chart conversion b. Chart transition c. Data conversion d. Data processing
C
A SWOT analysis created by the director of the HIM department indicates that all of the coding staff are credentialed and up to date on their continuing education credits. In a SWOT analysis, this would be considered a: a. Strength b. Weakness c. Opportunity d. Threat
A
A physician is interested in conducting research on herniated intervertebral disc disease. She wants to compare the success of conservative medical care versus surgical intervention. The best source of this information is the: a. Disease index b. Operative index c. Master patient index d. Trauma registry
A
A physician office is implementing a vendor's personal health record system to be used by a majority of patients in order to help improve the office's achievement of value-based care.What technology would help facilitate this goal? a. Patient portal b. Preadmission system c. Clinical database d. Chart conversion
A
A super user of health IT has complained to her supervisor that she is being asked by a physician to perform his data entry. What should the super user's role be? a. Aid others in using a new system during go-live and getting to adoption b. Serve as a scribe for physicians who are new to data entry c. Train users to learn how to use the system prior to go-live d. Troubleshoot issues with the system that did not come to light during testing
A
A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called: a. Strategy map b. Process innovations c. Balanced scorecard methodology d. SWOT analysis
C
A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers' compensation insurance. The workers' compensation insurance paid the neurosurgeon fees. Which entity is the "third party"? a. Patient b. Neurosurgeon c. Basic Manufacturing Company d. Workers' compensation insurance
D
What type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation? a. Vocational review b. Compulsory review c. Complimentary review d. Voluntary review
D
Which of the following do HIE participants use to search for health records on other healthcare organization systems using patient indexing and identification software? a. Admit, discharge, transfer b. Advance patient identifier c. Continuity of care document d. Record locator service
D
Which of the following healthcare entities' mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments? a. Accountable care entity b. Managed care entity c. Revenue reduction contractor d. Recovery audit contractor
D
Which of the following would be an indicator of process problems in a health information department? a. 5% decline in the number of patients who indicate satisfaction with hospital care b. 10% increase in the average length of stay c. 15% reduction in bed turnover rate d. 18% error rate on abstracting data
D
In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a. Note the condition as present on admission b. Query the physician to determine if the condition was present on admission c. Note the condition as unknown on admission d. Note the condition as not present on admission
B
Sam is the new HIM supervisor. His first assignment is to evaluate the efficiency and effectiveness of his work unit. He has met with the unit's customers to determine their expectations and met with his staff to understand their roles. In setting up systems to measure work performance, it is critical for Sam to establish: a. Proper ergonomics b. Standards c. Action plans d. Work distribution charts
B
A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. D50.0, N93.8 b. D62, N93.8 c. N93.8, D50.0 d. D50.0, D25.9
A
During new employee orientation, Elise, the assistant director of human resources, oversees diversity and sexual harassment training. This orientation is taking place at what level? a. Organizational b. Departmental c. Individual d. Administrative
A
For Medicare patients, how often must the home health agency's assessment and care plan be updated? a. At least every 60 days or as often as the severity of the patient's condition requires b. Every 30 days c. As often as the severity of the patient's condition requires d. Every 60 days
A
Jan, the new release of information manager, is participating in management orientation for the healthcare organization. One section of orientation thoroughly reviews the tools and practices for setting sustainable performance goals for employees, how to monitor employee progress toward job performance goals, and ways to provide feedback to employees regarding job performance. This section of orientation is called: a. Performance management b. Situational strength c. Critical incident method d. Benchmarking
A
John Smith, who was treated as a patient at a multihospital system, has three health record numbers. The term used to describe multiple health record numbers is: a. Duplicates b. Overlay c. Overlap d. Integrity
A
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? a. Laboratory b. Radiology c. Quality management d. Registration
A
This Health Information Exchange (HIE) consent model requires the patient to give their consent for the inclusion of their data in the HIE. a. Opt-in b. Opt-out c. Automatic consent d. No-consent
A
Using the following custom revenue production report, which coding error may be demonstrated in the report? a. Clustering b. Unbundling c. Missed charges d. Overcoding
A
What type of data display tool is used to display discrete categories? a. Bar graph b. Histogram c. Pie chart d. Line chart
A
A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as: a. Identify needs b. Monitor results c. Record feedback d. Specify requirements
B
A patient has a malunion of an intertrochanteric fracture of the right hip that 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
B
A patient is admitted with right diabetic cataract and extracapsular cataract extraction with simultaneous insertion of intraocular lens. a. H25.9, E11.36, 08DJ3ZZ b. E11.36, 08RJ3JZ c. E11.9, E11.36, H26.9, 08DJ3ZZ d. E25.9, E11.9, 08RJ3JZ
B
A physician is concerned that the data patients enter into an EHR is not as reliable as data entered by another provider. What function serves to distinguish the source of data in an EHR? a. Data dictionary b. Data provenance c. Data quality d. Data registry
B
Community Hospital has received a large number of claims denials for CT scans that were provided to patients. After review of the denied claims, the hospital has determined that clinical indications for the CT scan were not present. For which of the following reasons were these claims denied for payment? a. Patient preferences were ignored. b. These scans did not meet medical necessity. c. No order was present in the record for the scans. d. Best practices for billing were not used.
B
Community Memorial Hospital discharged nine patients on April 1. The length of stay for each patient is shown in the following table. The average length of stay for these nine patients was: a. 5 days b. 6 days c. 8 days d. 9 days
B
If an analyst wishes to predict future ancillary charges for hip replacement patients based on the age of the patient, which of the following is a correct statement? a. Age is the dependent variable; ancillary charges is the independent variable. b. Age is the independent variable; ancillary charges is the dependent variable. c. The average ancillary charge is the best estimator. d. The two variables cannot be related.
B
The best way to ensure that elements of a health information system work together is to: a. Adopt all components from a single vendor b. Ensure standards are applied to software development that support interoperability c. Use an application service provider that supports all vendors d. Verify that a vendor applies a systems' view to its product development
B
The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue.
B
The department of surgery has acquired an analytics engine to enable it to provide predictive information at the point of care via the EHR. However, the department is struggling to get physicians to use the functionality because it does not have support staff to program or train users. This situation refers to the fact that the project plan did not illustrate: a. Conflicts b. Dependencies c. Environmental issues d. Policy decisions
B
The financial manager of the physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group practice receiving? a. Traditional b. Episode-of-care c. Per diem d. Fee-for-service
B
The following table is an example of an: a. Insurance coverage advanced notice service waiver b. Explanation of benefits c. Insurance claim form d. Encounter form
B
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw300 patients, so he received $4,500 from the health plan. What method is the health plan usingto reimburse Dr. Tan? a. Traditional retrospective b. Capitated rate c. Relative value d. Discounted fee schedule
B
The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what action should the coding supervisor take? a. Counsel Tim and Jane because they have the highest error rates b. Encourage Tim and Jane to get additional training c. Provide Bob and Susan with incentive pay for low coding error rates d. Take no action since not enough information is given to make a judgment
D
A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility's internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area? a. Comparative performance data b. Internal infection reporting c. Master patient index d. Provider performance data
A
A professional basketball player from the local team 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: a. Whether access by employees is appropriate b. If the patient is satisfied with their stay c. If it is necessary to order prescriptions for the patient d. Whether the care to the patient meets quality standards
A
A researcher's informed consent form stated that the patients' information would be anonymous. Later, in the application form for Institutional Review Board (IRB) approval, the researcher described a coding system to track respondents and nonrespondents. The IRB returned the application to the researcher with the stipulation that the informed consent must be changed.What raised the red flag? a. The description of the use of a coding system to track respondents and nonrespondents b. The application form for the IRB approval c. The researcher's informed consent form d. The description of the use of a coding system to track respondents
A
Addressable Security Rule implementation specifications: a. Should be implemented unless a healthcare entity determines that the specification is not reasonable and appropriate and documents their reasoning b. Are not optional; the healthcare entity must implement them as stated in the regulation c. Are required if legal counsel determines this to be true and they do not conflict with state law d. Are only required to be read by healthcare entities; they do not have to be implemented
A
Assume you are the manager of a 10-physician group primary care practice. The physicians are interested in contracting with an application service provider to develop and manage patient records electronically. Which of the following statements is an indication that an application service provider (ASP) may be a good idea for this practice? a. The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor. b. The practice wants an electronic medical record system and wants to get into the IT management business as well. c. The practice would like to have the system up and running in a relatively short period of time (less than four months). d. The practice is not looking to purchase any additional hardware needed for an electronic medical record system.
A
Community Hospital is trying to improve its compliance with Medicare quality reporting requirements and, in turn, its reimbursement from Medicare's Hospital Value-Based Purchasing Program. The hospital has added a ________ to assist in educating medical staff members on documentation needed for accurate billing. a. Physician advisor b. Compliance officer c. Chargemaster coordinator d. Data monitor
A
Contracting for staffing to handle a complete function within the HIM department, such as the Cancer Registry function, would be considered what type of contracting arrangement? a. Full-service b. Part-time c. Project-based d. Temporary
A
Dr. Hansen saw a patient in his office with measles. He directed his office staff to call the local department of health to report this case of measles. The office manager called right away and completed the report as instructed. Which of the following provides the correct analysis of the actions taken by Dr. Hansen's office? a. Dr. Hansen's office followed protocol and reported this case of measles correctly. b. Dr. Hansen's office did not need to report this case to the local health department. c. Dr. Hansen's office should have mailed a letter to the local health department to report this case. d. Dr. Hansen's office should have reported the case to the local hospital and not to the health department.
A
In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n): a. Indicator b. Measurement c. Assessment d. Outcome
A
The HIM director has been asked to secure the record of patient John Smith due to impending ligation in a legal hold. The concept of legal hold requires: a. Special, tracked handling of patient records involved in litigation to ensure no changescan be made b. Attorneys for healthcare entities to stop all activity with records involved in litigation c. All records involved in litigation to be printed and held in a locked cabinet d. To not allow further documentation to occur in any record involved in litigation
A
The Security Rule leaves the methods for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be: a. Its own characteristics and environment b. The potential threats and vulnerabilities c. The level of risk d. An assessment of current security measures
A
Which of the following best differentiates the role of strategic management and strategic thinking as compared to other management tools and approaches? a. A component of each of the major functions of management b. An additional function that one learns after mastering other management functions c. A replacement for certain management functions d. A role for senior managers and board of trustees`
A
Which of the following terms is used to describe the requirement of the healthcare provider to obtain permission from the health insurer prior to providing service to the patient? a. Preauthorization b. Advance beneficiary notification c. Point of care collection d. Local coverage determination
A
You are the coding supervisor and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough, and the record states "rule out lung cancer." What should have been coded as the patient's diagnosis? a. Chronic cough b. Observation and evaluation without need for further medical care c. Diagnosis of unknown etiology d. Lung cancer
A
A breach occurs when unsecured protected health information is accessed or released. The Secretary of HHS and local media must be notified if this threshold of patient records breached has been met or exceeded. a. 1,000 b. 500 c. 100 d. 10,000
B
A coding manager wants to display the patient types that have the most coding errors in relationship to coder years of service. The desire of the coding manager is to display how coder years of service is responsible for coding errors. The type of graph or chart best suited for this is a: a. Bar graph b. Pareto chart c. Pie chart d. Line graph
B
A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena? a. Inform defense and plaintiff lawyers that the records no longer exist b. Submit a certification of destruction in response to the subpoena c. Refuse the subpoena since no records exist d. Contact the clerk of the court and explain the situation
B
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 andelectronic 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
B
A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: a. Problem-oriented progress notes b. Charting by exception c. Consultative notations d. Open charting
B
Anywhere Hospital has mandated that the Social Security number will be displayed in theXXX-XX-XXXX format for their patients. This is an example of the use of a: a. Wildcard b. Mask c. Truncation d. Data definition
B
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of: a. Identification and demographic integrity b. Authorship integrity c. Statistical integrity d. Auditing integrity
B
By querying the healthcare entity data, you find that patients admitted on a weekend have a mean length of stay that is 1.3 days longer than patients who are admitted Monday through Friday. This method of finding information is called: a. Structuring query language b. Data mining c. Multidimensional data structuring d. Satisficing
B
Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessingthe process must be included in this: a. Authorization b. Certificate of destruction c. Informed consent d. Continuity of care record
B
Every year, a director of health information services sponsors a series of presentations about the confidentiality of patient information. All facility employees are required to attend a session. This method of educational delivery is called: a. Career development b. In-service education c. On-the-job training d. Orientation
B
In a relational database, which of the following is an example of a many-to-many relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to hospital health records d. Primary care physician to patients
B
In the HIM department at Memorial Hospital, each newly hired coder spends an afternoon with a medical biller. The coder follows the biller around as they complete job tasks to get an idea of how coding and billing impact one another. This is an example of what type of on-the-job training? a. Job rotation b. Job shadowing c. Cross-training d. Coaching
B
In the data warehouse, the patient's last name and first name are entered into separate fields. This is an example of what? a. Query b. Normalization c. Key field d. Slicing and dicing
B
Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value report she received during her last physical exam. Dr. Ward responded to Jane's email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled? a. Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient's medical record. b. Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient's medical record. c. Since this is an email correspondence, it should be kept in a separate social media file within the health information management department. d. Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.
B
Kelly's husband is being transferred to a new position in another state. Kelly has to resign her position as director of HIM at Memorial Hospital, a job she has enjoyed for five years. This is an example of what type of employee turnover? a. Functional b. Voluntary c. Involuntary d. Separation
B
Mrs. Davis is preparing to undergo hernia repair surgery at Deaconess Hospital. Select the best statement of the following options. a. An employee from the hospital's surgery department should obtain Mrs. Davis' informed consent. b. The surgeon should obtain Mrs. Davis' informed consent. c. It does not matter who obtains Mrs. Davis' informed consent as long as it is documented in her medical record. d. Informed consent is not necessary because this is not major surgery.
B
Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith's health record? a. Data accuracy b. Data consistency c. Data accessibility d. Data comprehensiveness
B
Protected health information that is maintained in a designated record set can be accessed by the patient or other authorized party upon request. Covered entities must respond to requests within what timeframe after receipt of the request? a. 15 days b. 30 days c. 60 days d. 90 days
B
Strategic thinkers exhibit which of the following skills? a. Discomfort with uncertainty and risk b. The ability to gain a powerful core of healthcare entity supporters and customers c. Flexibility but lacking creativity d. An ability to implement the vision and plan and be uncomfortable with change
B
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following? a. Master data b. Metadata c. Structured data d. Unstructured data
B
The Breach Notification Rule requires covered entities to establish a process for investigating whether a breach has occurred and which of the following? a. Establish a new position for a Privacy Officer b. Notify affected individuals when a breach occurs c. Establish a policy on minimum necessary d. Notify the primary care physicians of all patients of the breach
B
The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a(n): a. Favorable variance of $2,000 b. Unfavorable variance of $2,000 c. Favorable variance of $23,000 d. Unfavorable variance of $23,000
B
The Kids' Foundation, a foundation related to Children's Hospital, is mailing fundraising information to the families of all patients who have been treated at Children's in the past three years. Based on the facts given: a. Children's Hospital violated the Privacy Rule by giving information to the foundation. b. Children's Hospital must have notified the patients or patients' guardians of this disclosure in the Notice of Privacy Practices. c. The Kids' Foundation cannot solicit donations from patients' families under any circumstances. d. The Kids' Foundation must request authorization from each patient or patient guardian to mail fundraising information out to their families.
B
The health information services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do? a. The manager should have each employee complete a serial work request. b. The manager should have each employee complete a work distribution chart. c. The manager should have the employees complete a use case analysis. d. The manager should develop a flow process chart.
B
What is the payment reduction for facilities that fail to successfully meet the requirements of Medicare's quality reporting programs? a. 1 percent reduction b. 2 percent reduction c. 3 percent reduction d. 4 percent reduction
B
Which of the following is a true statement about business process reengineering? a. It is intended to make small incremental changes to improve a process. b. It seeks to reevaluate and redesign organizational processes to make dramatic performance improvements. c. It implies making few changes to achieve significant improvements in cost, quality, service, and speed. d. Its main focus is to reduce services.
B
Which of the following would be considered an identifier under the Privacy Rule? a. Gender b. Vehicle license plate c. Blood pressure reading d. Temperature
B
Which of the following would likely be recorded on an information systems issues log? a. Alan is present every day there is a system test. b. Betty reported receiving 25 erroneous e-mail messages. c. Dr. Brown effectively uses e-prescribing. d. John requested a supply of tamperproof paper for his office.
B
A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm? a. Insomnia b. Hypertension c. Mental or behavioral problems d. Rheumatoid arthritis
C
A patient arrived via ambulance to the emergency department following a motor vehicle accident. The patient sustained a fracture of the ankle, a 3.0-cm superficial laceration of the left arm, a 5.0-cm laceration of the scalp with exposure of the fascia, and a concussion. The patient received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture requiring closed manipulative reduction, simple suturing of the arm laceration, and layer closure of the scalp. Provide CPT codes for the procedures performed in the emergency department for the facility bill. a. 27810, 12032 b. 27818, 12004, 12032-58 c. 27810, 12032, 12002-59 d. 27810, 12004
C
A physician performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy on his patient at Community Hospital. His office billed the following: Why was this claim rejected? a. Billed hysterectomy with wrong CPT code b. Not a covered procedure c. Unbundled procedures d. Covered procedure but insurance company requires additional information
C
A physician query may not be appropriate in which of the following instances? a. Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showingHaemophilus influenzae b. Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay c. Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis d. Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI
C
A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called: a. Training b. Job analysis c. Orientation d. Job rotation
C
According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary
C
At Medical Center Hospital, the master patient index system is not meeting facility needs. There are duplicate numbers and errors in patient identification information. The IS director replaces the system with a newer system from a different vendor. After several months, the new system is exhibiting many of the same problems as the old system, and the facility staff is frustrated and angry. What is the most likely cause of the problem? a. The new system has the same design flaws as the previous system. b. The old system was not properly disabled and has infected the new system. c. Underlying human and process problems were not identified and corrected prior to making a system change. d. Human error is the cause of all of the problems with both systems.
C
Dr. Collins admitted Mr. Smith to University Hospital. Blue Cross Insurance will pay Mr. Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Mr. Smith? a. Mr. Smith b. Blue Cross c. University Hospital d. Dr. Collins
C
Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughterwho was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25.Dr. Jones was the patient's physician. Of the options listed here, what is the best course of action? a. Allow Dr. Smith to see the records because he was the daughter's guardian at the time of the tonsillectomy. b. Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff. c. Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record. d. Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.
C
During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30 percent of the nursing home's population. This rate represents the: a. Distribution b. Frequency c. Incidence d. Prevalence
C
Given the information here, the case-mix index would be: a. 0.09 b. 0.6488 c. 0.8808 d. 88.08
C
In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed? a. Initial study b. Design c. Testing d. Operation
C
Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given: a. No information due to the highly sensitive nature of his illness b. Admission date and location in the facility c. General condition and acknowledgment of admission d. Location in the facility and diagnosis
C
Linda Wallace is being admitted to the hospital. She is presented with a Notice of Privacy Practices. In the Notice, it is explained that her PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes. Of the options listed here, what is the best course of action? a. The hospital must honor her wishes and not use her PHI for TPO. b. The hospital may decline to treat Linda because of her refusal. c. The hospital is not required to honor her wishes in this situation, as the Notice of PrivacyPractices is informational only. d. The hospital is not required to honor her wishes for treatment purposes but must honor them for payment and operations purposes.
C
Medical identity thefts are situations in which the following occurs: a. When health information on the wrong patient is put in the incorrect record b. When financial information is used to purchase nonmedical items c. When demographic and financial information is used to acquire medical services d. When demographic information is used to purchase nonmedical items
C
Once all data has been posted to patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have an internal auditing system that runs each claim through a set of edits. This internal auditing system is known as a: a. Chargemaster b. Superbill c. Scrubber d. Grouper
C
Pressed for time, Sara hired a new release of information clerk without doing a reference check. When the new clerk committed a violation of patient confidentiality, it came to light that she had committed similar violations at her previous place of employment. By not checking the clerk's references, Sara has opened the hospital to charge of: a. Discrimination b. Harassment c. Negligent hiring d. Overcompensation
C
Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room. a. Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule. b. Sally owns the information in her record, so she must be granted her request. c. Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record. d. Patients should never be given access to their actual medical records.
C
Sally is the HIM director at Memorial Hospital and has been asked to compose a record retention policy for the hospital. What should be her first consideration in determining how long paper and electronic records must be retained? a. The amount of space allocated for record filing and server set up b. The number of paper records currently filed and the number of electronic files added on a daily basis c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards d. The cost of filing space and equipment
C
Sarah, a coding manager, realizes that one of her long-term employees is experiencing a decrease in her coding quality. Sarah has counseled the employee several times and she has documented the issues and placed them in the employee's file. Sarah has been advised by her manager that she needs to initiate a performance improvement plan for the employee. The next step that Sarah needs to do is: a. Document performance issues b. Meet with the employee to review the performance improvement plan c. Develop an action plan incorporating SMART goals that will assist employee in achieving performance goals d. Review the performance improvement plan with the HIM manager and human resources
C
St. Joseph's Hospital has a psychiatric service on the sixth floor. A 31-year-old male came to the HIM department and requested to see a copy of his health record. He told the clerk he was a patient of Dr. Schmidt, a psychiatrist, and had been on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is: a. Prohibit the patient from accessing his record as it contains psychiatric diagnoses that may greatly upset him. b. Allow the patient to access his record. c. Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient. d. Deny access because HIPAA prevents patients from reviewing their psychiatric records.
C
The "custodian of health records" refers to the individual within a healthcare entity who is responsible for which of the following actions? a. Determining alternative treatment for the patient b. Preparing physicians to testify c. Testifying to the authenticity of records d. Testifying regarding the care of the patient
C
The Privacy Rule generally requires documentation related to its requirements to be retained: a. 3 years b. 5 years c. 6 years d. 10 years
C
The federal law that directed the Secretary of Health and Human Services (HHS) to develop healthcare standards governing electronic claims, national identifiers, the protection of privacy, and the assurance of the security of health information is the: a. Medicare Act b. Prospective Payment Act c. Health Insurance Portability and Accountability Act d. Social Security Act
C
The following data have been collected by the hospital quality council. What conclusions can be made from the data on the hospital's quality of care between the first and second quarters? Measure 1st Quarter 2nd Quarter Medication errors 3.2% 10.4% Patient falls 4.2% 8.6% Hospital-acquired infections 1.8% 4.9% Transfusion reactions 1.4% 2.5% a. Quality of care improved between the first and second quarters. b. Quality of care is about the same between the first and second quarters. c. Quality of care declined between the first and second quarters. d. Quality of care should not be judged by these types of measures.
C
The following information was abstracted from Community Hospital's balance sheet. A vendor selling a large dollar amount of goods to this hospital on credit would: a. Not be concerned because total assets exceed total liabilities b. Not be concerned because the debt ratio is less than one half c. Be somewhat concerned because the current ratio is less than one d. Not analyze the balance sheet because the vendor would care more about the income statement
C
The legal health record for disclosure consists of: a. Any and all protected health information data collected or used by a healthcare entity when delivering care b. Only the protected health information requested by an attorney for a legal proceeding c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings d. All of the data and information included in the HIPAA Designated Record Set
C
The slightly higher wage paid to an employee who works a less desirable shift is called a: a. Shift rotation b. Performance incentive c. Shift differential d. Work distribution ladder
C
What is the implication regarding the confidentiality of incident reports in a legal proceedingwhen a staff member documents in the health record that an incident report was completed abouta specific incident? 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.
C
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of current patients? a. Priority focus review b. Periodic performance review c. Tracer methodology d. Performance improvement
C
Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers? a. Healthcare Insurance Data Bank b. Medicare Protection Database c. National Practitioner Data Bank d. Healthcare Safety Database
C
Which of the following is not a characteristic of strategy? a. An action or set of actions b. A description of how one intends to achieve the goals c. A description of specific implementation plans d. A plan to improve the organization's fit within the external environment
C
Who has the legal right to refuse treatment? 1. Juanita who is 98 years old and sound mind. 2. Christopher who is 10 years old and sound mind. 3. Jane who is 35, incompetent, and didnt not express her treatment wishes prior to becoming incompetent. 4. Linda who is 35, incompetent, and created a living will prior to becoming incompetent stating that she did not wish to be kept alive by artificial means. 5. William who is a 35-year-old born with mental retardation and has the mental capacity of a 12 year old. a. 1 and 2 b. 1 and 3 c. 1 and 4 d. 4 and 5
C
You are a member of the hospital's Health Information Management Committee. The committee has created a HIPAA-compliant authorization form. Which of the following items does the Privacy Rule require for the form? a. Signature of the patient's attending physician b. Identification of the patient's next of kin c. Identification of the person or entity authorized to receive PHI d. Patient's insurance information
C
A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at a trial d. Bring records to a legal proceeding
D
Aaron's workspace is filled with notes posted to the walls regarding coding rules. He has even created file folders for coding tips according to body system. Aaron is most likely what type of sensory learner? a. Auditory b. Kinesthetic c. Tactile d. Visual
D
Community Hospital is evaluating the following three investments. Which one has the highest profitability index? a. Radiology investment b. Cardiology investment c. Pharmacy investment d. All three are equally profitable
D
Employees covered by the provisions of the Fair Labor Standards Act (FLSA) are called ________ employees. a. Waged b. Salaried c. Exempt d. Nonexempt
D
For the following excerpt from a patient satisfaction survey, determine if in the development of this survey the designer is adhering to good survey design principles. a. All survey design principles were applied in the development of this survey. b. The survey design principle of consistent format was applied in the development of this survey. c. The survey design principle of mutually exclusive categories was applied in the development of this survey. d. The survey design principles were not applied in the development of this survey.
D
Joe Smith, RHIA, works for an outsourcing company as interim health information department director in a large hospital. By the terms of the contract, the hospital pays the company for Joe's services based on a 40-hour workweek with overtime for any hours exceeding 40. Joe typically works 9 hours per day, Monday through Thursday, and 4 hours on Friday. He then flies home for the weekend. After several months, he discovers the hospital is billed for 44 to 48 hours per week almost every week. Joe confronts the company billing department because this practice conflicts with the tenet of the AHIMA Code of Ethics that states that health information management professionals: a. Respect the rights and dignity of all individuals b. Adhere to the vision, mission, and values of the association c. Promote and protect the confidentiality and security of health records and health information d. Refuse to participate in or conceal unethical practices or procedures
D
Pam is a nursing supervisor in the newborn intensive care unit. During her shift, several parents of newborns in the unit are visiting. The neonatologist has also recently been in and has provided orders for several of the newborns. Because of the current workload, another nurse in the unit, Jackie, has asked Pam to help her complete the orders. Pam is asked to administer a medication to one of the newborns that Jackie has already retrieved for the patient. Jackie tells Pam that she has double checked the medication both through bar coding and with the order. Before Pam administers the medication, she scans both the medication and the newborn's patient ID bandand learns that she has the incorrect medication for this patient. Pam does not administerthat medication but goes back to the order and, through the proper steps, administers the correct medication. Based on this scenario, which of the following occurred? a. Time-out b. Serious event c. Sentinel event d. Near miss
D
Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care: acute-care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled? a. Bills for each service from each physician, each facility, and each other healthcare provider from every encounter b. Bills for each service from each physician, each facility, and each other healthcare provider at the end of the 10-month period c. Consolidated billing for each encounter that includes the bills from all the physicians, facilities, and other healthcare providers involved in the encounter d. One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers
D
The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours. a. 30 days, 48 hours, 24 hours b. 14 days, 24 hours, 48 hours c. 14 days, 48 hours, 24 hours d. 30 days, 24 hours, 48 hours
D
The insured party's member identification number is an example of which type of data? a. Demographic data b. Clinical data c. Certification data d. Financial data
D
The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: a. Unbundling b. Billing for services not provided c. Medically unnecessary services d. Upcoding
D
The technology commonly utilized for automated claims processing (sending bills directly tothird-party payers) is: a. Optical character recognition b. Bar coding c. Neural networks d. Electronic data interchange
D
The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration is called: a. Secure messaging b. Consumer informatics c. Personalized medicine d. Telehealth
D
The user needs a list of all of the patients that were diagnosed a cerebral infarction or a cerebral hemorrhage. This is an example of a situation in which what type of search should be used? a. Structured query language b. Wildcard search c. Truncation d. Boolean search
D
Using the admission criteria provided, determine if the following patient meets the severity of illness and intensity of service criteria for admission. Sue presents with vaginal bleeding. An ultrasound showed a missed abortion so she is being admitted to the outpatient surgery suite for a D&C. a. The patient does not meet both severity of illness and intensity of service criteria. b. The patient does meet both severity of illness and intensity of service criteria. c. The patient meets intensity of service criteria but not severity of illness. d. The patient meets severity of illness criteria but not intensity of service.
D
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records? a. Administrative information b. Demographic information c. Progress notes d. Uniform data sets
D
When a patient collapses upon arrival at the entrance to an emergency department, what type of treatment authorization is in effect? a. Emergency consent b. Expressed consent c. Informed consent d. Implied consent
D
Which of the following is the unique identifier in the relational database patient table? Patient Table Patient # Patient Last Name Patient First Name Date of Birth a. Patient last name b. Patient last and first name c. Patient date of birth d. Patient number
D
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Abdominal pain b. Cholelithiasis c. Exploratory laparoscopy d. Ruptured appendix
A
An outpatient laboratory routinely mails the results of health screening exams to its patients. The lab has received numerous complaints from patients who have received another patient's health information. Even though multiple complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. How should the Privacy Officer for this healthcare entity respond to this situation? a. Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule b. Fire the responsible employees c. Do nothing, as these types of errors occur in every healthcare entity d. Retrain the entire hospital entity because these types of errors could result in a huge fine from the Office of Inspector General
A
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions): a. Resident Assessment Protocols (RAPs) b. Resident Assessment Instrument (RAI) c. Utilization Guidelines (UG) d. Minimum Data Sets (MDS)
A
The performance standard to "respond to release of information requests for continuing care in one working day 95 percent of the time" is an example of a: a. Qualitative standard b. Quantitative standard c. Joint Commission standard d. Compliance standard
A
What data model is most widely used to illustrate a relational database structure? a. Entity-relationship diagram (ERD) b. Object model c. Relational model d. Unified medical language system (UMLS)
A
You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use? a. Bar graph b. Histogram c. Line graph d. Pie chart
A
For which of the following situations would an audit log be useful? a. Holding an individual patient accountable for actions b. Reconstructing electronic events c. Defending the corporation against an IRS audit d. Stopping attacks from the intranet to the Internet
B
A community hospital looking to cut cost out of a vendor's proposal for health IT shouldconsider: a. Acquiring its own hardware b. Conducting process improvement in advance to improve return on investment c. Extending implementation over a longer period of time d. Writing its own software
B
A data breach occurred in your organization, and after the investigation it was determined that a total of 785 individuals were impacted by the data breach. What must be completed within 60 days of learning about the data breach? a. Update the notice of privacy practices and send to all patients b. Report the incident to the individuals impacted, local media, and the Department of Health and Human Services c. Conduct privacy training for members of the organization d. Document a note mentioning the data breach in each of the patients' charts and tell the local media
B
A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach? a. Access controls b. Device and media controls c. Facility access controls d. Workstation controls
B
A health information professional is preparing statistical information about the third-party payers that reimburse care in the facility. She finds the following information: Medicare reimburses 46 percent; Medicaid reimburses 13 percent; Blue Cross reimburses 21 percent; workers' compensation reimburses 1 percent; commercial plans reimburse 15 percent; and other payers or self-payers reimburse 4 percent. What is the best graphic tool to use to display this data? a. Histogram b. Pie chart c. Line graph d. Table
B
A possible justification for building an information system in-house rather than purchasing one from a vendor is that: a. It is cheaper to buy than to build b. The facility has development teams they do not want to give up c. Integration of systems will be easier d. Vendor products are not comprehensive enough
B
A requirements specification that lists what is needed from the vendor to support interoperability is necessary to: a. Create a checklist of user concerns about information systems b. Identify specific features and functions that must be in an information system c. Make a migration path for future phases of information systems d. Verify that an information system works as anticipated
B
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system? a. Context-based b. Role-based c. Situation-based d. User-based
B
HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors. But that information often is not shared with other departments within the healthcare entity. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems? a. Administration b. Registration or patient access c. Risk management d. Radiology and laboratory
B
If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? a. Survey sampling b. Systematic sampling c. Cluster sampling d. Stratified sampling
B
Training of staff on security practices at a healthcare organization is an example of this type of access safeguard, which is people-focused in nature: a. Technical b. Administrative c. Physical d. Addressable
B
Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINICcolumns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute PATIENT_MRN represent? a. It is the foreign key in PATIENT and the primary key in VISIT. b. It is the primary key in PATIENT and the foreign key in VISIT. c. It is the primary key in both PATIENT and VISIT. d. It is the foreign key in both PATIENT and VISIT.
B
What is the biggest problem with using mean length of stay as a facility statistic? a. It is not accurate. b. It is influenced by outlier values. c. It is mathematically incorrect. d. It is a dependent variable
B
Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care? a. Case management b. Minimum Data Set c. Outcomes and assessment information set d. Core measure abstracting
B
Which of the following materials are required elements in an emergency care record? a. Patient's instructions at discharge and a complete medical history b. Time and means of the patient's arrival, treatment rendered, and instructions at discharge c. Time and means of the patient's arrival, patient's complete medical history, and instructions at discharge d. Treatment rendered, instructions at discharge, and the patient's complete medical history
B
A healthcare organization must have a firewall in place to protect their health information system. Which of the following statements about a firewall is false? a. It is a system or combination of systems that supports an access control policy between two networks. b. The most common place to find a firewall is between the healthcare entity's internal network and the Internet. c. Firewalls are effective for preventing all types of attacks on a healthcare system. d. A firewall can limit internal users from accessing various portions of the Internet.
C
A hospital employee destroyed a health record so that its contents—which would be damaging to the employee—could not be used at trial. In legal terms, the employee's action constitutes: a. Mutilation b. Destruction c. Spoliation d. Spoilage
C
A hospital receives a valid request from a patient for copies of her medical 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. Yes, HIPAA only requires that current records be produced for the patient. b. Yes, this is hospital policy over which HIPAA has no control. c. No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. d. No, the records from the previous hospital are not included in the designated record set but should be released anyway.
C
Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a: a. Closed review b. Qualitative review c. Concurrent review d. Delinquent review
C
Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA Security Rule. What type of network uses a private tunnel through the Internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely? a. Intranet b. Local area network c. Virtual private network d. Wide area network
C
Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was: a. 0.05% b. 2% c. 5% d. 20%
C
Data that are collected on large populations of individuals and stored in a database without identifying any particular patient individually are referred to as: a. Statistics b. Accession data c. Aggregate data d. Standards
C
Decision-making and authority over data-related matters is known as: a. Data management b. Data administration c. Data governance d. Data modeling
C
The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called: a. Endorsement b. Confirmation c. Authentication d. Consent
C
What is the formatting problem in the following table? a. The variable names are missing b. The title of the table is missing c. The column headings are missing d. The column totals are inaccurate
C
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident? 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 discoverabledocument. d. The incident report cannot be discovered even though it is mentioned in a discoverabledocument.
C
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a: a. Case-mix index b. Master patient index c. Health record matrix d. Retention schedule
C
A patient has the right to request a(n) ________, which describes where the covered entity has disclosed patient information for the past six years outside of treatment, payment, and healthcare operations. a. Disclosure list b. Designated record set c. Amendment of medical record d. Accounting of disclosures
D
Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a: a. Case-mix index b. Master patient index c. Health record matrix d. Retention program
D
Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record? a. Integrated b. Practice-oriented c. Chronological d. Source-oriented
D
John is the privacy officer at General Hospital and conducts audit log checks as part of his job duties. What does an audit log check for? a. Loss of data b. Presence of a virus c. Successful completion of a backup d. Unauthorized access to a system
D
Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician? a. Closed communication b. Open communication c. Private communication d. Privileged communication
D
Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: a. Standardized data b. Codified data c. Aggregate data d. Unstructured clinical information
D
The data elements in a patient's automated laboratory result are examples of: a. Unstructured data b. Free-text data c. Financial data d. Structured data
D
Which legal doctrine was established by the Darling v. Charleston Community Hospital case of 1965? a. Hospital-physician negligence b. Clinical negligence c. Physician-patient negligence d. Corporate negligence
D
Which of the following conditions would most likely fall into the category of notifiable diseases as defined by the National Notifiable Diseases Surveillance System? a. Diabetes mellitus b. Coronary artery disease c. Fracture of major bones d. HIV infection
D
Which of the following is an acceptable means of authenticating a record entry? a. The physician's assistant electronically signs for the physician. b. The HIM clerk electronically signs using the physician's login. c. The charge nurse electronically signs for the physician. d. The physician personally signs the entry electronically.
D
