RHIT Practice Exam 1 - 150 Questions

A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used? Coder & Work Output Coder A: 500 Coder B: 480 Coder C: 300 Coder D: 360 a. 82 b. 156 c. 820 d. 1,550

a. 82 Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data. In this case, 82 records would be a sufficient number to review for coding quality. The calculation is: (500 × 0.05) + (480 × 0.05) + (300 × 0. 05) + (360 × 0.05) = 25 + 24 + 15 + 18 = 82 records OR (500 + 480 + 300 + 360) × 0.05 = 1640 × 0.05 = 82 records

To use a data element for aggregation and reporting, that data element must be: a. Abstracted or indexed b. Searched c. Subject to case finding d. Registered

a. Abstracted or indexed Abstracting is the process of extracting elements of data from a source document and entering them into an automated system. The purpose of this endeavor is to make those data elements available for later use. After a data element is captured in electronic form, it can be aggregated into a group of data elements to provide information needed by the user.

An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit controls c. Contingency controls d. Security incident controls

a. Access controls Establishing access controls is a fundamental security strategy. Basically, the term access Control means being able to identify which employees should have access to what data. The general practice is that employees should have access only to data they need to do their jobs. For example, an admitting clerk and a healthcare provider would not have access to the same kinds of data.

Which of the following is true regarding the development of health record destruction policies? a. All applicable laws must be considered b. The organization must find a way not to destroy any health records c. Health records involved in pending or ongoing litigation may be destroyed d. Only state laws must be considered

a. All applicable laws must be considered Not all information must be kept forever. Just as the HIM professional must consider multiple factors when determining retention, many factors must also be taken into consideration with regard to health record destruction. These include applicable federal and state statutes and regulations; accreditation standards; pending or ongoing litigation; storage capabilities; and cost.

How is the patient registration department assisted by the HIM department? a. Assigns the health record number b. Processes the healthcare claim c. Implements the information systems used by the HIM department d. Maintains the information systems used by the HIM department

a. Assigns the health record number The health record typically begins in patient registration with the capture of patient demographic information. The health record is assigned to new patients during the patient registration process. The HIM department works with patient registration to ensure the quality of the data collected and to correct duplicate and other issues with the MPI.

A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): a. Audit trail b. Facility access control c. Forensic scan d. Security management plan

a. Audit trail An audit trail is a record of system and application activity by users. It can track when an employee has accessed the system, the actions taken, and how long the employee has been logged into a system.

Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: a. By the hospital b. By the patient c. By the attending and consulting physician d. Jointly by the hospital, physician, and patient

a. By the hospital Health records, x-rays, laboratory reports, consultation reports, and other physical documents relating to the delivery of patient care are owned by the healthcare organization.

Continuing coding education is required for: a. Certified coders b. Inpatient coders c. All coders d. Inpatient and ambulatory surgery coders

a. Certified coders A well-trained coding staff helps ensure complete and accurate coding, which is essential for the integrity of the data collected. All coders in the facility should receive continuing education, but certified coders must demonstrate that they are continuing to maintain their knowledge and skill base. To maintain their certification, individuals must complete a designated set of continuing education units.

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

a. Code skin lesion 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.

What formatting problem is found in the following table? Community Hospital Admissions by Gender, 20XX Male 3,546 42.4 Female 4,825 57.6 Total 8,371 100 a. Column headings are missing b. Title of the table is missing c. Column totals are inaccurate d. Variable names are missing

a. Column headings are missing A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be organized into tables. Tables are useful for demonstrating patterns and other kinds of relationships. Tables need headings for columns and rows, and they need to be specific and understandable.

An alternative to the retrospective coding model is the __________ coding model in which records are coded while the patient is still an inpatient. a. Concurrent b. Analytical c. Prospective d. Auxiliary

a. Concurrent Concurrent coding is the type of coding that takes place in the hospital while the patient is still receiving care.

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations? a. Consultation b. Medical history c. Physical examination d. Progress notes

a. Consultation The consultation report documents the clinical opinion of a physician other than 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.

A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis? a. Dehydration b. Chemotherapy c. Liver carcinoma d. Complication of chemotherapy

a. Dehydration When the admission or encounter is for management of dehydration due to the malignancy and only the dehydration is being treated, the dehydration is sequenced first, followed by the code(s) for the malignancy.

What types of covered entity health records are subject to the HIPAA privacy regulations? a. Health records in any format b. Only health records in electronic format c. Only health records from hospitals d. Only health records in paper format

a. Health records in any format One of the most fundamental terms used in the Privacy Rule is protected health information (PHI). The Privacy Rule defines PHI as individually identifiable health information that is transmitted by electronic media, maintained in any electronic medium, or maintained in any other form or medium.

Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. Identification of the record as the one subpoenaed b. The care provided to the patient c. The qualifications of the treating physician d. Identification of the standard of care used to treat the patient

a. Identification of the record as the one subpoenaed Original health records may be required by subpoena to be produced in person and the custodian of records is required to authenticate those records through testimony.

Which of the following is the first step in analyzing data? a. Knowing your objectives or purpose of the data analysis b. Starting with basic types of data analysis and work up to more sophisticated analysis c. Utilizing a statistician to analyze the data d. Presenting your findings to administration

a. Knowing your objectives or purpose of the data analysis The first step in analyzing data is to know your objective or the purpose of the data analysis.

The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration

a. Laboratory As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected. This creates new challenges for organizations because merge functionality could be different in each system or module, which in turn creates data redundancy. When duplicates are identified, the department managers need to be notified. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare.

Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: a. Legitimate need for access b. Password to access the EHR c. Report development program d. Signed confidentiality agreement

a. Legitimate need for access The access controls standard requires implementation of technical procedures to control or limit access to health information. The procedures would be executed through some type of software program. This requirement ensures that individuals are given authorization to access only the data they need to perform their respective jobs.

Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching? a. Obliterating or deleting errors b. Leaving existing entries intact c. Labeling late entries as being late d. Ensuring the legal signature of an individual making a correction accompanies the correction

a. Obliterating or deleting errors To correct errors or make changes in the paper health record, a single line should be drawn in ink through the incorrect entry. The word error should be printed at the top of the entry along with a legal signature or initials, date, time, and discipline of the person making the change.

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 en

a. Notice of privacy practices is required on the first provision of service. 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.

Which of the following best represents the definition of the term data? a. Patient's laboratory value is 50. b. Patient's SGOT is higher than 50 and outside of normal limits. c. Patient's resting heartbeat is 70, which is within normal range. d. Patient's laboratory value is consistent with liver disease.

a. Patient's laboratory value is 50. Although sometimes used interchangeably, the terms data and information do not mean the same thing. Data represent the basic facts about people, processes, measurements, conditions, and so on. They can be collected in the form of dates, numerical measurements and statistics, textual descriptions, checklists, images, and symbols. After data have been collected and analyzed, they are converted into a form that can be used for a specific purpose. This useful form is called information. In other words, data represent facts and information represents meaning.

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond? 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

a. Provide the records in paper format only 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.

The clinical forms committee: a. Provides oversight for the development, review, and control of forms and computer screens b. Is responsible for the EHR implementation and maintenance c. Is always a subcommittee of the quality improvement committee d. Is an optional function for the HIM department

a. Provides oversight for the development, review, and control of forms and computer screens Every healthcare facility should have a clinical forms committee to establish standards for design and to approve new and revised forms. The committee should also have oversight of computer screens and other data capture tools.

What factor is medical necessity based on? a. The beneficial effects of a service for the patient's physical needs and quality of life b. The cost of a service compared with the beneficial effects on the patient's health c. The availability of a service at the facility d. The reimbursement available for a given service

a. The beneficial effects of a service for the patient's physical needs and quality of life Medical necessity is based on the effects of a service for the patient's physical needs and quality of life.

An employee views a patient's electronic health record. It is a trigger event if: a. The employee and patient have the same last name b. The patient was admitted through the emergency department c. The patient is over 89 years old d. A dietitian views a patient's nutrition care plan

a. The employee and patient have the same last name With appropriate policies and procedures in place, it is the responsibility of the organization and its managers, directors, CSO, and employees with audit responsibilities to review access logs, audit trails, failed logins, and other reports. One type of event that would be a trigger event would include employees viewing records of patients with the same last name or address of the employee.

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 individual's 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 wil

a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose 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.

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

a. The template was defined 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.

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record

a. Vital signs record The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information.

Recently, a local professional athlete was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine: 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. Whether access by employees is appropriate In order to maintain patient privacy certain audits may need to be completed daily. If a high profile patient is currently in a facility, for example, access logs may need to be checked daily to determine whether all access to this patient's information by workforce is appropriate.

The primary goals of __________ are to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. a. the National Health Information Network b. the National Committee on Vital and Health Statistics c. Health Level Seven (HL7) International d. the EHR Collaborative

a. the National Health Information Network The National Health Information Network is a group of federal agencies and no-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2? a. 240 b. 242 c. 280 d. 320

b. 242 A unit of measure that reflects the services received by one inpatient during a 24-hour period is called an inpatient service day. The number of inpatient service days for a 24-hour period is equal to the daily inpatient census—that is, one service day for each patient treated. The calculation is: [(250 + 30) − 40] + 2 = 242 [(patients at midnight on May 1 + patients admitted on May 2) - discharged patients] + patient deaths = total number of inpatient days for May 2

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? a. 30 b. 31.5 c. 32 d. 35

b. 31.5 The median is the midpoint of a frequency distribution. It is the point at which 50 percent of observations fall above and 50 percent fall below. If an even number of observations is in the frequency distribution, the median is the midpoint between the two middle observations. It is found by averaging the two middle scores, (x + y) / 2. In the example, the median is 31.5: ([30 + 33] / 2) Data set in order from least to greatest: 11, 20, 30, 30, 33, 35, 47, 50

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 - Lapa

b. 58670 No mention is made of biopsy, excision of lesion, or occlusion, so following proper steps for coding in CPT, the correct code is 58670.

Which of the following individuals may authorize release of health information? a. An 86-year-old patient with a diagnosis of advanced dementia b. A married 15-year-old father c. A 15-year-old minor d. The parents of an 18-year-old student

b. A married 15-year-old father Emancipated minors generally may authorize the access and disclosure of their own PHI. If the minor is married or previously married, the minor may authorize the disclosure or use of his or her information. If the minor is under the age of 18 and is the parent of a child, the minor may authorize the access and disclosures of his or her own information as well as that of his or her child.

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Call the Joint Commission and notify them of non-compliant physicians b. Consult with the medical director who has authori

b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices A coding manager or physician champion should present documentation issues to educate the medical staff. General areas of concern regarding documentation should be included.

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: a. Data comprehensiveness b. Data consistency c. Data currency d. Data granularity

b. Data consistency Consistency means ensuring the patient data is reliable and the same across the entire patient encounter. In other words, patient data within the record should be the same and should not contradict other data also in the patient record.

When data has been lost in an EHR, which action is taken to remedy this problem? a. Build a firewall b. Data recovery c. Review the audit trail d. Develop data integrity plan

b. Data recovery Data recovery is the process of recouping lost data or reconciling conflicting data after the system fails. These data may be from events that occurred while the system was down or from backed-up data.

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record

b. Delinquent record When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards.

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? a. Alert the Joint Commission that the hospital has not met its quality goal b. Determine whether there was a medical or other reason why

b. Determine whether there was a medical or other reason why patients were not given aspirin Patient care outcomes are reviewed to improve the safety and quality of care as well as to identify issues related to medical necessity for treatment and appropriateness of care. Accrediting and licensing entities expect that healthcare organizations will choose appropriate measures for the services they offer. In this situation is it important to determine whether there was a medical or other reason why patients were not given aspirin within 24 hours of arrival at the hospital. This determination is critical to assess compliance with the quality goal.

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

b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records 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.

In designing an input screen for an EHR, which of the following would be best to capture structured data? a. Speech recognition b. Drop-down menus c. Natural language processing d. Document imaging

b. Drop-down menus Structured data are data that are able to be read and interpreted by a computer. Examples of structured data include check boxes, drop-down boxes, and radio buttons.

Patient care managers use the data documented in the health record to: a. Determine the extent and effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care

b. Evaluate patterns and trends of patient care Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place.

A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which 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

b. Identify data content requirements for all areas of the organization 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.

Which of the following statements is true regarding HIPAA security? a. All institutions must implement the same security measures. b. Institutions are allowed flexibility in the way they implement HIPAA standards. c. All institutions must implement all HIPAA specifications. d. A security risk assessment must be performed every year.

b. Institutions are allowed flexibility in the way they implement HIPAA standards. HIPAA allows a covered entity to adopt security protection measures that are appropriate for its organization as long as they meet the minimum HIPAA security standards. Security protections in a large medical facility will be more complex than those implemented in a small group practice.

Which of the following is considered the authoritative resource in locating a health record? a. Disease index b. Master patient index c. Patient directory d. Patient registry

b. Master patient index (MPI) The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information.

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family conditions? a. Problem list b. Medical history c. Physical examination d. Clinical observation

b. Medical history 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.

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Minimum data set for long-term care b. Outcomes and Assessment Information Set c. Patient assessment instrument d. Resident assessment protocol

b. Outcomes and Assessment Information Set (OASIS-C) Medicare-certified home healthcare uses a standardized patient assessment instrument called the Outcomes and Assessment Information Set (OASIS-C). OASIS-C items are components of the comprehensive assessment that is the foundation for the plan of care

An HIM technician was alerted by registration that the system has a record for John Smith with two different birthdates. After an investigation the technician determined the documentation was for two different patients, both named John Smith, who have the same health record number in the EHR. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge

b. Overlay An issue with 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.

A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be: a. Normal delivery b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa In cases of a cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient's admission. If the patient was admitted with a condition that resulted in the performance of the cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission or encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission or encounter should be selected as the principal diagnosis even if a cesarean was performed.

Sometimes data do not follow a normal distribution and are pulled toward the tails of the curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it is called a __________. a. Negatively skewed distribution b. Positively skewed distribution c. Bimodal distributio

b. Positively skewed distribution When the tail is pulled toward the right side, it is called a positively skewed distribution; when the tail is pulled toward the left side of the curve it is called a negatively skewed distribution.

A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is: a. K21.9, Gastro-esophageal reflux disease without esophagitis b. R07.9, Chest pain, unspecified c. R10.11, Right upper quadrant pain d. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out

b. R07.9, Chest pain, unspecified Because this patient was seen only in the emergency department, he or she would be classified as an outpatient. Diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms in the outpatient setting indicate uncertainty and would not be coded as if existing. Rather, code the condition to the highest degree of certainty for that encounter or visit, such as signs, symptoms, abnormal test results, or other reason for the visit. In this case, unspecified chest pain would be coded.

Which of the following is true about health information retention? a. Retention depends only on accreditation requirements b. Retention periods differ among healthcare facilities c. The operational needs of a healthcare facility cannot be considered d. Retention periods are frequently shorter for health information about minors

b. Retention periods differ among healthcare facilities The HIM professional must consider multiple factors when developing health record retention policies that determine how long health records are to be kept. These factors include applicable federal and state statutes and regulations; accreditation standards; operational needs of the organization; and the type of organization, thus retention policies differ among healthcare facilities.

To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to ensure the history and physicals are present c. Retrospectively review ea

b. Review each patient's health record concurrently to ensure the history and physicals are present. The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital.

Which tool is used to display performance data over time? a. Status process control chart b. Run chart c. Benchmark d. Time ladder

b. Run chart A run chart displays data points over a period of time to provide information about performance. The measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time.

Which of the following is true regarding the reporting of communicable diseases? a. They must be reported by the patient to the health department. b. The diseases to be reported are established by state law. c. The diseases to be reported are established by HIPAA. d. They are never reported because it would violate the patient's privacy.

b. The diseases to be reported are established by state law. All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department.

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

b. The legal health record may contain metadata 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.

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a w

b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice. The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is to not interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure, and therefore, allowed in the Privacy Rule.

Copies of personal health records (PHRs) are considered part of the legal health record when: a. Consulted by the provider to gain information on a consumer's health history b. Used by the organization to provide treatment c. Used by the provider to obtain information on a consumer's prescription history d. Used by the organization to determine a consumer's DNR status

b. Used by the organization to provide treatment Organizational policy should address how personal health information provided by the patient will or will not be incorporated into the patient's health record. Copies of personal health records (PHRs), created, owned, and managed by the patient, are considered part of the legal health record when the organization uses them to provide treatment; however, the PHR does not replace the legal health record.

Based on this output table, what is the average coding test score for the beginner coder? Coding Test Score: Coder Status /Mean / N / Standard Deviation Advanced / 93.0000 / 3 / 5.00000 Intermediate / 89.5000 / 2 / 0.70711 Beginner / 73.3333 / 3 / 6.42910 Total / 84.7500 / 8 / 10.51190 a. 93 b. 6.4 c. 73 d. 90

c. 73 Since the mean is the average and the value next to the "beginner" under coder status is 73.3333, round the value to a whole number and the best answer is 73.

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

c. Aggregate data 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.

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 fol

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

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

c. Conditions of Participation 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.

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Determine that a formal

c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned The HIPAA Privacy Rule requires the covered entity to have business associate agreements in place with each business associate. This agreement must always include provisions regarding destruction or return of protected health information (PHI) upon termination of a business associate's services. Upon notice of the termination, the covered entity needs to contact the business associate and determine if the entity still retains any protected health information from, or created for, the covered entity. The PHI must be destroyed, returned to the covered entity, or transferred to another business associate. Once the PHI is transferred or destroyed, it is recommended that the covered entity obtain a certification from the business associate that either it has no PHI, or all PHI i

For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it: a. Contains only Medicare data b. Is used to determine pay for performance c. Contains data on all payer types d. Contains bibliographic listings from medical journals

c. Contains data on all payer types Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that are unique because they include data on inpatients whose care is paid for by all types of payers, including Medicare, Medicaid, private insurance, self-paying, and uninsured patients. Data elements include demographic information, information on diagnoses and procedures, admission and discharge status, payment sources, total charges, length of stay, and information on the hospital or freestanding ambulatory surgery center.

Which of the following is a risk of copy and pasting documentation in the electronic health record? a. Reduction in the time required to document b. System may not save data c. Copying the note in the wrong patient's record d. System thinking that the information belongs to the patient from whom the content is being copied

c. Copying the note in the wrong patient's record In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes propagation of false information in the record.

When coding a benign neoplasm of skin of the left upper eyelid, which of the following codes should be used? D23 - Other benign neoplasms of skin D23.0 - Other benign neoplasm of skin of lip D23.1 - Other benign neoplasm of skin of eyelid, including canthus D23.10 - Other benign neoplasm of skin of unspecified eyelid, including canthus D23.11 - Other benign neoplasm of skin of right eyelid, including canthus D23.111 - Other benign neoplasm of skin of right upper eyelid, including canth

c. D23.121 When subcategory codes are provided, they must be used. Codes are to be assigned to the highest level of specificity based on provider documentation. In this situation, code D23.121 is the most specific code for this diagnosis.

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? a. Reprimand the employee b. Terminate the employee c. Determine what information was printed and why d. Revoke the employee's access privileges

c. Determine what information was printed and why Audit trails are usually examined by system administrators who use special analysis software to identify suspicious or abnormal system events or behavior. Because the audit trail maintains a complete log of system activity, it can also be used to help reconstruct how and when an adverse event or failure occurred.

The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management

c. Federal and state confidentiality laws Release of information (ROI) is the process of providing PHI access to individuals or entities that are deemed to be authorized to either receive or review it. Protecting the security and privacy of patient information is one of a healthcare organization's top priorities, and the HIM department is usually responsible for determining appropriate access to and ROI from patient health records. Knowledge of state and federal confidentiality laws is critical to the ROI function.

What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? a. Risk management analysis b. Qualitative analysis c. Gap analysis d. Document management analysis

c. Gap analysis The gap analysis process compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis. Once complete, the HIM professional would analyze the data and develop a plan for correction.

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

c. Identify unbundling of codes 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.

The accounts not selected for the billing report is a daily report 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

c. In bill hold or in error and awaiting billing 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 .

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

c. It is the record disclosed upon request 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.

Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located. a. Accreditation b. Certification c. Licensure d. Permission

c. Licensure Licensure is the state's act of granting a healthcare organization or individual practitioner the right to provide healthcare services of a defined scope in a limited geographic area. It is illegal in all 50 states to operate healthcare facilities and practice medicine without a license.

Which of the following is an example of a physical safeguard that should be provided for in a data security program? a. Using password protection b. Prohibiting the sharing of passwords c. Locking computer rooms d. Annual employee training

c. Locking computer rooms Physical safeguards refer to the physical protection of information resources from physical damage, loss from natural or other disasters, and theft. This includes protection and monitoring of the workplace, computing facilities, and any type of hardware or supporting information system infrastructure such as wiring closets, cables, and telephone and data lines. To protect from intrusion, there should be proper physical separation from the public. Doors, locks, audible alarms, and cameras should be installed to protect particularly sensitive areas such as data centers.

A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical lab

c. Medication administration record and clinical laboratory reports Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed.

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

c. PHI sent to a physician who has not treated Sally 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.

The first step in an inpatient record review is to verify correct assignment of the: a. Record sample b. Coding procedures c. Principal diagnosis d. MS-DRG

c. Principal diagnosis To begin the review, the coding supervisor checks the inpatient health record to ensure that the diagnosis billed as principal meets the official Uniform Hospital Discharge Data Set (UHDDS) definition for principal diagnosis. The principal diagnosis must have been a principal reason for admission, and the patient received treatment or evaluation during the stay. When several diagnoses meet all of those requirements, any of them could be selected as the principal diagnosis.

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

c. Privacy In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information.

Carolyn works as an inpatient coder in a hospital HIM department. She views a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? a. Assign a code for the staph infection b. Put a note in the chart c. Query the physician d. Tell her supervisor

c. Query the physician As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries may be made in situations where there are clinical indicators of a diagnosis but no documentation of the condition.

A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? a. Review the subpoena to determine what documents must be produced b. Review the subpoena and notify the hospital administrator c. Review the subpoena and appear at the time and place supplied to give testimony d. Review the subpoena and alert the hospital's risk management department

c. Review the subpoena and appear at the time and place supplied to give testimony Sometimes HIM professionals are subpoenaed to testify as to the authenticity of the health records by confirming that they were compiled in the normal course of business and have not been altered in any way. A subpoena that is issued to elicit testimony is a subpoena ad testificandum.

Which of the following is a secondary purpose of the health record? a. Support for provider reimbursement b. Support for patient self-management activities c. Support for research d. Support for patient care delivery

c. Support for research Healthcare is a sophisticated industry and information from the health record is used for many purposes not related specifically to patient care. These secondary purposes include support for public health and research.

An external security threat can be caused by which of the following? a. Employees who steal data during work hours b. A facility's water pipes bursting c. Tornadoes d. The failure of a facility's software

c. Tornadoes All threats can be categorized as either internal threats (threats that originate within an organization) or external threats (threats that originate outside an organization). People are not the only threats to data security. Natural disasters such as earthquakes, tornadoes, floods, and hurricanes can demolish physical facilities and electrical utilities.

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578 - Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580 - Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subc

d. 36582 A complete replacement of the entire device by the same venous access site is being performed. It is a tunneled catheter inserted within the same venous access point. Code 36582 is the correct code.

Community Hospital's HIM department conducted a random sample of 200 inpatient health records to determine the timeliness of the history and physicals completion. Nine records were found to be out of compliance with the 24-hour requirement. Which of the following percentages represents the H&P timeliness rate at Community Hospital? a. 4.5% b. 21.2% c. 66.7% d. 95.5%

d. 95.5% A complete history and physical report represents the attending physician's assessment of the patient's current health status, and accreditation standards require it to be completed within 24 hours of admission. In this case, 191 instances of timely H&Ps out of 200 sampled is 95.5% accuracy. The calculation is (191/200) × 100 = 95.5%

Which of the following is an example of how an internal user utilizes secondary data? a. State infectious disease reporting b. Birth certificates c. Death certificates d. Benchmarking with other facilities

d. Benchmarking with other facilities Internal users of secondary data are individuals located within the healthcare facility. For example, internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities.

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

d. Case finding 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, such as cancer in the case of a cancer registry.

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

d. Cooperating Parties 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.

The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a: a. Data chargemaster report b. Data dictionary c. Database management system d. Data map

d. Data map Data mapping is a process that allows for connections between two systems. For example, mapping two different coding systems to show the equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose.

What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived

d. Derived Derived data consist of factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients. These data should have the same level of confidentiality as the legal health record.

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? Payer/Charges/Payments/Adjustment/Charges/Payments BCBS/$450,000/$360,000/$90,000/23%/31%/12% Commercial/$250,000/$200,000/$50,000/13%/17%/6% Medicaid/$350,000/$75,000/$275,000/18%/6%/36% Medicare $750,000 $495,000 $255,000 39% 42% 33% TRICARE/$150,000/$50,000/$100,000/7%/4%/13% Total/$1,950,000/$1,180,000/$770,000/100%/100% a. BC/BS b. Commercial c. TRICARE d. Medicare

d. Medicare In the "Payments" column, Medicare has the highest payment percentage (42 percent) of any of the payers; therefore, Medicare contributes more to the hospital's overall payments

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? a. Two CPT codes, one for each laceration b. One CPT code for the largest laceration c. One CPT code for the most complex closure d. One CPT code, adding the lengths of the lacerations together

d. One CPT code, adding the lengths of the lacerations together The length of multiple laceration repairs located in the same classification are added together and one code is assigned.

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 years old b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed

d. Present an authorization that at least one of them (Ted or Mary) has signed Because minors are, as a general rule, legally incompetent and unable to make decisions regarding the use and disclosure of their own health information, this authority belongs to the minor's parent(s) or legal guardian(s) unless an exception applies. Because privacy, security, and confidentiality of minor records are extremely regulated, HIM professionals should also consult state regulations or legal counsel for specific questions. Generally, only one parent signature is required to authorize the use or disclosure of the minor's PHI.

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance. Bar graph showing volume of procedures performed with the approximate values of: Procedure 1: 990 Procedure 2: 300 Procedure 3: 340 Procedure 4: 960 Procedure 5: 350 Procedure 6: 40 Procedure 7: 60 Procedure 8: 340 a. Procedures 1, 4 b. Procedures 2, 3, 5 c. Procedures 6, 7 d. Procedures

d. Procedures 1, 4, 6, 7 Performance measurement in healthcare provides an indication of an organization's performance in relation to a specified process or outcome. Healthcare performance improvement philosophies most often focus on measuring performance in the areas of systems, processes, and outcomes. Outcomes should be scrutinized whether they are positive and appropriate or negative and diminishing.

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

d. Provide copies of the records within 60 days 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.

How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met

d. To determine whether standards of care are being met Every participating healthcare organization is subject to a periodic accreditation survey. Surveyors visit each facility and compare its programs, policies, and procedures to a prepublished set of performance standards. A key component of every accreditation survey is a review of the facility's health records. Surveyors review the documentation of patient care services to determine whether the standards for care are being met.

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? a. CARF b. DEEDS c. UACDS d. UHDDS

d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient.

Which of the following is true about a primary key in a database table? a. Usually is not a unique number b. Changes in value c. Is dependent on the data in the table d. Uniquely identifies each row in a table

d. Uniquely identifies each row in a table Primary keys ensure that each row in a table is unique. A primary key must not change in value. Typically, a primary key is a number that is a one-up counter or a randomly generated number in large databases. A number is used because a number processes faster than an alphanumeric character. In large tables, this makes a difference. In the PATIENTS table, the PATIENT_ID is the primary key. It is good programming practice to create a primary key that is independent of the data in a table.

Which of the following is a key characteristic of the problem-oriented health record? a. Allows all providers to document in the health record b. Uses laboratory reports and other diagnostic tools to determine health problems c. Provides electronic documentation in the health record d. Uses an itemized list of the patient's past and present health problems

d. Uses an itemized list of the patient's past and present health problems The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems.

Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: a. Content and structure standards b. Security standard c. Transaction standards d. Vocabulary standards

d. Vocabulary standards Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field, such as to provide consistent descriptions of medical terms for an individual's condition in the health record.

As part of your job responsibilities, you are responsible for reviewing audit trails of access to patient information. The following are all types of activities that you would monitor except: 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

d. Whether the patient setup an account in the patient portal 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.