RHIT Practice Exam 2

Given the information here, which of the following MS-DRGs would have the highest payment rate? a. 191 b. 192 c. 193 d. 194

193 MS-DRG 193 has the highest weight and therefore would have the highest payment (Casto and White 2021, 73-74 ).

Community Hospital's physicians have requested the ability to access the EHR from their offices and from home. What advice should the HIM director provide? a. HIPAA regulations do not allow this type of access. b. This access would be covered under the release of PHI for treatment purposes and poses no security or confidentiality threats. c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. d. Access can be permitted because the physicians are on the medical staff of the hospital and are covered by HIPAA as employees.

Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. The HIPAA Privacy Rule permits healthcare providers to access protected health information for treatment purposes. However, there is also a requirement that the covered entity provide reasonable safeguards to protect the information. These requirements are not easy to meet when the access is from an unsecured location, although policies, medical staff bylaws, confidentiality or other agreements, and a careful use of new technology can mitigate some risks (Thomason 2013, 46).

In which type of distribution are the mean, median, and mode equal? a. Bimodal distribution b. Simple distribution c. Nonnormal distribution d. Normal distribution

Normal distribution The normal distribution is where data follows a symmetrical curve. The normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. In a normal distribution, the mean, median, and mode are equal (Williamson 2020, 408-409).

Clinical documentation systems that support clinical decision-making capture data via which of the following? Alerting programs Digital dictation Scanned images Templates

Templates Structured data are required for a CDS system; hence, templates guide collection of the structured data. Digital dictation and scanned images do not yield structured data for subsequent processing in a CDS system. Alerting programs are one of (many) functions of a CDS system (Bowe and Williamson 2020, 368-369).

If an employee produces 2,080 hours of work in the course of one year, how many employees will be required for the coding area if the coding time on average for one record is 30 minutes and there are 12,500 records that must be coded each year? a. 3 b. 6 c. 36 d. 69

a. 3 The number of records per FTE is 2 (number of records per hour) × 2,080 = 4,160. Therefore, three employees per year are required: 12,500 / 4,160 = 3.0 (Prater 2020, 626).

A coding compliance manager is reviewing a tool that identifies when a user logs in and out, what he or she does, and more. What is the manager reviewing? a. Audit trail b. Facility access control c. Forensics d. Security management plan

a. Audit trail Audit trails are a recording of activities occurring in an information system. Audit trails can monitor system level controls such as log-in, log-out, unsuccessful log-ins, print, query, and other actions. It also records user-identification information and the date and time of the activity. Audits should be scheduled periodically, but can also be performed when a problem is suspected (Sayles and Kavanaugh-Burke 2021, 297-298).

The hospital-acquired infection rate for our hospital is 0.2%, whereas the rate at a similar hospital across town is 0.3%. This is an example of a: a. Benchmark b. Check sheet c. Data abstract d. Run chart

a. Benchmark A benchmark is a systematic comparison of one organization's measurement characteristics to those of another similar organization. When an organization compares its current performance to its own internal historical data, or uses data from similar external organizations, it helps establish an organization benchmark (Carter and Palmer 2020, 558).

A PI team is concerned with the time it is taking for patients to get through the registration process. To better understand the causes or reasons for the delay in this process the PI team would like to gather observational data. What data collection tool would be appropriate for this team to develop for their observation data? a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool

a. Check sheet A check sheet is used to gather data based on sample observations in order to detect patterns. When preparing to collect data, a team should consider the four W questions: Who will collect the data? What data will be collected? Where will the data be collected? When will the data be collected? (Shaw and Carter 2019, 72-73).

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management, intubation b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management

a. Congestive heart failure, respiratory failure, ventilator management, intubation CHF is the principal diagnosis and must be sequenced first as shortness of breath is a symptom of CHF, and the respiratory failure is a result of the CHF. The principal diagnosis is the reason for the admission to the hospital after study (Schraffenberger and Palkie 2022, 95).

Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS

a. DEEDS Data Elements for Emergency Department Systems (DEEDS) is a data set to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records. Because DEEDS is based on emergency department records it would be helpful in developing a trauma registry (Brinda 2020, 156).

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

a. Data dictionary

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors is called: a. Data mining b. Data warehouse c. Data searching d. Big data

a. Data mining Data mining is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors (Bowe and Williamson 2020, 369).

A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as: a. Data precision b. Data consistency c. Data granularity d. Data comprehensiveness

a. Data precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For example, a precise data definition related to gender would include three values: male, female, and unknown (Brinda 2020, 180).

Dr. Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? a. Disease index b. Master patient index c. Operative index d. Physician index

a. Disease index A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period (Sharp 2020, 200-201).

Community Hospital provides voice recognition services for office notes of the private patients of physicians. All these physicians have medical staff privileges at the hospital. This is an essential service to the physicians and will provide additional revenue for the hospital. Which of the following should the hospital HIM director advise in order to comply with HIPAA regulations? a. Each physician practice should obtain a business associate agreement with the hospital. b. The hospital should obtain a business associate agreement with each physician practice. c. Because the physicians all have medical staff privileges, no business associate agreement is necessary. d. Because the physicians are part of an Organized Health Care Arrangement with the hospital, no business associate agreement is necessary.

a. Each physician practice should obtain a business associate agreement with the hospital. If physicians were to dictate information regarding patients they are treating in the facility, the disclosure of protected health information within the voice recognition system would be considered healthcare operations and, therefore, permitted under the HIPAA Privacy Rule. If physicians, who are separate covered entities, are dictating information on their private patients, however, it would be necessary for physicians to obtain a business associate agreement with the facility. It is permitted by the Privacy Rule for one covered entity to be a business associate of another covered entity (Thomason 2013, 26).

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

a. Enterprise master patient index (EMPI) The EMPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility. When a healthcare enterprise is more than one facility and the patient is seen at two or more places, the enterprise master patient index (EMPI) links the patient's information at the different facilities (Sayles 2020b, 71).

With regard to training in PHI policies and procedures: a. Every member of the covered entity's workforce must be trained. b. Only individuals employed by the covered entity must be trained. c. Training only needs to occur when there are material changes to the policies and procedures. d. Documentation of training is not required.

a. Every member of the covered entity's workforce must be trained. Every member of the covered entity's workforce must be trained in PHI policies and procedures to maintain the privacy of patient information, uphold individual rights guaranteed by the Privacy Rule, and report alleged breaches and other Privacy Rule violations (Rinehart-Thompson 2020b, 273).

Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Health information management b. Patient access c. Patient accounts d. Utilization management

a. Health information management Resolving failed edits is one of many duties of the health information management (HIM) department. Various hospital departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Casto and White 2021, 167-168).

When an individual requests a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may: a. Impose a reasonable cost-based fee b. Not charge the individual c. Impose any fee authorized by state statute d. Charge only for the cost of the paper on which the information is printed

a. Impose a reasonable cost-based fee HIPAA gives individuals the right to request access to their PHI, but the covered entity may require that requests be in writing. HIPAA allows a reasonable cost-based fee when the individual requests a copy of PHI or agrees to accept summary or explanatory information (Rinehart-Thompson 2020b, 255).

Which of the following is an argument against the use of the copy and paste function in the EHR? a. Inability to identify the author b. Inability to print the data out c. The time that it takes to copy and paste the documentation d. The users will not know how to perform the copy and paste function

a. Inability to identify the author 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 the inability to identify the author of the documentation (Sayles 2020b, 82).

Which of the following is true about information assets? a. Information considered to add value to an organization b. Data entered into a patient's health record by a provider c. Clearly defined elements required to be documented in the health record d. A list of all data elements added within a record

a. Information considered to add value to an organization Information assets refer to the information collected during the day-to-day operations of a healthcare organization that has value within an organization. For example, patient data collected to support patient care is an example of information assets for the organization (Brinda 2020, 166).

Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed. K20.90 Esophagitis, unspecified without bleeding K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding K21.9 Gastro-esophageal reflux disease without esophagitis a. K21.9, 0DB58ZX b. K20.90, 0DB58ZZ c. K21.00, 0DB58ZX d. K21.9, 0DJ08ZZ, 0DB58ZX

a. K21.9, 0DB58ZX The patient has esophageal reflux with no esophagitis mentioned, so K21.9 is the correct diagnosis code. For the ICD-10-PCS procedure code, a closed biopsy of the esophagus was performed via esophagoscopy, so 0DB58ZX is the correct code. The Section is Medical and Surgical—character 0; Body System is Gastrointestinal—character D; Root Operation is Excision—character B; Body Part is Esophagus—character 5; Approach—Via Natural or Artificial Opening Endoscopic—character 8; No Device—character Z; and the procedure was for diagnostic reasons (biopsy)—character X (Schraffenberger and Palkie 2022, 43-44; Kuehn and Jorwic 2021, 27-29, 72-73).

Which of the following would be considered a security vulnerability? a. Lack of laptop encryption b. Workforce employees c. Tornado d. Electrical outage

a. Lack of laptop encryption A security threat is anything that can exploit a security vulnerability. Vulnerability is a weakness or gap in security protection. In this situation the lack of encryption for the laptop would be considered a security vulnerability as the contents could be more easily accessed (Johns 2015, 219).

A patient has liver metastasis due to adenocarcinoma of the rectum. The rectum was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is: a. Liver metastasis b. Adenocarcinoma of the rectum c. Anemia d. Admission for radiotherapy

a. Liver metastasis When an admission or encounter is for the management of anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced first as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as D63.0, Anemia in neoplastic disease) according to ICD-10-CM Coding Guideline I.C.2.c.1 (Schraffenberger and Palkie 2022, 147-148).

Which of the following represents the required documentation elements needed to be included in a patient's health record when a surgical procedure is performed? a. Operative report, anesthesia report, recovery room report b. Discharge summary, anesthesia report, operative report c. Recovery room report, physical therapy notes, operative report d. Operative report, discharge summary, anesthesia report

a. Operative report, anesthesia report, recovery room report Any surgical procedure requires special documentation. The entire process is recorded with an anesthesia report, operative report, and recovery room report (Brickner 2020a, 108-109).

A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst include in the database? a. Patient date of birth b. Name of attending physician c. Patient room number d. Admitting diagnosis

a. Patient date of birth In the context of healthcare, demographic information includes the following elements: patient's full name; patient's facility identification or account number; patient's address; patient's telephone number; patient's date and place of birth; patient's gender; patient's race or ethnic origin; patient's marital status; name and address of patient's next of kin; date and time of admission; hospital's name, address, and telephone number (Sayles 2020b, 70).

Physician orders for DNR should be consistent with: a. Patient's advance directive b. Patient's bill of rights c. Notice of privacy practices d. Authorization for release of information

a. Patient's advance directive An advanced directive is a written document that provides directions about a patient's desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not capable of communication. Physician orders for do not resuscitate (DNR) should be consistent with the patient's advanced directives (Selman-Holman 2017, 377).

Which of the following individuals assists in educating medical staff members on the documentation needed for accurate coding? a. Physician champion b. Compliance officer c. Chargemaster coordinator d. Data monitor

a. Physician champion The health information manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion. Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement (Hess 2015, 123).

Community Hospital has a storage facility with older records that must be retained to meet retention laws and guidelines. The HIM professional has been tasked with removing health records from an associated clinic of patients who have not been treated for a specific period of time and sending those records to the storage area. This process is called: a. Purging records b. Assembling records c. Logging records d. Cycling records

a. Purging records Files of patients who have not been at the facility for a specified period, may be purged or removed and sent to the storage facility (Sayles 2020b, 74).

In reviewing a patient chart, the coding professional finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coding professional take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results. b. Code the COPD because the documentation substantiates it. c. Query the radiologist to determine whether the patient has COPD. d. Assign a code from the abnormal findings to reflect the condition.

a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results. This is an example of a circumstance in which the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS for a secondary diagnosis, and whether the COPD does is not clear so the provider should be queried (Schraffenberger and Palkie 2022, 100-101; Brinda 2020, 186-187).

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

a. Request that the physician dictate an addendum to the discharge summary. If missing or incomplete information is identified during record analysis, HIM personnel can issue deficiency notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a supplement to a signed report that provides additional health information within the health record. In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident (Sayles 2020b, 78).

Which of the following should be considered first when establishing health record retention policies? a. State retention requirements b. Accreditation standards c. AHIMA's retention guidelines d. Federal requirements

a. State retention requirements Health record retention policies depend on a number of factors. They must comply with state and federal statutes and regulations. Retention regulations vary by state and possibly by organization type. Health records should be retained for at least the period specified by the state's statute of limitations for malpractice, and other claims must be taken into consideration when determining the length of time to retain records as evidence (Rinehart-Thompson 2020a, 237).

A hospital HIM department receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's health 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. Submit a certification of destruction in response to the subpoena. b. Inform defense and plaintiff lawyers that the records no longer exist. c. Refuse the subpoena since no records exist. d. Contact the clerk of the court and explain the situation.

a. Submit a certification of destruction in response to the subpoena. If the paper health record is destroyed, the imaging record would be the legal health record. This may not be the case if the paper record is retained. State laws typically view the original health record as the legal record when it is available. Those who choose to destroy the original health record may do so within weeks, months, or years of scanning. If the record was destroyed according to guidelines for destruction and no scanned record exists, the certificate of destruction should be presented in lieu of the record (Rinehart-Thompson 2017b, 197-199).

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 (Thomason 2013, 173).

Mary's PHI has been breached. Of which of the following does Mary not need to be notified? a. Who committed the breach b. Date the breach was discovered c. Types of unsecured PHI involved d. What she may do to protect herself

a. Who committed the breach Individuals who are notified that their PHI has been breached must be given a description of what occurred (including date of breach and date that breach was discovered); the types of unsecured PHI that were involved (such as name, Social Security number, date of birth, home address, account number); steps that the individual may take to protect himself or herself; what the entity is doing to investigate, mitigate, and prevent future occurrences; and contact information for the individual to ask questions and receive updates (Rinehart-Thompson 2020b, 271).

In May, 270 women were admitted to the obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculating the C-section rate? a. 33 b. 263 c. 270 d. 296

b. 263 The denominator (the number of times an event could have occurred) in this case would be 263 as 263 women delivered (McNeill 2020, 434).

City Hospital's Revenue Cycle Management team has established the following benchmarks: (1) The value of discharged, not final billed cases (DNFB) should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. The net average daily revenue is $1,000,000. The following data indicate that City Hospital's DNFB cases met its benchmarks: a. 25 percent of the time b. 50 percent of the time c. 75 percent of the time d. 100 percent of the time

b. 50 percent of the time In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 percent of the time (Shaw and Carter 2019, 26-27).

Which of the following situations is considered a breach of PHI? a. A nurse views the record of a patient that she is not caring for. b. A patient's attorney is sent records not authorized by that patient. c. A nurse starts to place PHI in a public area where a patient is standing and immediately picks it up. d. An HIM employee keys in the incorrect health record number but closes it out as soon as it is realized.

b. A patient's attorney is sent records not authorized by that patient. There are three exceptions to a breach. All of these answers fall into one of these categories with the exception of the records sent to the patient's attorney. He does not work for the covered entity and an authorization is required (Rinehart-Thompson 2020b, 270).

You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide to the physician? a. Patient-specific data b. Aggregate data c. Operating room data d. Nothing—you cannot obtain this data after the fact

b. Aggregate data Aggregate data is data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed (Sayles 2020b, 66).

Which of the following principles is being followed when a health information management professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

b. Beneficence Beneficence would require the HIM professional to ensure that the information is released only to individuals who need it to do something that will benefit the patient (for example, to an insurance company for payment of a claim) (Hamilton 2020, 656).

A dietary department donated its old laptop to a school. Some old patient data were still on the computer. What controls would have minimized this security breach? a. Access controls b. Device and media controls c. Facility access controls d. Workstation controls

b. Device and media controls Device and media controls require the facility to specify proper use of electronic media and devices (external drives, backup devices, and such). Included in this requirement are controls and procedures regarding the receipt and removal of electronic media that contain protected health information and the movement of such data within the facility. The entity must also address procedures for the transfer, removal, or disposal—including reuse or redeployment—of electronic media (Brickner 2020b, 310).

A newborn is treated for pulmonary valve stenosis, with stretching of the valve opening accomplished via a percutaneous balloon pulmonary valvuloplasty. In ICD-10-PCS, what root operation would be coded for this procedure? a. Alteration b. Dilation c. Repair d. Restriction

b. Dilation Though the term valvuloplasty in the Index leads to Repair, Replacement, or Supplement, this procedure was performed as a percutaneous Dilation. The root operation Dilation is expanding an orifice or the lumen of a tubular body part (Kuehn and Jorwic 2021, 109).

The EHR may have multiple versions of the same document; for example, a signed and unsigned copy. How can a healthcare organization manage version control of documents in the EHR? a. Delete old versions and retain only the most recent version. b. Employ policies and procedures to control which version(s) is displayed. c. Do not consider signed and unsigned documents to be two versions. d. Previous versions are accessible to administration only.

b. Employ policies and procedures to control which version(s) is displayed. The health record may have multiple versions of the same document; for example, a signed and an unsigned copy of a document. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed (Sayles 2020b, 81-82).

Which of the following refers to guarding against improper information modification or destruction? a. Confidentiality b. Integrity c. Privacy d. Security

b. Integrity Data integrity means that data should be complete, accurate, consistent, and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules (Johns 2015, 211).

Why is the MEDPAR file limited in terms of being used for research purposes? a. It only provides demographic data about patients. b. It only contains Medicare patients. c. It uses ICD-10-CM diagnoses and procedure codes. d. It breaks charges down by specific type of service.

b. It only contains Medicare patients. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients (Sharp 2020, 211).

Patient is admitted with prepatellar bursitis following a crushing injury to the left knee as a result of being hit by a car two years ago. What diagnosis codes would be assigned for this patient? M70.40 Prepatellar bursitis, unspecified knee M70.42 Prepatellar bursitis, left knee S87.02XA Crushing injury of left knee, initial encounter S87.02XD Crushing injury of left knee, subsequent encounter S87.02XS Crushing injury of left knee, sequela a. M70.40, S87.02XA b. M70.42, S87.02XS c. M70.42, S87.02XD d. M70.40, S87.02XS

b. M70.42, S87.02XS The bursitis was the result of the previous crush injury and should be coded as sequela with the seventh character coded as "S" for sequela. The code for the left knee is also used to identify laterality (Schraffenberger and Palkie 2022, 649-650).

The credentialing process of independent practitioners within a healthcare organization must be defined in: a. Hospital policies and procedures b. Medical staff bylaws c. Accreditation regulations d. Hospital licensure rules

b. Medical staff bylaws The credentialing and privileging process for the initial appointment and reappointment of independent practitioners should be defined in the healthcare organization's medical staff bylaws and should be uniformly applied (Shaw and Carter 2019, 279).

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 (Sayles 2020b, 72).

Placenta previa with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergent C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be: a. Third-degree perineal laceration b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa

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

b. Provide a template for entering data in the field. Templates are a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date (Sayles and Kavanaugh-Burke 2021, 217 ).

Health departments use the health record to monitor outbreaks of diseases. In this situation what type of use of the health record does this represent? a. Educational b. Public health and research c. Medical review organization d. Patient care

b. Public health and research Public health and research uses data in the health record for many reasons including monitoring disease outbreaks (Sayles 2020b, 65).

Which of the following can be used to develop a focused inpatient coding review? a. Controversial issues identified in CPT Assistant b. Recent data quality issues identified by external review agencies c. Analysis of HCPCS comparative data d. Top 25 APC groups by volume and charges

b. Recent data quality issues identified by external review agencies The HIM department can plan focused review based on specific problem areas after the initial baseline review has been completed (Schraffenberger and Kuehn 2011, 314-315).

Community Hospital discharged nine patients on April 1. The length of stay for each of the patients was as follows: patient A, 1 day; patient B, 5 days; patient C, 3 days; patient D, 3 days; patient E, 8 days; patient F, 8 days; patient G, 8 days; patient H, 9 days; patient I, 9 days. What was the average length of stay for these nine patients? a. Five days b. Six days c. Eight days d. Nine days

b. Six days The average length of stay is the mean length of stay of hospital inpatients discharged during a given period of time. Add the total days for each patient (for a total of 54 days) and divide by nine patients = six days (McNeill 2020, 441).

The facility privacy officer receives a phone call from a patient who is concerned that her former sister-in-law, a hospital employee, has accessed her health record. The privacy officer requests an audit log of activity within the patient's health record. What part of the audit log must be analyzed to determine if this complaint has merit? a. The patient demographic information. b. Which employees viewed, created, updated, or deleted information. c. The ownership of the record. d. Whether the patient had requested to be omitted from the facility patient directory.

b. Which employees viewed, created, updated, or deleted information It is a requirement of the HIPAA Security Rule to implement ways that document access to information systems that contain electronic PHI. One of the ways to do this is to review the individuals that have viewed, created, updated, or deleted information within a health record. In this instance, the privacy officer should review this information to determine if the patient complaint is valid (Thomason 2013, 177).

The HIM manager recently performed an audit of health record documentation in the EHR looking for reports that had been indexed incorrectly. The audit showed that for the 100 records reviewed there was a 4 percent error rate. Given that the national average labor cost of each misindexed report is $200, what is the labor cost for the department for handling these misindexed reports? a. $8,000 b. $500 c. $800 d. $500,000

c. $800 Indexing in the EHR can be checked by conducting a random audit. To conduct a study, a subsection of the EHR reports can be checked for mislabeled reports. Any mislabeled reports that are found are noted, and an accuracy rate can be determined and compared against the established standard. In this scenario, there was a 4 percent error rate for the 100 records in the sample. If the cost of each misfile is $200, this would cost the facility $800 (100 × 0.04) × $200 = $800 (White 2020, 156).

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? 49560 Repair initial incisional or ventral hernia; reducible 49565 Repair recurrent incisional or ventral hernia; reducible 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft-tissue infection 49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible a. 49565 b. 49565, 49568 c. 49656 d. 49560, 49568

c. 49656 Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope, and is reducible makes the answer 49656. Notice that the use of mesh is included in the code (Huey 2021, 24, 152).

From the information provided, how many APCs would this patient have? Billing Number Status Indicator CPT/HCPCS APC 998323 V 99285-25 0612 998323 T 25500 0044 998323 X 72050 0261 998323 S 72128 0283 998323 S 70450 0283 a. 1 b. 4 c. 5 d. Unable to determine

c. 5 Each HCPCS code is assigned to one and only one ambulatory payment classification (APC). The APC assignment for a procedure or services does not change based on the patient's medical condition or the severity of illness. There may be an unlimited number of APCs per encounter for a single patient. The number of APC assignments is based on the number of reimbursable procedures or services provided for that patient. In this instance, the patient has five APCs (Casto and White 2021, 109).

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

c. Administrative data Administrative data describes patient identification, diagnosis, procedures, and insurance. Patient registration information would be considered administrative data as would patient account information. A significant portion of administrative data is demographic data (Brickner 2020a, 110).

The laboratory director wants the EHR to notify a physician when lab values are higher or lower than the stated normal range for this new lab test. He asks Dana to program an alert mechanism into the EHR to help physicians make quicker decisions on the patient's care. In what area of metadata is Dana functioning? a. Descriptive metadata b. Structural metadata c. Administrative metadata d. Prescriptive metadata

c. Administrative metadata Administrative metadata is programmed in the information system in order to generate data about the usage of the information system, such as audit trail and activity reports. Administrative metadata also includes decision support functions wherein the information system assists in helping to assemble, manipulate, and prioritize data and make recommendations about specific courses of action that can be taken to address an identified issue (Sayles and Kavanaugh-Burke 2021, 42).

According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy

c. Colonoscopy Colonoscopy includes examining the transverse colon. Proctosigmoidoscopy involves examining the rectum and sigmoid colon. Sigmoidoscopy involves examining the rectum, sigmoid colon, and may include portions of the descending colon (Smith 2021, 142).

Which of the following is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis

c. Comorbidity A comorbidity is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay (Schraffenberger and Palkie 2022, 93).

What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system? a. Administrator of records b. Custodian of records c. Director of records d. Supervisor of records

c. Custodian of records Associated with ownership of health records is the legal concept of the custodian of records. The custodian of health records is the individual who has been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records (Brodnik 2017a, 9).

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error? a. Access controls b. Audit trail c. Edit checks d. Password controls

c. Edit checks

Which of the following is not a recommended guideline for maintaining integrity in the health record? a. Specifying consequences for the falsification of information b. Requiring periodic training covering the falsification of information and information security c. Ensuring documentation that is being changed is permanently deleted from the record d. Prohibiting the entry of false information into any of the organization's records

c. Ensuring documentation that is being changed is permanently deleted from the record Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy. Assuring documentation that is being changed is permanently deleted from the record would not be a guideline for maintaining the integrity of the health record (Brinda 2020, 172-173).

After implementing a new EHR, the HIM department is noticing that documents are occasionally found in the wrong health record or are mislabeled. Which of the following would be the best approach to manage these errors in the EHR? a. Ignore them because it does not matter. b. Establish an error-management team to receive notice of these instances and correct them. c. Establish a policy for HIM staff to be more careful. d. Report these issues to the IT department to resolve them.

c. Establish an error-management team to receive notice of these instances and correct them. Error management is part of data integrity which means that data should be complete, accurate, consistent, and up-to-date. Ensuring the integrity of healthcare data is important because providers use data in making decisions about patient care (Johns 2015, 211).

Community Hospital has been collecting quarterly data on the average monthly health record delinquency rate for the hospital. This graph depicts the trend in the delinquency rate. The hospital has established a 35 percent benchmark. Given this data, what should the hospital's Performance Improvement Council recommend? a. Continue tracking the delinquency rate to see if the last two quarters' trend continues. b. Establish a higher benchmark to accommodate an increase in delinquent records. c. Further analyze the data to determine why the benchmark is not being met. d. Take an average of all the data points to arrive at a new benchmark.

c. Further analyze the data to determine why the benchmark is not being met. Once a benchmark for each performance measure is determined, analyzing data collection results becomes more meaningful. Often, further study or more focused data collection on a performance measure is triggered when data collection results fall outside the established benchmark. When variation is discovered or when unexpected events suggest performance problems, members of the organization may decide there is an opportunity for improvement (Shaw and Carter 2019, 27).

Which of the following is the goal of the quantitative analysis performed by HIM professionals? a. Ensuring that the health record is legible b. Verifying that health professionals are providing appropriate care c. Identifying deficiencies early so they can be corrected d. Ensuring bills are correct

c. Identifying deficiencies early so they can be corrected Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record (Sayles 2020b, 76-77).

Release of birth and death information to public health authorities: a. Is prohibited without patient consent b. Is prohibited without patient authorization c. Is a public health activities disclosure that does not require patient authorization d. Requires both patient consent and authorization

c. Is a public health activities disclosure that does not require patient authorization There are circumstances where PHI can be used or disclosed without the individual's authorization and without granting the individual the opportunity to agree or object. Some of these circumstances include preventing or controlling diseases, injuries, and disabilities, and reporting disease, injury, and vital events such as births and deaths (Rinehart-Thompson 2020b, 265-268).

Which of the following is a characteristic of breach notification? a. It is only required when 500 or more individuals are affected. b. It applies to both secured and unsecured PHI. c. It applies when one person's PHI is breached. d. Is only applies when 20 or more individuals are affected.

c. It applies when one person's PHI is breached.

Spoliation can be defined as which of the following? a. It is required after a legal hold is imposed. b. It is the negligent destruction or changing of information. c. It is destroying, changing, or hiding evidence intentionally. d. It can only be performed on records that are involved in a court proceeding.

c. It is destroying, changing, or hiding evidence intentionally. To preserve discoverable data, they must also ensure that records involved in litigation or potential litigation are preserved through a legal hold, which is generally a court order to preserve a health record if there is concern about destruction. A legal hold supersedes routine destruction procedures. It also prevents spoliation—the act of destroying, changing, or hiding evidence intentionally (Rinehart-Thompson 2020a, 228).

Suppose you want to display the number of deaths due to breast cancer for the years 2012 through 2022. What is the best graphic technique to use? a. Table b. Histogram c. Line graph d. Bar chart

c. Line graph A line graph may be used to display time trends. A line graph is especially useful for plotting a large number of observations. It also allows several sets of data to be presented on one graph (Williamson 2020, 398).

Which of the following would be the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in an EHR? a. Add validation edits on all essential fields. b. Provide an input mask for essential data fields. c. Make all essential data fields required by using a template. d. Provide sufficient space for all essential fields.

c. Make all essential data fields required by using a template. Standardization of the collection of patient data is essential to collect the proper information and reach data quality levels needed to support the enhancement of patient care and the healthcare industry. Templates can be created for common types of notes, visits, and procedures (Brinda 2020, 180-181).

Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report

c. Operative report The operative report describes the surgical procedures performed on the patient. Each report typically includes the name of the surgeon and assistants; date, duration, and description of the procedure; preoperative and postoperative diagnosis; estimated blood loss; descriptions of any unusual or unique events during the course of the surgery, normal and abnormal findings, as well as any specimens that were removed (Brickner 2020a, 108-109).

A home health agency has a computer system where its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect laptop and network data from a virus introduced from an external device? a. Biometrics b. Encryption c. Personal firewall software d. Session terminations

c. Personal firewall software A firewall is a part of a computer system or network that is designed to block unauthorized access while permitting authorized communications. It is a software program or device that filters information between two networks, usually between a private network like an intranet and a public network like the internet (Brickner 2020b, 301).

The director of nursing and cardiopulmonary therapy needs to know how many staff to schedule and how many ventilators will be necessary to treat the number of COVID-19 patients being admitted to ABC Hospital. You run workload and equipment projections to help determine these numbers. What type of data analytics is being performed in this scenario? a. Descriptive analytics b. Diagnostic analytics c. Predictive analytics d. Prescriptive analytics

c. Predictive analytics Predictive analytics is a process to identify patterns that can be used to predict the odds of a particular outcome based upon observed, historical data—think of the daily weather forecast. Predictive analytics can forecast the hospitalization rate and ventilator demand to help healthcare organizations prepare for the increase in admissions (Sayles and Kavanaugh-Burke 2021, 36).

An individual's right to control access to his or her personal information is known as: a. Security b. Confidentiality c. Privacy d. Access control

c. Privacy Privacy, confidentiality, and security are related, but distinct, concepts. In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information. 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. Security is the protection of the privacy of individuals and the confidentiality of health records (Johns 2015, 210-211).

General Hospital is performing peer reviews of their medical providers for quality outcomes of care. The hospital has more than 500 providers on its medical staff. The process to peer review even 10 cases for each provider is quite extensive. The quality department has concluded that to accomplish this review process, they will review 20 percent of each provider's inpatient admissions to the hospital every other year. In this situation, the quality department has applied to their review process. a. Benchmarking b. Data analysis c. Sampling d. Skewing

c. Sampling Sometimes the organizational characteristic or parameter about which data are being collected occurs too frequently to measure every occurrence. In this case, those collecting the data might want to use sampling techniques. 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 (Shaw and Carter 2019, 72).

Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system? a. Congestive heart failure b. Acute myocardial infarction c. Stage III or IV pressure ulcers d. Diabetic retinopathy

c. Stage III or IV pressure ulcers The hospital-acquired conditions (HAC) provision is an additional component of pay-for-performance utilizing reported ICD-10-CM diagnosis codes and the present-on-admission (POA) indicator to identify quality issues. A Stage III or IV pressure ulcer not present on admission or identified with the POA indicator on the claim would not be paid for as a CC or MCC because it would be considered an HAC (Casto and White 2021, 85-86).

Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event an amendment, addendum, or deletion needs to be made, which of the following should occur? a. The EHR should retain only the latest version of the document in order to avoid confusion as it is not necessary to document who made a change and when. b. The EHR should not allow any amendments, addendums, or deletions of electronic documents as this violates accreditation standards. c. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made. d. The EHR is not capable of allowing documentation changes. If a document needs to be amended, it must printed, redlined, and scanned into the EHR.

c. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made the EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made (Sayles 2020b, 83).

The HIM manager was asked by the medical director to present the hospital's policy on deletion of erroneous information from the electronic health record (EHR) to the medical staff. This policy requires that the original documentation is retained in the EHR along with the corrected documentation. Which of the following is a key component of this policy? a. The new documentation must be reviewed by the chief of the medical staff. b. Natural language processing would be utilized to delete erroneous information. c. The new and old documentation would be included in the same document with a comment section. d. The new documentation needs to be reviewed by the risk manager.

c. The new and old documentation would be included in the same document with a comment section. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made the EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made (Sayles 2020b, 81-82).

Which of the following is a correct statement regarding DNR orders? a. A DNR is a form of advance directive and only requires the patient's desire for the withholding of care. b. The record should be clearly marked to indicate the presence of a DNR order. c. A DNR replaces the need for an advance directive since it is the ultimate in advance directive notifications. d. The Patient Self-Determination Act is federal so there are no differences in state law that need to be consulted.

c. The record should be clearly marked to indicate the presence of a DNR order.

In the following scatter chart what can be concluded about the relationship between age and income? a. There is a strong negative relationship between age and income. b. There is no relationship between age and income. c. There is a strong positive relationship between age and income. d. There is not enough information to determine the relationship.

c. There is a strong positive relationship between age and income. The scatter chart is showing a strong positive relationship between age and income because as age increases so does income. A negative relationship would show that as age increases income decreases, and that is not the case in this scatter chart example (Williamson 2020, 399-401).

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

c. Voluntarily or by state law Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central statewide registry or incidence surveillance program (Sharp 2020, 202).

A consumer nonprofit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. An HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. Which of the following would notbe a quality consideration in using billing data? a. Accuracy of the data b. Consistency of the data c. Appropriateness of the data elements d. Cost to process the data

d, Cost to process the data Several factors must be addressed when assessing data quality. These include data accuracy, consistency, comprehensiveness, and timeliness. Cost to process the data does not influence the quality (Brinda 2020, 176-180).

The sum of a hospital's relative DRG weights for a year was 15,192, and the hospital had 10,471 discharges for the year. Given this information, what would be the hospital's case-mix index for that year? a. 0.689 b. 0.689 × 100 c. 1.45 × 100 d. 1.45

d. 1.45 The weight of each diagnosis-related group (DRG) is multiplied by the number of discharges for that DRG to arrive at the total weight for each DRG—in this situation 15,192. The total weights are summed and divided by the number of total discharges to arrive at the case-mix index for a hospital: 15,192 / 10,471 = 1.45 (McNeill 2020, 451-452 ).

Community Hospital had a total of 3,000 inpatient service days for the month of September. What was the average daily census for the hospital during September? a. 10 patients b. 96.77 patients c. 97 patients d. 100 patients

d. 100 patients The average daily census is the average number of inpatients treated during a given period of time. There are 30 days in September, so 3,000 / 30 = 100 (McNeill 2020, 437).

HIPAA requires a covered entity to establish policy to ensure that protected health information cannot identify a specific individual. One method used to meet this deidentification standard is the expert determination model. The expert determination model requires these four steps: One: Determine the statistical and scientific method to be used to determine the risk of reidentification. Two: Analyze and assess the risk to the deidentified data. Three: The expert applies the method to the deidentified data. Four: The facility should choose the expert for the deidentification analysis.What is the correct order in which these steps should be performed? a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 4, 3, 1 d. 4, 1, 3, 2

d. 4, 1, 3, 2 The process for expert determination of deidentification has four recommended steps. Step 1: The facility should choose the expert for the deidentification analysis. Step 2: Determine the statistical and scientific method to be used to determine the risk of reidentification. Step 3: The expert applies the method to the deidentified data. Step 4: Analyze and assess the risk to the deidentified data (Marc and Sandefer 2016, 22-23).

Community Hospital's HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timeliness rate. Thirteen discharges were determined to be out of compliance with completion standards. Which of the following percentages represents the timeliness rate for discharge summaries at Community Hospital? a. 8.7% b. 9.5% c. 41.5% d. 91.3%

d. 91.3% Hospitals set completion standards based on this requirement. Record completion would include the discharge summary (137 / 150) × 100 = 91.3% (McNeill 2020, 433).

A hospital is planning to allow coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended? a. Username and password b. Encryption c. Cable locks d. Automatic session log-off

d. Automatic session log-off In the HIPAA Security Rule, one of the technical safeguards standards is access control. This includes automatic log-off, which ensures processes that terminate an electronic session after a predetermined time of inactivity (Reynolds and Brodnik 2017, 277).

A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at trial d. Bring records to a legal proceeding

d. Bring records to a legal proceeding A subpoena duces tecum instructs the recipient to bring documents and other records with himself or herself to a deposition or to court (Rinehart-Thompson 2017a, 59).

A hospital can monitor its performance under the MS-DRG system by monitoring its: a. Accounts receivable b. Operating costs c. RBRVS payments d. Case-mix index

d. Case-mix index A hospital can monitor its performance under the MS-DRG system by monitoring its case-mix index (CMI). The CMI is the average of the relative MS-DRG weights of all cases treated at a given hospital. The CMI can be used to make comparisons between hospitals and to assess the quality of documentation and coding at a particular hospital (Gordon, M. L. 2020, 493-494).

Two coding professionals have found the same abbreviation in two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation in another patient's record was used to mean "overdose" in an abuse record. What data quality component is lacking here? a. Timeliness b. Completeness c. Security d. Consistency

d. Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Data must have definitions and be uniform to prevent information inconsistencies (Sayles and Kavanaugh-Burke 2021, 25).

Which type of data identifies the patient (such as name, health record number, address, and telephone number)? a. Accession data b. Indicator data c. Reference data d. Demographic data

d. Demographic data

Dr. Smith wants to use a lot of free text in his EHR. What should be your response? a. Good idea, Dr. Smith. This allows you to customize the documentation for each patient. b. Dr. Smith, we recommend that you do not use any free text in the EHR. c. Dr. Smith, we recommend that you should use free text only in your more complex cases. d. Dr. Smith, we recommend that you use little, if any, free text in the EHR.

d. Dr. Smith, we recommend that you use little, if any, free text in the EHR. Because the ability to manipulate the data is reduced, it is recommended that little, if any, free text is used (Sayles 2020b, 82).

This type of chart plots all data points as a cell for two given variables of interest and, depending on frequency of observations in each cell, provides color to visualize high or low frequency. a. Barplot b. Scatter plot c. Boxplot d. Heat map

d. Heat map A heat map plots all data points as a cell for two given variables or interest, and depending on frequency of observations in each cell, provides color to visualize high or low frequency (Marc and Sandefer 2016, 41).

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin

d. Hematuria; adverse reaction to Coumadin Hematuria is an adverse effect as opposed to a poisoning because it was correctly prescribed and correctly taken (Schraffenberger and Palkie 2022, 620-621).

Typically, healthcare facilities should retain the master patient index: a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently

d. Permanently Record retention should only be done in accordance with federal and state law and written retention and destruction policies of the organization. AHIMA's recommended retention standards for the master patient index (MPI) is permanent retention (Fahrenholz 2017b, 122).

Clara maintains and updates an individual health record for herself as a tool she can use to collect, track, and share her past and current information about her health with providers. What is this tool called? a. Hybrid health record b. Paper health record c. Duplicate health record d. Personal health record

d. Personal health record The tool that Clara is using is a personal health record. An individual can use a personal health records to collect, track, and share past and current information about his or her health (Sayles 2020b, 88).

Identify the report where the following information would be found: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." a. Discharge summary b. Health history c. Medical laboratory report d. Physical examination

d. Physical examination

Which of the following is true about the legal health record? a. It is inadmissible into evidence. b. It may not be hybrid. c. It must consist in part on paper. d. It will be disclosed upon request.

d. t will be disclosed upon request. One of the major purposes of a health record is to serve as the legal business record of an organization and as evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request (Rinehart-Thompson 2017b, 170-171).