CCA

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate A) the overall quality of documentation in the record. B) quality of care through the use of preestablished criteria. C) adverse effects and contraindications of drugs utilized during hospitalization. D) potentially compensable events.

A Explanation: "Adverse effects and contraindications of drugs utilized during hospitalization" and "quality of care through the use of preestablished criteria" deals with issues directly linked to quality of care reviews. "Potentially compensable events" deals with risk management. Only "the overall quality of documentation in the record" points to a review aimed at evaluating the quality of documentation in the health record.

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is: A) pathology report. B) operative report. C) recovery room record. D) discharge summary.

A Explanation: Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.

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

A Explanation: Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a pre-established time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.

Discharge summary documentation must include: A) significant findings during hospitalization. B ) a note from social services or discharge planning. C) correct codes for significant procedures. D) a detailed history of the patient.

A Explanation: Some reference to the patient's history may be found in the discharge summary but not a detailed history. The attending physician rather than a social worker records the discharge summary. Procedure codes are usually recorded on a different form in the record.

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the A) MDS. B) OASIS. C) UHDDS. D) DEEDS.

A Explanation: The Minimum Data Set (MDS) is a basic component of the long-term care RAI. UHDDS is used primarily in acute care. OASIS is used in home health, and DEEDS is used in emergency departments.

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? A) operation index B) master patient index C) physician index D) disease index

A Explanation: The master patient index—the disease index is a listing in diagnostic code number order. Physician index—The physician index is a listing of cases in order by physician name or number. Disease index—The MPI cross-references the patient name and medical record number. Therefore, operation index is the correct choice.

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to disclose proof of immunization to a school without A) any communication with the parent B) written authorization of the parent C) written authorization by the child D) documentation of any kind

B Explanation: The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.

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

B Explanation: The statute of limitations for each state is information that is crucial in determining record retention schedules.

Engaging patients and their families in health care decisions is one of the core objectives for A) HIPAA 5010 regulations. B) achieving meaningful use of EHRs. C) the Joint Commission's National Patient Safety goals. D) establishing flexible clinical pathways.

B Explanation: There are several core objectives for achieving meaningful use. Engaging patients and their families is one of these core objectives.

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

B Explanation: Unlike the acute care hospital, where most health care practitioners document separately, the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved.

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process? A) Mark the surgical site. B) Confirm the patient's true identity. C) Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. D) Review the medical records and/or imaging studies.

C Explanation: "Confirm the patient's true identity," "mark the surgical site," and "review the medical records and/or imaging studies"—these are usually in the protocol to prevent wrong site, wrong patient, or wrong surgery. The correct answer is following the daily surgical patient listing—that choice would NOT be an appropriate step in making sure you have the correct identity of the patient, the correct site, or the correct surgery.

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the A) HIM director. B) risk manager. C) attending physician. D) chief of staff.

C Explanation: Although the nursing staff, hospital administration, and the health information management professional play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician.

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the A) prohibited use of any abbreviations. B) use of abbreviations in the final diagnosis. C) use of prohibited or "dangerous" abbreviations. D) flagrant use of specialty-specific abbreviations.

C Explanation: As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred.

One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with A) meaningful use requirements. B) Conditions of Coverage rules. C) the HIPAA Privacy Rule. D) Joint Commission standards.

C Explanation: Certified EHRs must have the functionality to allow the creation of an electronic copy of the patient's health record.

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency. A) OSHA B) CMS C) ONC D) CDC

C Explanation: The Office of the National Coordinator (ONC) for Health Information Technology is the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

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

D Explanation: Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A) doctors' progress notes. B) integrated progress notes. C) nurses' notes. D) incident report.

D Explanation: Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record.

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that A) you apologize for not noticing the H&P she provided. B) Joint Commission standards do not allow copies of any kind in the original record. C) a new H&P is required for every inpatient admission. D) the H&P copy is acceptable as long as she documents any interval changes.

D Explanation: Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the original H&P is readily available.

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates A) compliance with Joint Commission standards. B) compliance with Joint Commission standards for nonsurgical patients. C) compliance with Medicare regulations. D) noncompliance with Joint Commission standards.

D Explanation: Joint Commission specifies that H&Ps must be completed within 24 hours or prior to surgery.

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

D Explanation: Of the processes listed, only "nurses using bedside terminals to record vital signs" pertains to the clinical application of data entry into the patient's record at the time and location of service.

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

D Explanation: Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be A) principal diagnosis. B) procedures and dates. C) personal identification. D) cognitive patterns.

D Explanation: Principal diagnosis, procedures and data, and personal identification represent items collected on Medicare inpatients according to UHDDS requirements. Only cognitive patterns represent a data item collected more typically in long-term care settings and required in the Minimum Data Set for Long Term Care.

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for A) apprising the patient of all complications that might occur. B) including the primary caregiver in surgery consults. C) including the surgeon in the pre-anesthesia assessment. D) marking the surgical site.

D Explanation: The Joint Commission requires hospitals to mark the correct surgical site and to involve the patient in the marking process to help eliminate wrong site surgeries.

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the A) labor and delivery record. B) discharge summary. C) postpartum record. D) prenatal record.

D Explanation: The antepartum or prenatal record should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history.

Joint Commission requires the attending physician to countersign health record documentation that is entered by A) business associates. B) consulting physicians. C) physician partners. D) interns or medical students.

D Explanation: Those who make entries in the medical record are given that privilege by the medical staff. Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.