Information Retention and Access
A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2016. Which of the following indices would be the best source in locating the needed records? a) master patient index b) physician index c) disease index d) operation index
c) disease index
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased? a) 11 b) 12 c) 13 d) 14
d) 14
Out of 2,543 records requested from the HIM department, 2,375 were located. What is the filing accuracy rate? a) 6.61% b) 75.33% c) 89.01% d) 93.39%
d) 93.39%
The total number of records filed during the month is 2500 and, upon completion of a filing accuracy study, 90 records were not found. What is the accuracy rate for filing? a) 1% b) 4% c) 28% d) 96%
d) 96%
Which one of the following would NOT be a strategy when purchasing an EHR system? a) Recognize stakeholders from different organizational levels and engage them appropriately. b) Determine return on investment or cost-benefit analysis. c) Identify system requirements. d) Broaden the vendor field and select several vendors of choice.
d) Broaden the vendor field and select several vendors of choice.
Which of the following statements is FALSE when addressing characteristics of the legal health record in an electronic document management system? a) The storage media used and the format of the scanned documents must protect data from loss and damage. b) The storage format must be efficient, manageable, and in compliance with laws and regulations. c) The backup and disaster recovery process is certified to ensure that all data can be recovered. d) Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems.
d) Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems.
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors? a) statute of limitations b) volume of research c) readmission rate d) department staffing
d) department staffing
The Director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Director's response? a) decreased clinical documentation errors b) increased work efficiency c) faster access to health data d) elimination of the need for expensive desktop computers
d) elimination of the need for expensive desktop computers
The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using? a) EHR system b) results reporting system c) financial information system d) executive information system
d) executive information system
Which of the following features should NOT be considered when designing screens to capture quality health data? a) a prompt for more information b) built-in alerts to notify users of possible errors c) the use of abbreviations on data fields d) left to right and bottom to top formatting
d) left to right and bottom to top formatting
Color coding of record folders is used to assist in the control of: a) record tracking b) loose reports c) record completion d) misfiles
d) misfiles
Which of the following is NOT an alternative storage method for paper-based records? a) microfilm b) optical imaging c) computer d) outguide
d) outguide
Which one of the following is NOT an electronic document management system component? a) scanner b) file server c) laser printer d) reader-printer
d) reader-printer
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long? a) age of majority plus statute of limitation b) 10 years after the most recent encounter c) 10 years after the age of majority d) permanently
a) age of majority plus statute of limitation
University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs? a) application service provider model b) clinical workstation c) IBM Medical Information Systems Program d) legacy system
a) application service provider model
Under the Patient Self-Determination Act of 1990, evidence of advance directives: a) are required to be documented in the health record b) are not required to be documented in the health record c) require a doctor's approval d) must be prepared by an attorney
a) are required to be documented in the health record
A file area has limited space, medium file activity, and two file clerks. The HIM department would benefit from choosing which type of storage equipment? a) compressible filing units b) lateral filing cabinets c) open shelf files d) motorized revolving units
a) compressible filing units
If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the: a) date of birth b) date of admission c) social security number d) mother's maiden name
a) date of birth
The HIM Department maintains 500,000 records and responds to 5,000 requests for records in a given period of time. What is the record usage rate? a) 0.01% b) 1% c) 5% d) 10%
b) 1%
How many inches are recommended for aisles between file units when using stationary open-shelf files? a) 24 b) 36 c) 60 d) 72
b) 36
How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least _____ years unless a longer period is required by state or local laws. a) 3 b) 5 c) 7 d) 10
b) 5
Which set of records filed consecutively on a shelf displays terminal digit filing order? a) 00-79-99, 00-79-01, 99-78-99 b) 57-78-00, 57-78-01, 56-78-99 c) 99-05-26, 01-06-26, 49-04-02 d) 55-55-55, 33-33-33, 44-44-44
b) 57-78-00, 57-78-01, 56-78-99
Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be: a) 5 years b) 7 years c) 10 years d) either 5 or 7 years, as determined by the facility
b) 7 years
Case finding methods for patients with diabetes include a review of all but which one of the following? a) health plans b) CPT diagnostic codes c) billing data d) medication lists
b) CPT diagnostic codes
When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT: a) state laws and licensing standards b) Communities of Practice requirements c) needs of patients d) Medicare requirements
b) Communities of Practice requirements
Which of the following lists is in correct alphabetical order? a) Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip; Ferlazzo, J. b) Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip c) Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, J.; Ferlazzo, Joshua Philip d) Ferlazzo, Joshua A.; Ferlazzo, B.; Ferlazzo, Joshua; Ferlazzo, Joshua Philip
b) Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip
According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30? a) 99-98-30 b) 00-00-31 c) 01-00-31 d) 99-99-31
b) 00-00-31
At Community Hospital the average admission will create a file that will take up to 0.25 inch of file space. Each new ER record requires 0.125 inch of file space. Approximately, 25,000 new patients are admitted per year and 15,000 ER patients are treated each year. The shelving cost is $1.05 per filing inch. How much money should be allocated for storage space in next year's budget? a) $8531.25 b) $8125.00 c) $853.25 d) $1875.00
a) $8531.25
In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26? a) 00-06-26 b) 02-06-26 c) 03-06-26 d) 99-99-25
a) 00-06-26
Of 750 records filed during the week, 75 were not located. What is the filing error rate? a) 10% b) 90% c) 0.1% d) 0.9%
a) 10%
If there are 150,000 records and the HIM Department receives 3,545 request for records within a given period of time, what is the request rate? a) 2.4% b) 3.5% c) 4.6% d) 5.1%
a) 2.4%
If the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number? a) 8 b) 10 c) 12 d) 100
a) 8
Which of the following statements would be found in the laboratory report section of the health record? a) BUN reported as 20 mg b) Morphine sulfate gr. 1/4 q.4h. for pain c) IV sodium Pentothal 1% started at 9:05 am d) TPR records q.h. for 12 hours
a) BUN reported as 20 mg
The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the EHR. Which of the following would be the key advantage in using this type of data entry? a) Enhanced databases will provide information for improved clinical care. b) Training will be offered by the hospital. c) Those physicians not in compliance will be denied admitting privileges. d) Multiple users will not have access to the same information simultaneously.
a) Enhanced databases will provide information for improved clinical care.
Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital? a) National Practitioner Data Bank b) Healthcare Integrity and Protection Data Bank c) MEDPAR file d) State Administrative Data Bank
a) National Practitioner Data Bank
When operating under HIPAA, what is a basic tenet in information security for health care professionals to follow? a) Security training is provided to all levels of staff. b) Patients are not educated about their right to confidentiality of health information. c) The information system encourages mass copying, printing, and downloading of patient records. d) When paper-based records are no longer needed, they are bundled and sent to a recycling center.
a) Security training is provided to all levels of staff.
Which of the following is NOT an advantage of a centralized filing system? a) There is less transportation time and effort when a facility operates from several sites. b) There is less duplication of effort to create, maintain, and store records. c) Record control and security are easier to maintain. d) There is decreased cost in space and equipment.
a) There is less transportation time and effort when a facility operates from several sites.
Brian Hills was discharged from the hospital after a 3-day hospitalization and instructed to return to the outpatient department for follow-up care. On his first visit as an outpatient, a new record was created and he was assigned a new record number. Following completion of the outpatient appointment, his outpatient record is filed permanently in the outpatient department. What is the filing system used in this situation? a) decentralized b) unit record c) centralized d) terminal digit
a) decentralized
What is the business of buying and selling information as a commodity? a) information brokering b) e-health consumerism c) telehealth d) competitive data
a) information brokering
As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to: a) install a computerized access control panel b) hire a security guard to monitor entrance to the file area c) convert from a terminal digit filing system to serial unit filing d) utilize a sign-in and sign-out log for admittance to the file area
a) install a computerized access control panel
Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(n): a) interfaced system b) integrated system c) OLAP d) standard
a) interfaced system
As the record retention supervisor, you are evaluating storage devices for a new health information management system. Which of the following would you NOT consider as an option for storing health information? a) light pen b) optical disc drive c) microfilm d) magnetic tape
a) light pen
Which of the following is NOT a data retrieval tool? a) light pen b) SQL c) color, animation, sound, icons d) screen design
a) light pen
According to AHIMA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently? a) physician index b) register of births c) register of surgical procedures d) register of deaths
a) physician index
As a prerequisite in the implementation of an EHR, what process would facilitate automatic indexing? a) redesigning forms to include bar codes b) removing portions of the patient record that will not be scanned c) converting all microfilm to optical disk format d) scanning only emergency room records initially
a) redesigning forms to include bar codes
Mary Schnering was admitted to Community Hospital on 10/3/15 and assigned a record number of 54-47-53. The patient was later admitted on 1/14/16 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/filing system is being used at Community Hospital? a) serial-unit b) serial c) unit d) terminal digit
a) serial-unit
The health care providers in an acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should: a) staff the department with personnel 24 hours a day. b) be on call every evening and weekends for emergency requests. c) train security guards to retrieve records after the department closes. d) arrange for records to be retrieved at 7:00 am every morning.
a) staff the department with personnel 24 hours a day.
The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions should be most effective in reducing the delay in retrieval of requested records? a) Offer a prize to the employee who locates the requested records first b) Review and possibly reengineer the retrieval process to decrease retrieval time c) Allow the requesters to retrieve the record themselves d) Increase file area staff to include one additional file clerk devoted to pulling records for the ER
b) Review and possibly reengineer the retrieval process to decrease retrieval time
Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used? a) HTML b) SQL c) XML d) data dictionary
b) SQL
In the master patient index, which is filed by last name, Jill Thomas-Jones would be: a) J-I-L-L-T-H-O-M-A-S-J-O-N-E-S b) T-H-O-M-A-S-J-O-N-E-S,J-I-L-L c) T-H-O-M-A-S,J-I-L-L-J-O-N-E-S d) J-O-N-E-S,J-I-L-L-T-H-O-M-A-S
b) T-H-O-M-A-S-J-O-N-E-S,J-I-L-L
Which one of the following is an advantage of straight numeric filing over terminal digit filing? a) All sections of the file expand uniformly. b) The training period is short. c) Work can be evenly distributed, causing accountability for accuracy in each of the 100 sections. d) Inactive records can be purged evenly.
b) The training period is short.
The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of? a) concurrency b) access c) integrity d) cost
b) access
What is the chief criterion for determining record inactivity? a) Medicare's definition of inactivity b) amount of space available for storage of newer records c) efficiency of microfilming d) preference of the medical staff
b) amount of space available for storage of newer records
Which of the following technologies works best with automated record-tracking systems to speed the data entry process? a) discharge lists b) bar codes c) compressible filing units d) computerized chart-out slips
b) bar codes
A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would: a) be filed in a health record created for the infant b) be filed in the mother's record c) be retained in a separate file in the administrative offices d) not be retained in hospital records
b) be filed in the mother's record
The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should: a) issue a copy of the birth certificate from the patient's record b) direct the request to the state's office of vital records c) direct the request to the attending physician d) issue a copy of the newborn's record
b) direct the request to the state's office of vital records
What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft? a) budget b) disaster c) case management d) patient care
b) disaster
Which of the following items is the Health Information Manager primarily concerned with when purchasing file guides? a) cost and color b) durability and visibility c) cost and visibility d) color and durability
b) durability and visibility
If the department staff are having trouble locating the terminal digit sections quickly, the supervisor could add more: a) outguides b) file guides c) requisitions d) staff
b) file guides
Electronic health record built-in tools that can make data capture easier include all but which one of the following? a) data dictionaries b) flow process charts c) automated quality measures d) clinical decision support systems
b) flow process charts
An example of a primary data source is the: a) physician index b) health record c) cancer registry d) hospital statistical report
b) health record
Which item is collected and maintained in the organ transplant registry? a) vaccine manufacturer b) histocompatibility information c) cytogenic results d) stage at the time of diagnosis
b) histocompatibility information
Fetal monitoring strips are part of the ____ record and should be maintained ___. a) newborn's; 10 years past the age of majority b) mother's; according to the length of time required for a minor's records c) newborn's; according to the time period specified in the state's statute of limitations d) mother's; 10 years
b) mother's; according to the length of time required for a minor's records
The steps in developing a record retention program include all but which of the following? a) determining the storage format and location b) notifying the courts of the destruction c) assigning each record a retention period d) destroying records that are no longer needed
b) notifying the courts of the destruction
Where in the health record would the following statement be located? "Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"? a) operative report b) pathology report c) anesthesia report d) radiology report
b) pathology report
What term involved moving a document from one episode of care to a different episode of care within the same patient record? a) correction b) reassignment c) resequencing
b) reassignment
Messenger, pneumatic tube, dumbwaiter, and conveyor belt are all examples of: a) record security systems b) record circulation systems c) loose filing d) filing controls
b) record circulation systems
Which of the following microform types is the least expensive to prepare and results in the greatest storage density? a) microfilm jackets b) roll microfilm c) microfiche d) ultrafiche
b) roll microfilm
A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? a) 6 b) 8 c) 10 d) 12
d) 12
What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital? a) storing the records off-site at a cost of $25,000 per year b) scanning all 250,000 records for a cost of $195,000 c) purging and storing all death records off-site at a cost of $20,000 per year d) destroying all records older than 3 years for a cost of $50,000
b) scanning all 250,000 records for a cost of $195,000
What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79? a) terminal digit b) straight numeric c) social security number d) middle digit
b) straight numeric
How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained? a) 5 b) 7 c) 30 d) permanently
c) 30
Palm Beach Healthcare Center has been in operation for 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admissions per year from now on. There are 2,500 linear feet of filing space available and half is being used. The facility expects a 30% readmission rate. If a unit numbering/filing system is used, how many file folders will be needed for the next year? a) 1,800 b) 1,860 c) 4,340 d) 6,200
c) 4,340
A HIM Department wants to buy new open-shelf filing units for its file expansion. Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average record is 1-inch thick. How many filing units should be purchased? a) 2 b) 4 c) 6 d) 8
c) 6
What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program? a) 70% b) 80% c) 90% d) 100%
c) 90%
A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken? a) Return inactive records to each individual patient. b) Destroy records of all deceased patients. c) Destroy inactive records that exceed the statute of limitations. d) Maintain the records indefinitely in hard copy.
c) Destroy inactive records that exceed the statute of limitations.
On his 12/23/15 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous record number assigned to Mr. Robinson during a 9/1/15 admission was 07-10-47. In a serial numbering/filing system, how would these records be filed? a) Both records are combined under 07-10-47. b) Both records are combined under 07-23-38. c) Each admission is filed under its own number. d) Previous records are brought forward and filed under the latest number issued.
c) Each admission is filed under its own number.
What data cannot be retrieved from the MEDPAR? a) ICD-10-CM diagnosis codes b) Charges broken down by specific types of services c) Non-Medicare patient data d) Data on the provider
c) Non-Medicare patient data
Which of the following is a disadvantage of terminal digit filing as compared to straight numeric filing? a) File personnel are crowded in the highest numbers. b) Inactive records are pulled from one common area. c) The training period is slightly longer. d) Files expand at the end of the number series, requiring back shifting.
c) The training period is slightly longer.
Microfilmed records are considered: a) inadmissible evidence b) never admissible as hearsay evidence c) acceptable as courtroom evidence d) not admissible as secondary evidence
c) acceptable as courtroom evidence
A surgeon requests the name of a patient he admitted on 1/11/13. Which of the following would be used to retrieve this information? a) master patient index b) number index c) admission register d) operation index
c) admission register
Which of the following is NOT a step in developing a health record retention schedule? a) conducting an inventory of the facility's records b) determining the format and location of storage c) assigning all records the same retention period d) destroying records that are no longer needed
c) assigning all records the same retention period
The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for? a) release of information b) coding c) chart tracking d) transcription
c) chart tracking
Which of the following is NOT considered a challenge in the adoption of an EHR system? a) design of the work flow and processes b) physician willingness to adopt c) contribution to the quality of patient care d) individual state legal and regulatory issues
c) contribution to the quality of patient care
General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity? a) desktop publishing b) word processing c) database management system d) command interpreter
c) database management system
Which of the following is NOT a benefit of the electronic document management system in the HIM Department? a) online availability of information b) multiuser simultaneous access c) decreased use of computer technology d) system security and confidentiality
c) decreased use of computer technology
A major consideration in a hospital or facility closure is to: a) notify all patients to pick up their original records by the date of closure b) seek approval for destruction of all records with a last date of treatment over 3 years ago c) ensure that authorized parties have access to the information as provided by law d) arrange for donating the records to an HIA/HIT education program for student use
c) ensure that authorized parties have access to the information as provided by law
Which of the following issues would be of LEAST concern when storing health records in off-site storage? a) operating hours of the storage facility b) safety and confidentiality procedures c) filing order of the records d) procedure for request of a record in an emergency
c) filing order of the records
Information found in which of the following would not be considered secondary data? a) disease index b) implant registry c) health record d) National Practitioner Data
c) health record
A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the: a) accuracy of analyzing records b) number of incomplete records c) inclusion of late reports d) tracking of release of information requests
c) inclusion of late reports
What mircoform should the HIM practitioner select if the records must be unitized and color-coded for filing purposes? a) roll microfilm b) cartridge c) jacket microfilm d) cassette
c) jacket microfilm
A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data? a) overwriting data with a series of characters b) disk reformatting c) magnetic degaussing d) overwriting the backup tapes
c) magnetic degaussing
Which index is used by the HIM department to link the patient's name and number in relation to access and retention of the patient record? a) physician index b) disease index c) master patient index d) operation index
c) master patient index
The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information? a) patient register b) disease index c) operation index d) birth defects register
c) operation index
For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which of the following elements? a) unique and serialized transaction number b) location of destruction c) patient notification d) acceptance of fiduciary responsibility
c) patient notification
Which one of the following is NOT a data retrieval tool? a) color b) sound c) point-and-click fields d) icons
c) point-and-click fields
Which of the following is NOT a document input device in the electronic document management system? a) scanner b) bar codes c) printer d) touch screen
c) printer
Which of the following is NOT a factor to consider when developing a record retention program? a) legal requirements as determined by statute of limitations b) record usage in the facility determined by health care provider activity c) reimbursement guidelines d) cost of space to maintain paper records
c) reimbursement guidelines
Which of the following is NOT a safety hazard in the HIM Department? a) tightly packed open-shelf files b) heavy objects placed in top file drawers c) stepladders that are fully open and locked in place d) plastic wastebasket for trash
c) stepladders that are fully open and locked in place
Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital? a) terminal digit b) unit c) straight numeric d) serial unit
c) straight numeric
When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract? a) who performs record preparation b) provision for destruction of original records c) type of reader or printer needed to view the microfilm d) confidentiality of information being filmed
c) type of reader or printer needed to view the microfilm
The master patient index must, at a minimum, include sufficient information to: a) summarize the patient's medical history b) list all physicians who have ever treated the patient c) uniquely identify the patient d) justify the patient's hospital bill
c) uniquely identify the patient
Which of the following is NOT a consideration in file folder size and design? a) reinforced top and side panels b) scoring on folder bottoms c) vendor location d) weight of folder
c) vendor location
Which one of the following is NOT an advantage to a computerized master patient index? a) It allows access to data alphabetically, phonetically, or by DOB, SSN, medical record, or billing number. b) It solves most space and retrieval problems. c) It provides other departments with immediate access to the information maintained in the master patient index. d) Duplication of patient registration can never occur.
d) Duplication of patient registration can never occur.
Which of the following is NOT a major management challenge in the storage and retention of EHR systems? a) Following state and federal laws and accreditation requirements when developing retention and destruction policies. b) Keeping technology updated in order to retrieve data. c) Ensuring that health information can be retrieved in a timely manner. d) Maintaining the paper-based storage system.
d) Maintaining the paper-based storage system.
Which of the following actions would NOT be included in the professional obligations of the health information practitioner that lead to responsible handling of patient health information? a) Educate consumers about their rights and responsibilities regarding the use of their personal health information. b) Extend privacy and security principles into all aspects of the data use, access, and control program adopted in the organization. c) Honor the patient-centric direction of the national agenda. d) Take a compromising position toward optimal interpretation of nonspecific regulations and laws.
d) Take a compromising position toward optimal interpretation of nonspecific regulations and laws.
Which of the following is NOT a consideration when implementing a disaster plan? a) Include disaster training in staff orientation. b) Establish a plan for conducting drills. c) Provide staff with tools needed to implement the plan. d) Test the disaster plan only once.
d) Test the disaster plan only once.
The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed? a) Visit corporate headquarters of the vendor. b) Perform a vendor reference check. c) Read consumer reports before buying. d) Test the software prior to purchase.
d) Test the software prior to purchase.
The same patient was admitted on three different occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be used given the following information? admitted 5/4/15, Patty Miller, 23-33-56 admitted 6/5/15, P. J. Miller, 25-56-88 admitted 9/27/15, Patricia Miller, 27-12-12 a) Void the first and last numbers and file all admissions under 25-56-88. b) Delete all previous numbers and assign a completely new number. c) Void the first two numbers and file all admissions under 27-12-12. d) Void the last two numbers and file all admissions under 23-33-56.
d) Void the last two numbers and file all admissions under 23-33-56.
The HIM practitioner's duty to retain health information via the archiving and storage of health data includes all but which of the following? a) strategies that consider accessibility, natural disasters, and innovations in storage technology b) strategies ensuring that inactive records are as secure as active records c) a retention plan for multiple volumes of records d) a retention plan for financial data
d) a retention plan for financial data
When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data? a) audit control b) person or entity authentication c) transmission security d) access control
d) access control
Which one of the following is NOT a technical security control employed by EHR systems? a) audit trails b) data encryption protocols c) user-based access controls d) automatic logon
d) automatic logon
A health care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the: a) newborn records b) state bureau of vital statistics c) maternal records d) birth defects registry
d) birth defects registry
When evaluating an outside contract microfilm company, all but which of the following are important factors to rate? a) cost b) emergency returns c) storage after filming d) cache memory
d) cache memory
The function of a(n)_______ is limited to data retrieval. a) electronic health record b) executive information system c) database management system d) clinical data repository
d) clinical data repository
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using? a) intranet b) extranet c) Internet d) clinical information system
d) clinical information system
In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing? a) who completes the list of what records are to be stored b) what are the billing terms c) who will purge inactive files for transfer d) confidentiality policies and liability concerns
d) confidentiality policies and liability concerns
Which of the following is NOT a mandatory disclosure according to the HIPAA Privacy Rule? a) emergencies concerning public health b) quality assurance reviews by authorized authorities c) instances concerning victims of domestic violence d) dates not covered in destruction
d) dates not covered in destruction
Which of the following should NOT be included in the documentation of record destruction? a) statement that records were destroyed in the normal course of business b) method of destruction c) signature of the individuals supervising and witnessing the destruction d) dates not covered in destruction
d) dates not covered in destruction
It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed? a) discharge summaries b) physician names c) nursing notes d) dates of admission, discharge, and encounters
d) dates of admission, discharge, and encounters
Capital Health Center is moving to a new facility in December 2016. The CEO is projecting a conversion to an EHR system by then. This new facility will not include space for filing of paper-based health records. Which of the following items would not be considered when planning this conversion? a) changing role of department functions and work flow b) challenges of maintaining records that are partially paper and partially electronic c) whether to scan older paper records d) relationship with the microfilm vendor
d) relationship with the microfilm vendor
What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms? a) past medical history b) social and personal history c) chief complaint d) review of systems
d) review of systems
Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate all but which of the following? a) security controls and access privileges of staff b) policies and procedures developed to safeguard privacy and security c) use of a back-up system d) salary for the database administrator
d) salary for the database administrator
As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system? a) authentication b) encryption c) disaster recovery plan d) stonewall
d) stonewall
Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements? a) method of destruction or disposal b) time that will elapse between acquisition and destruction or disposal c) safeguards against breaches d) the hospital's liability insurance in specified amounts
d) the hospital's liability insurance in specified amounts