RHIT exam prep

Which of the following definitions best describes the concept of confidentiality? a. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The right of individuals to control access to their personal health information d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

A. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

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

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

DEEDS?

Data Elements for Emergency Department Systems - A data set designed to support the uniform collection of information in hospital-based emergency departments.

What is EMDS?

Essential Medical Data Set

What is UHDDS

The Uniform Hospital Discharge Data Set (UHDDS)

What is UACDS?

Uniform Ambulatory Care Data Set (includes reasons for the encounter, living arrangements, marital status; recommended, not required)

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

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

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

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

The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments

a. Accusations of fraud and abuse The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance

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

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

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

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

A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist

a. Code skin lesion In the outpatient setting, do not code a diagnosis documented as "probable." Rather, code the conditions to the highest degree of certainty for the encounter (

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

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

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

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

As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all of the divisions within the HIM department. The following table shows sample productivity benchmarks for record analysis the director found through a literature search. Given this information, how should the director proceed in establishing benchmarks for the department? Sample Productivity Benchmarks productivity Benchmarks Per Hour Low Average High Function Assembly (charts per hour) 0 0 0 Inpatient 8 2 0 Observation/outpatient surgery/newborn/maternity 5 14 60 Other outpatient 0 20 120 a. Determine whether the source of the benchmark data is from a comparable institution b. Use the low benchmark example as a beginning point for implementation c. Contact the hospital statistician to determine whether the data are relevant d. Use the average benchmark example as a beginning point for implementation

a. Determine whether the source of the benchmark data is from a comparable institution Comparing an organization's performance to the performance of other organizations that provide the same types of services is known as external benchmarking. The other organizations need not be in the same region of the country, but they should be comparable organizations in terms of patient mix and size

The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team? a. Insufficient knowledge of team members b. Too many team members c. Unspecific team charge d. Too few team members

a. Insufficient knowledge of team members Whether selecting a permanent staff team or members of a team for a short-term project, making the right choice is fundamental to the team's success. Putting together a team involves understanding the challenges to be faced and considering all of the perspectives, experience, and knowledge that will be needed. The members of the team should be selected for what they can contribute to the team. Member selection should not be based purely on job title; rather, team members should be selected for the tasks that they actually can perform and the responsibilities they can carry out

The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration

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

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways? a. Makes it lower than warranted by the actual service and resource intensity of the facility b. Makes it higher than warranted by the actual service and resource intensity of the facility c. Hospital's MS-DRG case mix is never monitored so there is no impact d. Coding has nothing to do with a hospital's MS-DRG case mix

a. Makes it lower than warranted by the actual service and resource intensity of the facility Medicare severity diagnosis-related group (MS-DRG) sets exist where the listings of diagnoses used to drive the grouping are the same, but the presence or absence of a complication or comorbidity (CC) diagnosis or major complication or comorbidity (MCC) diagnosis assigns the case to a higher or lower MS-DRG. MS-DRG sets may contain two or three MS-DRGs. These MS-DRG relationships and sets pose a compliance concern because the health record documentation used to support the coding of principal diagnosis, complications, and comorbidities may not always be clear or used appropriately by the coder (such as undercoding). Therefore, inaccurate coding can lead to incorrect MS-DRG assignment and thus inappropriate reimbursement and can affect a hospital's case mix

A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. b. Yes; this is hospital policy for which HIPAA has no control. c. No; the records from the previous hospital are not included in the designated record set but should be released anyway. d. Yes; HIPAA only requires that current records be produced for the patient.

a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. When other healthcare providers provide records, it is done to ensure the continuity of care for the individual. Many covered entities either include the whole file or copies of the file as part of the covered entity's record, with the assumption that the treating physician has used some or all of the records to decide how to treat the patient. Any copies that are included with the records of the individual are, therefore, considered part of the individual's designated record set and should be released

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

a. Obliterating or deleting errors To correct errors or make changes in the paper health record, a single line should be drawn in ink through the incorrect entry. The word error should be printed at the top of the entry along with a legal signature or initials, date, time, and discipline of the person making the change. The existing entry should be left intact and corrections should be entered in chronological order. Late entries should be labeled as such. Error correction in EHR is particularly important because courts have historically viewed their integrity as suspect

The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas? a. Operative and other invasive procedures, medication management, and blood and blood product use b. Blood and blood product use, medication management, and appointment to the board of directors c. Medication management, marketing strategy, and blood use d. Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use

a. Operative and other invasive procedures, medication management, and blood and blood product use appointments to the Board of Directors is important information, but the Joint Commission requires detailed information on the responsibilities and actions of the Board, not necessarily its composition. The Joint Commission requires healthcare organizations to collect data on each of these areas: medication management, blood and blood product use, restraint and seclusion use, behavior management and treatment, operative and other invasive procedures, and resuscitation and its outcomes

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all of the designated records in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically

a. Provide the records in paper format only The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be provided in that format

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

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

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

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

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? Costs Associated with Each IT Help Desk Call to Resolve Password Issues Personnel Cost Cost User's time—30 minutes.............$15 Telephone cost—30 minutes..............$2 Call Desk time—30 minutes.................$16 Call Desk IS facilities time....................$17 Total................................................................$50 a. Training will provide $146,000 savings in help desk support and can be justified. b. The results of training will provide $365,000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.

a. Training will provide $146,000 savings in help desk support and can be justified. Current cost: $50 × 40 calls per day = $2,000 per day × 365 days = $730,000. Cost with reduced number of help desk calls: $50 × (40 × 0.80) calls per day = $1,600 per day × 365 days = $584,000, or a savings of $146,000. Training costs of $100,000 will be recouped and a savings of $46,000 realized ****0.80 is the 20 percent reduction

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

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

In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis and complaints b. Chargemaster description c. Clinical laboratory results d. Radiology orders

b. Chargemaster description One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description for accuracy

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital? a. $40,300 b. $39,375 c. $26,250 d. $13,125

b. $39,375 Unbundling is the practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure code. In this situation, the penalty is the overpayment of the $75 for all 175 claims overpaid as well as 3 times the total amount of the overpayment (175 × $75 = $13,125 then; $13,125 × 3 = $39,375)

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

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

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

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

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? 49320-Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662-Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671Laparoscopy, surgical; with occlusions of oviducts by device (e.g., band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320

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

Which of the following situations is considered a breach of PHI? a. A nurse sees 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 wrong 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 here 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

Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare: a. The full DRG amount, and Big Medical Center will receive a per diem rate for the three-day stay b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment c. The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the three-day stay d. No payment; Community Hospital must bill Big Medical Center a per diem rate for the two-day stay

b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment There are two types of transfer cases under the inpatient prospective payment system (IPPS). The first category is a patient transfer between two IPPS hospitals. A type 1 transfer is when a patient is discharged from an acute IPPS hospital (Community Hospital in this case) and is admitted to another acute IPPS hospital (Big Medical Center) on the same day. Payment is altered for the transferring hospital and is based on a per diem rate methodology. The transferring facility receives double the per diem rate for the first day plus the per diem rate for each day thereafter for the patient LOS. The receiving facility receives the full PPS payment rate for the case

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Call the Joint Commission b. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices c. Post the hospital policy in the emergency department d. Routinely send out a fourth notice

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

Performance monitoring is data driven and the HIM department needs access to data in order to make important decisions. One way to provide real-time data and important information that can be monitored at a glance is to use which of the following? a. Benchmark b. Dashboards c. Pareto chart d. Time ladder

b. Dashboards Performance monitoring is data driven. The organization's leadership uses the information displayed on the dashboard to guide operations and determine improvement projects. Having real-time data in an easily assessable format like a dashboard allows leaders to keep track of high-impact, high-risk, or high-value processes and make adjustments on a daily basis if needed

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

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

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? a. Alert the Joint Commission that the hospital has not met its quality goal b. Determine whether there was a medical or other reason why patients were not given aspirin c. Institute an in-service training program for clinical staff on the importance of administering aspirin within 24 hours d. Determine which physicians did not order aspirin

b. Determine whether there was a medical or other reason why patients were not given aspirin Quality measures are identified using ICD-10-CM diagnosis codes. Acute MI is also a Core Measure. These data are monitored, rated, and ultimately compared to nationwide benchmarks to point to areas of potential improvement in patient care outcomes. In this situation is it important to determine whether there was a medical or other reason why patients were not given aspirin within 24 hours of arrival at the hospital. This determination is critical to assess compliance with the quality goal

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records c. Perform a quality check on all health record systems in the practice d. Develop a listing and categorize all information requests for health information over the past two years

b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record as the first step in determining the components of the legal health records

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

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

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

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

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation

b. Extirpation The root operation extirpation is defined as taking or cutting out solid material from a body part. The matter may have been broken into pieces during the lithotripsy previous to this encounter, but at this time the pieces of the calculus are being removed

The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following tools would best aid the team in identifying the root cause of the problem? a. Flowchart b. Fishbone diagram c. Pareto chart d. Scatter diagram

b. Fishbone diagram A cause-and-effect diagram, also known as a fishbone diagram because of its characteristic fish shape, is an investigation technique that facilitates the identification of the various factors that contribute to a problem. It facilitates root-cause analysis, in order to determine the cause of the problem

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit

b. Focused audit Focused selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-risk areas or other areas of specific concern, such as a focused audit of cases with no CC/MCC to determine why the case-mix is dropped

A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to get their input d. Contact CMS to determine what data sets are required to be collected

b. Identify data content requirements for all areas of the organization Data content standards allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes. The HIM director should identify data content requirements for all areas of the organization to ensure the data content standards are met

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

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

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

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

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

b. Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits

b. Medical necessity Local coverage determination (LCD) is used to determine coverage on a Medicare Administrative Contractor-wide, intermediary-wide, or carrier-wide basis (rather than nationwide, as with a NCD). LCDs are educational materials that assist facilities and providers with correct billing and claims processing. Within the LCD is a listing of ICD-10-CM codes that indicate what is covered and what is not covered. For example, a procedure may be covered by Medicare, but is not reimbursed by Medicare because it does not meet medical necessity

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

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

Two patients' records were filed together by mistake. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge

b. Overlay Another problem with the question of the quality of the MPI is an overlay, where a patient is erroneously assigned another person's health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient as well

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

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

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

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

HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into? a. Reasonable cause b. Reasonable diligence c. Willful neglect d. Abuse

b. Reasonable diligence Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements

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

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

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

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

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

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

How many identifiers must be removed for a data to be considered deidentified under the Safe Harbor Method? a. 12 b. 15 c. 18 d. 20

c. 18 The safe harbor method of deidentification requires the removal of 18 specific identifiers from the protect health information

Based on this output table, what is the average coding test score for the beginner coder? Coding Test Score Coder Status Mean N Standard Deviation Advanced 93.0000 3 5.00000 Intermediate 89.5000 2 .70711 beginner 73.3333 3 6.42910 Total 84.7500 8 10.51190 a. 93 b. 6.4 c. 73 d. 90

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

Data elements collected on large populations of individuals and stored in databases are referred to as: a. Statistics b. Information c. Aggregate data d. Standard

c. Aggregate data Data about patients can be extracted from individual health records and combined as aggregate data. Aggregate data are used to develop information about groups of patients. For example, data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database

The organization that you work for just concluded an investigation of a USB thumb drive that was lost and contained a file with the information of 765 patients on it, including name, address, telephone number, and social security number. As the privacy officer, you are required to manage the notification process for the data breach. All of the following would need to be notified of this data breach within 60 days of the discovery except: a. Individual patients b. Local media c. Attending physicians of the patients d. Department of Health and Human Services

c. Attending physicians of the patients All individuals whose information has been breached must be notified without unreasonable delay, and not more than 60 days, by first-class mail or a faster method such as by telephone if there is the potential for imminent misuse. If 500 or more individuals are affected they must be individually notified immediately and media outlets must be used as a notification mechanism as well. The Secretary of HHS must specifically be notified of the breach. The attending physicians of the patients do not need to be notified of the breach

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses would be reported as POA? a. Catheter-associated urinary tract infection, COPD, Hypertension b. Cerebral vascular accident, COPD, Catheter-associated urinary tract infection c. Cerebral vascular accident, COPD, Hypertension d. Hypertension, Catheter-associated urinary tract infection, Cerebral vascular accident

c. Cerebral vascular accident, COPD, Hypertension Present on admission (POA) is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission. This patient was not admitted with a catheter-associated urinary infection and so that condition cannot be coded as POA. The patient was admitted with symptoms of a stroke and diagnoses of COPD and hypertension. The CVA was documented after admission, but the symptoms of the stroke were POA, so this condition would be coded as POA

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set

c. Conditions of Participation Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Participation

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Determine that a formal letter of termination meets HIPAA requirements and no further action is required. b. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years. c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned. d. Inform the CFO that business associate agreements cannot be terminated.

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

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

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

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

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

The advent of the EHR has increased the amount of documentation largely due to: a. Storage capabilities b. Joint Commission requirements c. Ease of entry d. Reporting

c. Ease of entry The advent of the electronic health record (EHR) came with improvements as well as challenges related to clinical documentation. Overall, the EHR has increased the amount of documentation based largely on the ease of entry

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

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

Which of the following is a function of the outpatient code editor? a. Validate the patient's age on a claim b. Validate the patient's encounter number c. Identify unbundling of codes d. Identify cases that don't meet medical necessity

c. Identify unbundling of codes The latest version of the Medicare integrated outpatient code editor (OCE) should be installed to review claims prior to releasing billed data to the Medicare program. OCE software contains the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT). The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to control improper coding leading to inappropriate payment and unbundling on the Part B claims. They also identify component codes that were used instead of the appropriate comprehensive code, as well as other types of coding errors

The risk manager's principal tool for capturing the facts about potentially compensable events is the: a. Accident report b. RM report c. Incident report d. Event report

c. Incident report An incident report is a structured data tool that risk managers use to gather information about potentially compensable events. Effective incident reports carefully structure the collection of data, information, and facts in a relatively simple format

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

c. Licensure Compliance with state licensing laws is required in order for healthcare organizations to begin or remain in operation within their states. To continue licensure, organizations must demonstrate their knowledge of, and compliance with, documentation regulations

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

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

Which of the following is the approved method for implementing an organization's formal position? a. Hierarchy chart b. Organizational chart c. Policy and procedure d. Mission statement

c. Policy and procedure Policies and procedures also can be considered organizational tools. Policies are written descriptions of the organization's formal positions. Procedures are the approved methods for implementing those positions. Together, they spell out what the organization expects employees to do and how they are expected to do it (Gordon and Gordon

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

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

The right of an individual to keep personal health information from being disclosed to anyone is a definition of: a. Confidentiality b. Integrity c. Privacy d. Security

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

Which policy ensures that the minimum penalty appropriate to the level of employee offense is applied? a. Employment at will b. Downsizing c. Progressive penalties d. Discipline without punishment

c. Progressive penalties Progressive penalties ensure that the minimum penalty appropriate to the level of offense is applied. Penalties may include but are not limited to oral warning for first unexcused tardiness and written warning for the second instance; serious rule violations, such as bringing a weapon to work, may result in immediate dismissal

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

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

David works for an organization that utilizes health record data to prove or disprove the efficacy of a healthcare treatment. What type of organization does David work for? a. Educational b. Policy-making c. Research d. Third-party payer

c. Research Research organizations conduct medical research and include state disease registries such as the cancer registry, research centers, and others who explore diseases and their treatments

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

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

In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited? a. Drop-down menus b. Point and click fields c. Speech recognition d. Structured templates

c. Speech recognition Speech recognition can be very effective in certain situations when data entry is fairly repetitive and the vocabulary used is fairly limited. As speech recognition improves, it is becoming a replacement for other forms of dictation. In some cases, the user reviews the speech as it is being converted to type and makes any needed corrections; in other cases, the speech is sent to a special device where it generates type for another individual to review and edit

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

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

An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system? a. DEEDS b. EMEDS c. UACDS d. UHDDS

c. UACDS The Uniform Ambulatory Care Data Set (UACDS) data characteristics include patient-specific items for outpatient care (Russo 2013a, 295-297).

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day? a. 10 hours per day b. 11.11 hours per day c. 12.5 hours per day d. 22.5 hours per day

d. 22.5 hours per day Timeliness of the storage and retrieval processes should be monitored. In this situation, each clinic visit represents a patient record that will need to be retrieved (or pulled) and stored (filed back). The calculation is: (500 / 50) + (500 / 40) = 22.5 hours per day

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580 Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access 36597 Repositioning of previous placed central venous catheter under fluoroscopic guidance a. 36578 b. 36580 c. 36582, 36597 d. 36582

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

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

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

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

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

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

d. Case finding After the cases to be included have been determined, the next step is usually case finding. Case finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry

The national patient safety goals score organizations on areas that: a. Affect the financial stability of the organization b. Commonly lead to overpayment c. Affect compliance with state law d. Commonly lead to patient injury

d. Commonly lead to patient injury The national patient safety goals outline for healthcare organizations the areas of organizational practice that most commonly lead to patient injury or other negative outcomes that can be prevented when staff utilize standardized procedures

An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: a. American Health Information Management Association b. American Medical Association c. Centers for Medicare and Medicaid Services d. Cooperating Parties

d. Cooperating Parties Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the Cooperating Parties and any other official coding rules and guidelines established for use with mandated standard code sets

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

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

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system

d. Database management system The database management system is the best option to collect, store, manipulate, and retrieve data for this situation. Paper and word-processing documents cannot sort and store the data in a meaningful way for this purpose. Spreadsheets should be used for accounting-type functions and not for data storage

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

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

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

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

One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following? a. Serial work division b. Job sharing c. Job rotation d. Parallel work division

d. Parallel work division In parallel work division, the same tasks are handled simultaneously by several workers; each completes all steps in the process from beginning to end, working independently of the other employees

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations? a. Provide copies of the records within 15 days b. Provide copies of the records within 30 days c. Provide copies of the records within 45 days d. Provide copies of the records within 60 days

d. Provide copies of the records within 60 days The HIPAA Privacy Rule requires that records be produced within 30 days to a patient or their personal representative, with a one-time extension of an additional 30 days if necessary. If such an additional 30 days is needed, the covered entity must notify the patient in writing of the need for additional time

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

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

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

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

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

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

When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following? a. Performance measurement b. Workforce planning c. Work observation study d. Variance analysis

d. Variance analysis Reported performance data are regularly analyzed for variance. Variance—where actual performance does not meet, varies, or is significantly different from the standard—should be further assessed

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

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

As part of your job duties, you are responsible for reviewing audit trails of access to patient information. All of the following are types of activity that you would monitor except: a. Every access to every data element or document type b. Whether the person viewed, created, updated, or deleted the information c. Physical location on the network where the access occurred d. Whether the patient setup an account in the patient portal

d. Whether the patient setup an account in the patient portal The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. Often they record: time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred. Creation of an account through the patient portal by the patient is appropriate use