RHIT Exam Review Domain 1

Dr. Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? a. A disease index b. A master patient index c. An operative index d. A physician index

a. A disease index A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period.

Which of the following is an institutional user of the health record? a. A third-party payer b. Patient c. Physician d. Employer

a. A third-party payer Institutional users of the health record are organizations that need access to health records in order to accomplish their mission. These institutional users include healthcare delivery organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, and policy-making bodies.

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

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

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

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

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

a. Consultation The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record.

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

a. DEEDS In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.

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

a. Data dictionary A data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology.

In a database the LAST_NAME column in a table would be considered a: a. Data element b. Record c. Primary key d. Row

a. Data element A data element is an individual fact or measurement that is the smallest unique subset of a database.

Patient name, zip code, and health record number are typical: a. Data elements b. Data sources c. Aggregate data d. Data monitors

a. Data elements The types of data elements that are abstracted, or defined as indexed fields in an automated system, vary from facility to facility. Generally, however, any data elements that are needed for selecting cases for reports must be abstracted or indexed. Some of the typical data fields that can be searched for the purpose of finding and reporting include: patient name, zip code, health record number, patient account number, attending physician, and the like.

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

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

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

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

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

a. Inability to identify the author In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes the inability to identify the author of the documentation.

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

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

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

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

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.

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

a. Operative report, anesthesia report, recovery room report Any surgical procedure requires special documentation. The entire process is recorded with an anesthesia report, operative report, and recovery room report.

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

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

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

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

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

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

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer

a. The template was defined A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry.

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

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

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

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

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

b. Aggregate data Aggregate data is data extracted from individual health records and combined to form de- identified information about groups of patients that can be compared and analyzed.

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

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

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

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

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

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

A 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 new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to ensure the history and physicals are present c. Retrospectively review each patient's health record to ensure the 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 ensure the history and physicals are present. The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital.

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

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

Which of the following is a true statement about the content of the legal health record? a. The legal health record contains only clinical data b. The legal health record may contain metadata c. The legal health record should not include e-mail d. The legal health record should not include diagnostic images

b. The legal health record may contain metadata Organizations should develop and maintain an inventory of all documents and data that could comprise the legal health record, considering all locations in the organization (for example, separate departments or servers) where such information could be housed. Organizations should also carefully consider whether to include data such as pop-up reminders, alerts, and metadata. Metadata are data about data and include information that track actions such as when and by whom a document was accessed or changed.

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

b. The record should be clearly marked to indicate the presence of a DNR order. A do-not-resuscitate order is a physician's order documenting a patient's (or a substitute decision maker's) desire for no desired resuscitation attempts. Although a DNR order results from a desire expressed in an advanced directive, it does not replace the need for that directive. The health record should contain documentation indicating the presence of a DNR order.

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

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

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

b. Voluntarily or by state law Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central state-wide registry or incidence surveillance program who in turn reports the data to the Centers for Disease Control (CDC).

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

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

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.

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

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

The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record? a. Print out all electronic data postdischarge and file with the rest of the paper record b. Microfilm all electronic data and link to the paper record c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system d. Do not scan any of the paper records

c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system Many hospitals incorporate documents into their EHR systems. Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files in their electronic document management system (EDMS). Using scanned images solves many of the problems associated with traditional paper-based health records and hybrid records.

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

c. Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer.

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

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

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

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

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

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

Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request d. It includes a patient's personal health record

c. It is the record disclosed upon request The legal health record distinction is important for several reasons. First, it is important to an organization's business and legal processes. Second, because the legal health record is the record that is produced upon request, including legal requests, it becomes important to ensure that the legal health record is legally sound and defensible as a valid document in legal situations.

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

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

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

c. Make all essential data fields required Standardization of the collection of patient data is essential to collect the proper information and reach data quality levels needed to support the enhancement of patient care and the healthcare industry. Templates can be created for common types of notes, visits, and procedures.

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

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

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

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

Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event an amendment, addendum, or deletion needs to be made, which following should occur? a. The EHR should retain only the latest version of the document in order to avoid confusion as documenting who made a change and when is never necessary. b. The EHR should not allow any amendments, addendums, or deletions of electronic documents as this violates accreditation standards. c. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made. d. The EHR is not capable of allowing documentation changes. If a document needs to be amended, it must printed, redlined, and scanned into the EHR

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

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

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

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

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

Which of the following are components of AHIMA's principles of information governance? a. Accountability and accessibility b. Integrity and safeguards c. Safeguards and accessibility d. Accountability and integrity

d. Accountability and integrity AHIMA defined the following principles to support proper information governance across an organization: accountability, transparency, integrity, protection, compliance, availability, disposition, and retention.

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

d. Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Data must have definitions and be uniform to prevent information inconsistencies.

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.

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

d. Demographic data Demographic data is used to identify an individual, such as name, address, gender, age, and other information linked to a specific person.

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

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

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

d. Personal health record The tool that Clara is using is a personal health record. Personal health records are a tool that an individual can use to collect, track, and share past and current information about their health.

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

d. Physical examination Review of body systems is typically documented in the report of a physical examination. This would include documentation regarding the HEENT (head, eyes, ears, nose, and throat) and the chest.

Which of the following should be avoided when designing forms for an electronic document management system (EDMS)? a. Color borders around the edge of a form b. Mnemonic descriptor used for nonbarcode recognition engine c. Quarter-inch border on each side of document without bar code d. Shading of bars or lines that contain text

d. Shading of bars or lines that contain text The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images.

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

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

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

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

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

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

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

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

Which of the following is true about the legal health record: a. Is inadmissible into evidence b. May not be hybrid c. Must consist in part on paper d. Will be disclosed upon request

d. Will be disclosed upon request One of the major purposes of a health record is to serve as the legal business record of an organization and as evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request.