PRG Guide RHIT Exam 2016 Questions -- Health Data Content and Standards
42. According to the following table, the most serious record delinquency problem occurred in which of the following months? A. April B. May C. June D. cannot determine from these data
A. April
88. A quarterly review reveals the following data for Springfield Hospital. What is the percentage of incomplete records during this quarter? A. 55% B. 54% C. 33% D. 32%
A. 55%
64. As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set? A. DEEDS B. UHDDS C. MDS D. ORYX
A. DEEDS
68. The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job Description Summative Report" identified that most Clinical Documentation Improvement Specialists report directly to the A. HIM Department. B. CEO. C. Quality Management Department. D. CFO.
A. HIM Department.
19. As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency. A. ONC B. CMS C. OSHA D. CDC
A. ONC
4. Engaging patients and their families in health care decisions is one of the core objectives for A. achieving meaningful use of EHRs. B. the Joint Commission's National Patient Safety goals. C. HIPAA 5010 regulations. D. establishing flexible clinical pathways.
A. achieving meaningful use of EHRs.
75. Stage I of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? A. Use CPOE for medication orders B. Smoking cessation counseling for MI patients C. Appropriate use of HL-7 standards D. Establish critical pathways for complex, high-dollar cases
A. Use CPOE for medication orders
73. Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient." A. discharge summary B. physical exam C. admission note D. clinical laboratory report
A. discharge summary
76. Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? A. disease index B. patient register C. pediatric census sheet D. procedure index
A. disease index
10. You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's A. disease index. B. number control index. C. physicians' index. D. patient index.
A. disease index.
39. You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and will end in 2014. You remind him that by 2015, sanctions for noncompliance will appear in the form of A. downward adjustments to Medicare reimbursement. B. the withdrawal of permission to treat Medicare and Medicaid patients. C. a mandatory action plan for implementing a meaningful use EHR. D. monetary fines up to $100,000.
A. downward adjustments to Medicare reimbursement.
45. As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the A. facility's data dictionary. B. MDS. C. glossary of health care terms. D. UHDDS.
A. facility's data dictionary.
54. In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the A. general appearance as assessed by the physician. B. chief complaint. C. family history as related by the patient. D. subjective review of systems.
A. general appearance as assessed by the physician.
60. In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing A. integrated progress notes. B. interdisciplinary treatment plans. C. source-oriented records. D. SOAP notes.
A. integrated progress notes.
11. Joint Commission requires the attending physician to countersign health record documentation that is entered by A. interns or medical students. B. business associates. C. consulting physicians. D. physician partners.
A. interns or medical students.
23. A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates A. noncompliance with Joint Commission standards. B. compliance with Joint Commission standards. C. compliance with Medicare regulations. D. compliance with Joint Commission standards for nonsurgical patients.
A. noncompliance with Joint Commission standards.
94. One record documentation requirement shared by BOTH acute care and emergency departments is A. patient's condition on discharge. B. time and means of arrival. C. advance directive. D. problem list.
A. patient's condition on discharge.
28. Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? A. pharmacy consultation B. medical consultation C. physical exam D. emergency record
A. pharmacy consultation
98. Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "The patient is alert and in no acute distress. Initial vital signs: T 98, P 102 and regular, R 20 and BP 120/69..." A. physical exam B. past medical history C. social history D. chief complaint
A. physical exam
8. As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the A. prenatal record. B. labor and delivery record. C. postpartum record. D. discharge summary.
A. prenatal record.
13. Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to A. reduce clinical denials for medical necessity. B. decrease medication errors through CPOE systems. C. increase patient engagement through patient portals. D. report sentinel events to the Joint Commission.
A. reduce clinical denials for medical necessity.
83. A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data A. reliability. B. accessibility. C. legibility. D. completeness.
A. reliability.
24. The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to A. require written authorization from a custodial parent before disclosing proof of the child's immunization to the school. B. allow the minor to authorize the disclosure of the proof of immunization to the school. C. simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school. D. allow school officials to authorize immunization disclosures on behalf of a child attending their school.
A. require written authorization from a custodial parent before disclosing proof of the child's immunization to the school.
36. When developing a data collection template, the most effective approach first considers A. the end user's needs. B. applicable accreditation standards. C. hardware requirements. D. facility preference.
A. the end user's needs.
58. The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. B. whether a postoperative infection occurred and how it was treated. C. the quality of follow-up care. D. whether the severity of illness and/or intensity of service warranted acute level care.
A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.
69. Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? A. database B. problem list C. initial plan D. progress notes
B. problem list
46. You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) will be added to his health record. A. interval summary B. consultation report C. advance directive D. interdisciplinary care plan
B. consultation report
17. The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the A. UHDDS. B. MDS. C. OASIS. D. DEEDS.
B. MDS.
44. In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the A. UHDDS. B. MDS. C. Uniform Clinical Data Set. D. Uniform Ambulatory Core Data.
B. MDS.
2. Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be A. personal identification. B. cognitive patterns. C. procedures and dates. D. principal diagnosis.
B. cognitive patterns. The other answer choices represent items collected on Medicare inpatients according to UHDDS requirements. Only "cognitive patterns" represents a data item collected more typically in longterm care settings and required in the MDS.
89. Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital. A. 55% B. 32% C. 33% D. 54%
B. 32%
72. Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. A. Patient admitted with COPD 1/4/2016 and discharged 1/7/2016 B. Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016 C. Baby Boy Hiltz's mother admitted 1/5/2016, C-section delivery, and discharged 1/7/2016 D. Baby Boy Doe admitted 1/3/2016, died 1/4/2016
B. Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016
81. The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an) A. Joint Commission-approved system. B. Certified EHR. C. Functional EMR. D. AMA-approved product.
B. Certified EHR.
82. Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the A. peer review organization. B. National Practitioner Data Bank. C. risk manager. D. Health Plan Employer Data and Information Set.
B. National Practitioner Data Bank.
90. Still referring to the information in the table in question 88 and the delinquent record rate shown in the answer for question 89, would the facility be out of compliance with Joint Commission standards? A. Yes B. No
B. No
34. You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? A. Minimum Data Set B. Uniform Hospital Discharge Data Set C. Conditions of Participation D. Federal Register
B. Uniform Hospital Discharge Data Set
50. A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) A. reviewer. B. analyst. C. educator. D. ambassador.
B. analyst.
16. Ultimate responsibility for the quality and completion of entries in patient health records belongs to the A. chief of staff. B. attending physician. C. HIM director. D. risk manager.
B. attending physician.
93. Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is A. beta blocker at discharge. B. blood culture before first antibiotic received. C. early administration of aspirin. D. discharged on antithrombotic.
B. blood culture before first antibiotic received.
7. Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that A. it is too easy to delegate use of computer passwords. B. evidence cannot be provided that the physician actually reviewed and approved each report. C. electronic signatures are not acceptable in every state. D. tampering too often occurs with this method of authentication.
B. evidence cannot be provided that the physician actually reviewed and approved each report.
57. The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation? A. tissue examination done by the pathologist B. impressions of a cardiologist asked to determine whether patient is a good surgical risk C. interpretation of a radiologic study D. technical interpretation of electrocardiogram
B. impressions of a cardiologist asked to determine whether patient is a good surgical risk
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin and used for administration of drugs during resuscitation." A. physician progress notes B. operative record C. nursing progress notes D. physical examination
B. operative record
61. Which of the following services is LEAST likely to be provided by a facility accredited by CARF? A. chronic pain management B. palliative care C. brain injury management D. vocational evaluation
B. palliative care
1. In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is A. recovery room record. B. pathology report. C. operative report. D. discharge summary.
B. pathology report. Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.
63. Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a A. data warehouse. B. regional health information organization. C. continuum of care. D. data retrieval portal group.
B. regional health information organization.
80. A primary focus of screen format design in a health record computer application should be to ensure that A. programmers develop standard screen formats for all hospitals. B. the user is capturing essential data elements. C. paper forms are easily converted to computer forms. D. data fields can be randomly accessed.
B. the user is capturing essential data elements.
41. Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court C. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record D. when the record is taken to a physician's private office for a follow-up patient visit postdischarge
B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court
66. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of A. peer review. B. quantitative review. C. qualitative review. D. legal analysis.
C. qualitative review.
30. The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is A. 15-0000/00. B. 15-0000/01. C. 15-0001/00. D. 15-0001/01.
C. 15-0001/00.
86. Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every A. week. B. month. C. 60 days. D. 90 days.
C. 60 days.
31. Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data A. reliability. B. timeliness. C. precision. D. validity.
C. precision.
59. In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from A. generic screens used by record abstractors. B. disease index. C. R-ADT system. D. indicator monitoring program.
C. R-ADT system.
51. Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement? A. Yes, within 8 hours postsurgery B. No, as long as it is done ASAP C. Yes, prior to surgery D. Yes, within 24 hours postsurgery
C. Yes, prior to surgery
70. As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use A. patient abstracts. B. patient index. C. accession register. D. follow-up files.
C. accession register.
92. For inpatients, the first data item collected of a clinical nature is usually A. principal diagnosis. B. expected payer. C. admitting diagnosis. D. review of systems.
C. admitting diagnosis.
78. Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data A. timeliness. B. accuracy. C. comprehensiveness. D. security.
C. comprehensiveness.
56. Which of the following is least likely to be identified by a deficiency analysis technician? A. missing discharge summary B. need for physician authentication of two verbal orders C. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist D. x-ray report charted on the wrong record
C. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
47. A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to a large percentage of the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n) A. reviewer. B. analyst. C. educator. D. ambassador.
C. educator.
91. In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the A. information security manager. B. clinical data specialist. C. health information manager. D. risk manager.
C. health information manager.
5. A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A. doctors' progress notes. B. integrated progress notes. C. incident report. D. nurses' notes.
C. incident report.
18. The foundation for communicating all patient care goals in long-term care settings is the A. legal assessment. B. medical history. C. interdisciplinary plan of care. D. Uniform Hospital Discharge Data Set.
C. interdisciplinary plan of care.
20. As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for A. including the primary caregiver in surgery consults. B. including the surgeon in the preanesthesia assessment. C. marking the surgical site. D. apprising the patient of all complications that might occur.
C. marking the surgical site.
40. In creating a new form or computer view, the designer should be most driven by A. QIO standards. B. medical staff bylaws. C. needs of the users. D. flow of data on the page or screen.
C. needs of the users.
14. Discharge summary documentation must include A. a detailed history of the patient. B. a note from social services or discharge planning. C. significant findings during hospitalization. D. correct codes for significant procedures.
C. significant findings during hospitalization.
12. The minimum length of time for retaining original medical records is primarily governed by A. Joint Commission. B. medical staff. C. state law. D. readmission rates.
C. state law.
9. As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman A. a new H&P is required for every inpatient admission. B. that you apologize for not noticing the H&P she provided. C. the H&P copy is acceptable as long as she documents any interval changes. D. Joint Commission standards do not allow copies of any kind in the original record.
C. the H&P copy is acceptable as long as she documents any interval changes.
37. A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the A. physical findings. B. lab and diagnostic test results. C. time and means of arrival. D. instructions for follow-up care.
C. time and means of arrival.
3. In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the A. prohibited use of any abbreviations. B. flagrant use of specialty-specific abbreviations. C. use of prohibited or "dangerous" abbreviations. D. use of abbreviations in the final diagnosis.
C. use of prohibited or "dangerous" abbreviations. The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4." Spelling out the unit is preferred.
85. The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave A. documented in an incident report and filed in the patient's health record. B. reported as a potentially compensable event. C. reported to the Executive Committee. D. documented in both the progress notes and the discharge summary.
D. documented in both the progress notes and the discharge summary.
48. You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at A. 12 hours after admission. B. 24 hours after admission. C. 12 hours after admission or prior to surgery. D. 24 hours after admission or prior to surgery.
D. 24 hours after admission or prior to surgery.
71. As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling A. EMTALA. B. Health Care Quality Improvement Act. C. HIPAA. D. ARRA.
D. ARRA.
62. Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record? A. written signature of the provider of care B. identifiable initials of a nurse writing a nursing note C. a unique identification code entered by the person making the report D. delegated use of computer key by radiology secretary
D. delegated use of computer key by radiology secretary
74. The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the A. Conditions of Participation for Rehabilitation Facilities. B. Medical Staff Bylaws, Rules, and Regulations. C. Joint Commission manual. D. CARF manual.
D. CARF manual.
97. Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets A. Joint Commission standards. B. NHIN standards. C. HL-7 standards. D. CMS standards.
D. CMS standards.
95. In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain A. standing orders. B. telephone orders. C. stop orders. D. discharge order.
D. discharge order.
32. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the A. CARF manual. B. hospital bylaws. C. Joint Commission accreditation manual. D. Federal Register.
D. Federal Register.
22. One of the Joint Commission National Patient Safety Goals (NSPGs) requires that healthcare organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would not be a considered part of a preoperative verification process? A. Confirm the patient's true identity. B. Mark the surgical site. C. Review the medical records and/or imaging studies. D. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
D. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
65. As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the A. Consolidated Manual for Hospitals. B. Federal Register. C. Policy and Procedure Manual. D. Hospital Bylaws, Rules, and Regulations.
D. Hospital Bylaws, Rules, and Regulations.
35. Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's A. EDMS system. B. CPOE. C. expert system. D. RHIO.
D. RHIO.
33. In an acute care hospital, a complete history and physical may not be required for a new admission when A. the patient is readmitted for a similar problem within 1 year. B. the patient's stay is less than 24 hours. C. the patient has an uneventful course in the hospital. D. a legible copy of a current H&P performed in the attending physician's office is available.
D. a legible copy of a current H&P performed in the attending physician's office is available.
27. Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to A. placement of hospital logo. B. signature line for authentication. C. use of box design. D. bar code placement.
D. bar code placement.
29. The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case? A. data comprehensiveness B. data granularity C. data precision D. data accuracy
D. data accuracy
38. A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be A. chief complaint. B. condition on discharge. C. time and means of arrival. D. growth and development record.
D. growth and development record.
53. An example of a primary data source for health care statistics is the A. disease index. B. accession register. C. MPI. D. hospital census.
D. hospital census.
21. One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with A. Joint Commission standards. B. the HIPAA privacy rule. C. Conditions of Coverage rules. D. meaningful use requirements.
D. meaningful use requirements.
87. You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be A. medical staff bylaws. B. quality management plan. C. Joint Commission accreditation manual. D. medical staff rules and regulations.
D. medical staff rules and regulations.
79. In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show A. missing signatures on progress notes. B. missing discharge summaries. C. absence of SOAP format in progress notes. D. missing operative reports.
D. missing operative reports.
26. The best example of point-of-care service and documentation is A. using an automated tracking system to locate a record. B. using occurrence screens to identify adverse events. C. doctors using voice recognition systems to dictate radiology reports. D. nurses using bedside terminals to record vital signs.
D. nurses using bedside terminals to record vital signs.
25. You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? A. disease index B. physician index C. master patient index D. operation index
D. operation index
43. Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following. A. sciatica unimproved with hot pack therapy B. patient moving about very cautiously, appears to be in pain C. adjust pain medication; begin physical therapy tomorrow D. patient states low back pain is as severe as it was on admission
D. patient states low back pain is as severe as it was on admission
52. The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing A. quantitative record review. B. clinical pertinence review. C. concurrent record analysis. D. point-of-care documentation.
D. point-of-care documentation.
6. For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the A. interdisciplinary patient care plan. B. discharge summary. C. transfer record. D. problem list.
D. problem list.
55. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? A. utilization review B. quantitative review C. legal review D. qualitative review
D. qualitative review
84. Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be A. written within 24 hours of the patient's admission. B. accepted by charge nurses only. C. cosigned by the attending physician within 4 hours of giving the order. D. recorded by persons authorized by hospital regulations and procedures.
D. recorded by persons authorized by hospital regulations and procedures.
77. As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with A. the OIG. B. MEDPAR representatives. C. QIO physicians. D. recovery audit contractors.
D. recovery audit contractors.
67. Accreditation by Joint Commission is a voluntary activity for a facility and it is A. considered unnecessary by most health care facilities. B. required for state licensure in all states. C. conducted in each facility annually. D. required for reimbursement of certain patient groups.
D. required for reimbursement of certain patient groups.
96. As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document A. objective symptoms observed by the physician. B. past and current activities, such as smoking and drinking habits. C. a chronological description of patient's present condition from time of onset to present. D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.
D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.
15. The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate A. quality of care through the use of preestablished criteria. B. adverse effects and contraindications of drugs utilized during hospitalization. C. potentially compensable events. D. the overall quality of documentation in the record.
D. the overall quality of documentation in the record.
