Health Data Content and Standards

Question 1

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that_____

Answer 1

evidences cannot be provided that the physician actually reviewed and approved each report.

Question 2

As a concurrent record reviewer for an acute care facility, you hae asked Dr. Crossman to provide an updated hx and px 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
B. apologize for not noticing this H&P
C: the H&P copy is acceptable as long as she documents any interval changes.
D. Joint Commission does not allow copies of any kind

Answer 2

C: the H&P copy is acceptable as long as she documents any interval changes.

Question 3

As a working HIM professional, you are investigating the workforce development projections of EHR specialists as outlined by ARRA ad HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency:

Answer 3

ONC: Office of the National Coordinator for HIT. Federal Agency; charged with coordination of nationwide efforts to implement and use the most advance HIT and the electronic exchange of health information.

Question 4

The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known hx 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

Answer 4

C. 15-0001/00

Question 5

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 immunization records.
B. all the minor to authorize the disclosures of immunization records.
C. Simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
D. refuse to disclose any information regarding child immunizations.

Answer 5

C. Simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.

Question 6

A recommendation for improvement from Joint Commission is indicated if the number of delinquent records is greater than __% or if the percentage of records with delinquent records due to missing H&Ps exceeds __% of the average monthly discharges. The percentage of incomplete records is ___ ________.

Answer 6

50; 2; not relevant.

Question 7

Facilities that area 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

Answer 7

D. Bar code placement

Question 8

A data element you would expect to be collected in the MDS, but NOT on the UHDDS would be:

A. Personal identification
B. Cognitive Patterns
C. Procedures and dates.
D. Principal Diagnosis

Answer 8

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 long-term care settings and required in the MDS.

Question 9

When a patient is readmitted within __ days for the same or a related condition, an interval H&P may be completed if the original H&P is readily available.

Answer 9

30

Question 10

Pt. presents to the ER in a coma. Her sister says the patient has had a recent medical history taken at the public health department. The physician on call can access this patient information using the area’s _____.

Answer 10

RIO

Regional Health Information Organization

Question 11

The minimum length of time for retaining original medical records is primarily governed by:

Answer 11

state law

Question 12

As part of a quality improvement study, you have been asked to provide information on the menstrual hx, number of pregnancies, and number of living children for each OB patient from a stack of old OB records. The best place to locate this information is the:

A. Prenatal record.
B. labor and delivery records
C. Postpartum Record
D. Discharge Summary

Answer 12

A: Prenatal record

(antepartum=prenatal)
The antepartum (prenatal) record should include a comprehensive hx and px exam on each OB patient with particular attention to menstrual and reproductive hx.

Question 13

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of

Answer 13

Office of Civil Rights

Question 14

The 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:

Answer 14

Pathology report

Question 15

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________ _________.

Answer 15

Federal Register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.

Question 16

You notice on the admission H&P that Mr. McKahan, a medicare pt, 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 records.

Answer 16

CONSULTATION REPORT

Question 17

In 1987, OBRA helped shift the focus in long-term care to patient outcomes.  As a result, core assessment datea elements are collect on each SNF resident as defined in the 
A. UHDDS
B. MDS
C Uniform Clinical Data Set
D. Uniform Ambulatory Core Data.

Answer 17

B. MDS (Minimum Data Set)

Question 18

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

Answer 18

A. Achieving meaningful use of EHRs

Question 19

A major contribution to a succcessful CDI program is the ability to demonstrate the impact that documentation has on data reporting to the facility's staff.  In this role, the Clinical Documentation specialist is acting as a(n)\_\_\_\_\_\_\_
A.  reviewer
B. analyst
C. auditor
D. ambassador

Answer 19

C. auditor

Question 20

The Clinical Documentation Specialist is 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 is acting as a(n)
A. reviewer
B. analyst
C. educator
D. ambassador

Answer 20

B. analyst

Question 21

Joint Commission standards require that a complete H&P 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 post surgery

Answer 21

C. Yes, prior to surgery

Question 22

To consistently enter data into the patient’s record at the time and location of service instead of waiting for retrospectively is called __________________documentation

Answer 22

point-of-care

Question 23

An example of a primary data source for health statistics is the 
A. disease index
B. accession register
C. MPI
D. health record

Answer 23

D. Health record

The other answers are examples of secondary data sources

Question 24

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 the acute level care

Answer 24

A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

Question 25

What review category?

The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

.

Answer 25

Qualitative

Question 26

What review category?

Whether a postoperative infection occurred and how it was treated.

Answer 26

Infection Control Officer

Question 27

What review category?

The quality of follow-up care

Answer 27

Clinical Care Evaluation Process

Question 28

What review category?

Whether the severity of illness and/or intensity of service warranted the acute level care

Answer 28

Utilization review