HIM 1000

Question 1

Sunny Valley Hospital has adopted the following as part of its patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices.

1. All entries should be documented and signed by the author.
2. Complete only necessary entries on preprinted forms. Leave others blank.
3. If other patient(s) are referenced in the record, document their name(s).
4. All documentation should be entered in permanent black ink.
5. Be sure to document specific information and to avoid vague entries.

a. 2 and 3
b. 2 and 5
c. 1 and 4
d. 1 and 2

Answer 1

A: 2 and 3

Question 2

Review the following patient record entry, and determine in which report it would be documented.

Skin No jaundice reveals pale, cool, and moist surface.
Chest Respirations normal.
Lungs Clear on inspection, percussion, and auscultation.
Abdomen No tenderness, guarding, or rigidity.
Extremities No significant findings.
Genitalia Normal.
Rectal Deferred.

a. physical examination
b. review of systems
c. chief complaint
d. history of present illness

Answer 2

A: physical examination

Question 3

Ms. RHIT is developing an audit tool to be used to review records in preparation for the Joint Commission survey. Which of the following is a standard that should be included on the audit tool?
a. The discharge summary must be completed within 35 days of discharge.
b. Each record needs to include a statistical summary sheet.
c. The record needs to document evidence of appropriate informed consent.
d. The attending physician must sign an attestation statement.

Answer 3

C: The record needs to document evidence of appropriate informed consent.

Question 4

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the
a. surgery committee.
b. forms committee.
c. executive board.
d. medical staff.

Answer 4

B: forms committee

Question 5

Dr. Cook records the following as part of a history and physical examination: “Patient presents with abdominal pain of seven days’ duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon.” The diagnoses recorded are
a. secondary diagnoses.
b. differential diagnoses.
c. admission diagnoses.
d. primary diagnoses.

Answer 5

B: differential diagnoses

Question 6

In which of the following cases would documentation of an interval history be acceptable?
a. 74-year-old readmitted for pneumonia seven days following discharge for this condition.
b. 34-year-old woman readmitted for chest pain following delivery of a baby girl three days ago.
c. Newborn admitted four days after birth for dehydration who is treated with IV fluids.
d. 17-year-old patient admitted for appendicitis who undergoes routine surgery during admission.

Answer 6

A: 74-year-old readmitted for pneumonia seven days following discharge for this condition.

Question 7

The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the:
a. discharge summary
b. ambulatory record
c. short stay summary
d. inpatient record

Answer 7

B: Ambulatory record

Question 8

Dr. Smith wants to implement a new form to record postoperative complications. This should be reviewed to be approved for use in the medical record by the:
a. tissue committee
b. forms committee
c. supervising operating room nurse
d. medical director

Answer 8

B: forms commitee

Question 9

Which statement regarding the patient record is true?

a. Only the front page of a two-page document must contain patient identification.
b. An alias cannot be used in a patient record.
c. All entries must be legible and complete.
d. The author of each entry does not have to sign the note if another supervising professional has signed it.

Answer 9

c. All entries must be legible and complete.

Question 10

The name, address, and phone number of the third-party payer is considered

a. identification data.
b. supplemental data.
c. demographic data.
d. financial data.

Answer 10

D: financial data

Question 11

The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the
a. Uniform Hospital Discharge Data Set.
b. Medicare/Medicaid Discharge Data Set.
c. Medicare/Medicaid Core Data Set.
d. Hospital Core Data Set.

Answer 11

A. Uniform Hospital Discharge Data Set.

Question 12

A document that informs a health care provider of a patient’s desire regarding various life-sustaining treatment is a

a. organ donation card.
b. do not resuscitate order.
c. living will.
d. health care proxy.

Answer 12

c. living will.

Question 13

The agency that oversees the nation’s organ transplantation system and works to decrease infant mortality and improve child health is called the:

a: Administration for Children and Families

b: Centers for Medicare and Medicaid Services

c: Health Resources and Services Administration

d: Program Support Center

Answer 13

C: Health Resources and Services Administration

Question 14

A hospital that provides emergency care, performs surgery, and admits patients for a range of problems is a ____ hospital.

a: behavioral health

b: general

c: specialty

d: rehabilitation

Answer 14

B: general

Question 15

The agency known as the premier medical research organization in the United States that supports research projects nationwide is called the

A: Health Resources and Services Administration

B: National Institutes of Health

C: Office of the Secretary of Health and Human Services

D: Program Support Center

Answer 15

B: National Institutes of Health

Question 16

An HMO in which the physicians are employed by the HMO, subscribers pay premiums to the HMO, and all ambulatory care services are provided within HMO corporate buildings is a(n):

A: direct contract

B: group model

C: individual practice

D: staff model

Answer 16

D: staff model

Question 17

Which of the following agencies supports research designed to improve the outcomes and quality of health care, reduce costs, address patient safety and medical errors, and broaden access to effective services?

A: ACF

B: AoA

C: AHRQ

D: CDC

Answer 17

C: AHRQ

Question 18

Which of the following agencies supports a nationwide aging network to provide services to the elderly to enable them to remain independent?

A: AMA

B: AoA

C: CDC

D: CMS

Answer 18

B: AoA

Question 19

Which organization was founded to improve the quality of care for surgical patients by establishing standards for surgical education and practice?
A: American College of Surgeons
B: American Hospital Association
C: American Medical Association
D: National Medical Association

Answer 19

A: American College of Surgeons

Question 20

Medical assistants routinely perform which task?
A: completing insurance claims
B: writing prescriptions
C: examining and treating patients
D: documenting in patient records

Answer 20

A: completing insurance claims

Question 21

Suzy Staff’s job responsibilities include coordinating patient care to ensure that patients receive timely discharge or transfer. Her job title is:
A: privacy officer.
B: quality manager.
C: risk manager.
D: utilization manager.

Answer 21

D: utilization manager.

Question 22

The quality improvement committee wants to determine the number of patients admitted with a fever. The quickest way to locate this information would be to review the:

A: admission history and physicals

B: face sheets

C: input/output records

D: nursing assessments

Answer 22

D: nursing assessments

Question 23

Sally Smith, a pediatric nurse, is collecting the birth weights of children that have a length of stay in the neonatal intensive care unit longer than 60 days. This represents:

A: health information

B: patient information

C: health data

D: clinical data and information

Answer 23

C: health data

Question 24

A(n) _____ includes the merging of data from different data systems into one centralized database.

a: clinical information system

B: automated patient record system

C: clinical data repository

d: hybrid data repository

Answer 24

C: clinical data repository

Question 25

Which of the following would not be documented on a medication administration record? A: provisional diagnosis B: medication given c: dosage given d: nurse who administered medication

Answer 25

A: provisional diagnosis

Question 26

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary’s chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the: A: discharge summary B: interval history and physical C: report of consultation D: review of systems

Answer 26

C: report of consultation

Question 27

Ms. RHIT is given an alphabetical listing of patients who had surgery during the time period January 2 through March 1. She needs to determine their patient numbers and pull the records. Her first step would be to reference the: A: master patient index B: number index C: surgery schedule D: surgery index

Answer 27

A: master patient index

Question 28

A disadvantage of the serial numbering system is that: A: computer software must be purchased to manage the system B: multiple locations must be accessed to retrieve patient records C: previous folders must remain in the file system D: staff training is difficult and time consuming

Answer 28

B: multiple locations must be accessed to retrieve patient records

Question 29

Rebecca Brown was born at Mercy Hospital in 1967 and assigned patient number 576890. She was admitted in 1974 for a tonsillectomy and reassigned number 576890. All of her admissions are filed in a single folder. The system being used is: A; numerical B: serial numbering C: serial-unit numbering D: unit numbering

Answer 29

D: unit numbering

Question 30

Hillcrest Hospital and Endwell Hospital are merging. The new HIM director for both hospitals needs to ensure that the two MPIs are accurately merged. Each hospital currently uses manual MPIs, and they will convert to one automated MPI. Which activity below should the director avoid? A: establish a merger plan for the hospital MPIs B: perform a manual alphabetical search to identify duplicate MPI files C: shred the manual MPI within four weeks after the conversion D: use software to identify and correct errors in the automated MPI

Answer 30

C: shred the manual MPI within four weeks after the conversion

Question 31

The HIM director is writing a policy to ensure the accuracy of an automated MPI. The two departments that should be allowed to enter or update information in the master patient index are: A: admissions and nursing B: admissions and health information C: health information and nursing D: health information and medical staff

Answer 31

B: admissions and health information

Question 32

Sally Jones presents to the department (ED) with lower-left abdominal pain. The ED physician asks the ED clerk to determine if the patient was previously seen in the facility. The quickest way for the ED clerk to obtain this information is to reference the: A: disease index B: ED log C: master patient index D: patient’s record

Answer 32

C: master patient index

Question 33

Dr. James is completing a report for a medical staff committee. He needs to determine the number of patients admitted by Dr. Tops for the month of July with the diagnosis of anemia. The best source for this information would be the: A: disease index B: master patient index C: procedure index D: physician index

Answer 33

D: physician index

Question 34

The chief of surgery wants to determine the number of cholecystectomies performed over the last six months using a scope and as open surgeries. This information can be obtained from the: A: disease index B: master patient index C: procedure index D: physician index

Answer 34

C: procedure index

Question 35

Sally Smith, a health information department employee, is placed on the witness stand during a court hearing. She may testify that: A: The patient’s cardiac arrest was drug-induced. B: Dr. Top was the best physician to cover this case. C: The patient was comatose upon arrival in the emergency department. D: Progress notes were kept in the normal course of business.

Answer 35

D: Progress notes were kept in the normal course of business.

Question 36

PHI includes all of the following except: A: patient’s name B: patient’s date of birth C: hospital address D: medical record numbers

Answer 36

C: hospital address

Question 37

Dr. Smith operated on Polly Jones, and it was determined three weeks after surgery that Dr. Smith left a small needle in the patient’s abdomen. Which doctrine would apply to this negligent act? A: res gestae B: res ipsa loquitur C: res judicata D: respondeat superior

Answer 37

B: res ipsa loquitur

Question 38

The doctrine of respondeat superior would apply in which of the following situations? A: An ambulance company documents incorrect information on an ambulance report. The hospital is liable. B: An X-ray technician prepares the wrong patient for a CT scan. The supervisor is liable. C: A nurse administers the wrong medication to a patient. The hospital is liable. D: An attending physician operates on a patient’s wrong leg. The hospital is liable.

Answer 38

C: A nurse administers the wrong medication to a patient. The hospital is liable.

Question 39

Mark Jones is receiving traction in the physical therapy department at Happy Hospital. The therapist sets the traction unit at a level higher than ordered, and Mark is injured. The hospital is liable for the negligent act under the doctrine of: A: res gestae B: res ipsa loquitur C: res judicata D: respondeat superior

Answer 39

D: respondeat superior

Question 40

Sally is a coder for a dentist and needs to purchase updated service and procedure coding books. She should purchase: A: CDT B: CPT C: HCPCS Level II D: CDT and ICD-10-CM

Answer 40

A: CDT

Question 41

The inpatient prospective payment system (IPPS) 72-hour rule requires that outpatient preadmission services provided by a hospital up to three days prior to a patient’s inpatient admission be covered by the DRG payment for: A: diagnostic services B: diagnostic and pharmacy services C: diagnostic and therapeutic services with the same principal diagnosis code D: therapeutic services

Answer 41

C: diagnostic and therapeutic services with the same principal diagnosis code

Question 42

National Drug Codes are managed by the: A: American Medical Association B: American Pharmacy Association C: Centers for Medicare and Medicaid Services D: Food and Drug Administration

Answer 42

D: Food and Drug Administration

Question 43

A durable medical equipment company would classify medical equipment using: A: CPT codes B: CDT codes C: HCPCS Level II codes D: NDC codes

Answer 43

C: HCPCS Level II codes

Question 44

The Joint Commission requires that a discharge summary be completed within ____ days of discharge. a.25 b.15 c.30 d.20

Answer 44

C 30

Question 45

Which of the following statements would be found as part of a preanesthesia note? 1. Patient denies any previous reactions to anesthesia. 2. Anesthesia to be used-general. 3. Patient had no reaction to current surgery. 4. Patient is at risk due to smoking history. a.2 and 3 b.1, 2, and 3 c.1 and 2 d.1, 2, and 4

Answer 45

D 1, 2, 4

Question 46

The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the a. Uniform Hospital Discharge Data Set. b. Medicare/Medicaid Discharge Data Set. c. Medicare/Medicaid Core Data Set. d. Hospital Core Data Set.

Answer 46

a. Uniform Hospital Discharge Data Set.

Question 47

Nurse Jones takes a telephone order from Dr. Blake. Determine which of the following should occur. A: Dr. Blake needs to sign the order within the time period specified by the facility's medical staff bylaws. B: the order need to be signed by the phone staff C: Dr Blake needs to sign the order if the order is altered D: The order doesnot need to be signed by dr blake if it was signed by nurse jones

Answer 47

A: Dr. Blake needs to sign the order within the time period specified by the facility's medical staff bylaws.

Question 48

Sunny View Hospital is part of a large university hospital with a very active and congested file area. Records are filed and refiled throughout the day. Which filing system should be used to distribute the records equally in the file area? A. numeric B. serial C. serial-unit D. terminal digit

Answer 48

D. terminal digit

Question 49

Which of the following is not a primary care service? A: Vision and hearing screening B: Family planning C: Annual physical examination D: Hysterectomy

Answer 49

D: Hysterectomy

Question 50

Sunny Valley Hospital uses auto-authentication for transcribed records. Which of the following would apply? A: Physicians enter a unique identifier before a report is transcribed. B: physicians enter a unique identifier after a report is transcribed C: Physicians sign the report after the report is placed on the chart D: Physicians enter a unique indentifier immediately following transcription

Answer 50

A: Physicians enter a unique identifier before a report is transcribed.

Question 51

Critical access hospitals (CAHs) are those located more than ____ miles from any other hospital or another CAH A: 20 B 35 C 30 D 50

Answer 51

B 35

Question 52

Mrs. organized has developed a draft strategic plan for Sunny Valley Hospital and will present the plan at the hospital board of trustees meeting next month. Ms. organized's role at Sunny Valley Hospital is most likely _______ A chairperson of the board B chief executive officer C chief information official D chief operating officer

Answer 52

B chief executive officer

Question 53

Dr. Smith operated on Polly Jones, and it was determined three weeks after surgery that Dr. Smith left a small needle in the patient's abdomen. Which doctrine would apply to this negligent act? A

Answer 53

res ipsa loquitur

Question 54

Dr. Smith is applying for health care privileges at Hilltop Hospital. As part of the process Sally Jones, medical staff coordinator, needs to obtain information about Dr. Smith's licensure, medical malpractice history, and record of clinical privileges. This information can best be obtained from the:

Answer 54

National Practitioner Data Bank

Question 55

Nurse Robin is using a report that records the late dosing of patients' medications. This report was generated from which type of application? A nursing B pharmacy C administrative D medical documentation

Answer 55

A nursing

Question 56

The National Commission on Correctional Health Care establishes standards that cover the following except: A health record b health care service support c facility D Inmate Visitation Schedule

Answer 56

Inmate Visitation Schedule

Question 57

The QI department needs to obtain a list of patients discharged within the last three months with a diagnosis of diverticulitis. This information can be obtained from the: A disease index b physician index c procedure index d counter partner index

Answer 57

Disease Index

Question 58

Which statement regarding the credentialing of a medical assistant is true? A. Both the RMA and CMA credentials are obtained through the Association of Medical Technologists. B. CMA credentialing is obtained through the American Association of Medical Assistants (AAMA). C. CMA-eligible students can graduate from a program accredited by the United States Department of Education. D. RMA-eligible students must graduate from a CAAHEP or ABHES accredited academic program.

Answer 58

B. CMA credentialing is obtained through the American Association of Medical Assistants (AAMA).

Question 59

which as a standard classification of mental disorders published by the american psychiatric association APA a ICHDH b ncd c dsm d cpt

Answer 59

c dsm

Question 60

Which coding system is used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures? a

Answer 60

ICD-10-CM/ICD-10-PCS

Question 61

is a hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or who need certain surgeries a military service b acute care c long-term care d rehabilitation

Answer 61

b acute care

Question 62

Which of the following describes alphabetic filing systems?

Answer 62

Changed patient names are cross-referenced.

Question 63

AHIMA requires RHITs and RHIAs to submit proof of continuing education every:

Answer 63

A: two years

Question 64

An Internet-based third-party entity that manages and distributes software-based services across a WAN from a central data center is known as a(n) ____ provider.

Answer 64

✓ application service

Question 65

Movable files are also known as: a. compressible files b. closed files c. lateral files d. open files

Answer 65

a. compressible files

Question 66

Medical staff members are granted clinical privileges by the_______.

Answer 66

governing board

Question 67

The type of law passed by a legislative body that can be amended, repealed, or expanded by that legislative body is called:

Answer 67

✓ statutory law

Question 68

A health care professional who oversees the development, implementation, maintenance of, and adherence to the organization's policies that cover the safeguarding of patient health information is called a

Answer 68

A: privacy officer

Question 69

Inpatients admitted to critical access hospitals are restricted to stays of ___ hours A) 96 B) 24 C) 72 D) 48

Answer 69

A) 96

Question 70

The Joint Commission and _____ work together to standardize common measures called the National Hospital Quality Measures. A) AHIMA B) AMA C) CMS D) WHO

Answer 70

CMS

Question 71

The Medicaid Integrity Program, a fraud and abuse detection program, was established by the:

Answer 71

A: Deficit Reduction Act of 2005

Question 72

data is defined as

Answer 72

raw facts

Question 73

Which of the following statements is true? A) A covered entity must protect PHI of a deceased patient for six years. B) A covered entity may not disclosure PHI to a business associate. C) HIPAA mandates a time limit of 60 days for covered entities to respond to amendment requests. D) Patients are not allowed access to their medical records until 60 days after discharge.

Answer 73

C) HIPAA mandates a time limit of 60 days for covered entities to respond to amendment request.

Question 74

Which of the following observations would be found in the physical examination report? a. Abdomen soft and tender with no rebound tenderness. b. Has smoked two packs of cigarettes daily for past 30 years. c. Needs assistance to perform activities of daily living. d. Review of systems negative for hypertension and diabetes.

Answer 74

a. Abdomen soft and tender with no rebound tenderness.

Question 75

An authorization to disclose protected health information is NOT required when A) a patient's new employer wishes to verify his past medical history. B) Dr. Jones releases records to Dr. Smith for continuity of patient care. C) Happy Hospital identifies a patient as a cancer survivor in their newsletter. D) ABC Insurance Company verifies that a patient was diagnosed with HIV.

Answer 75

B) Dr. Jones releases records to Dr. Smith for continuity of patient care.

Question 76

The organization that continues to improve the quality and availability of substance abuse prevention, addiction treatment, and mental health services is: A) FDA B) IHS C) NIH D) SAMHSA

Answer 76

A: SAMHSA

Question 77

Sally works in a pathology laboratory, gathering information for staff pathologists. Which nonenclature does she use in her job? A) DSM B) SNO C) SNOMED D) SNDO

Answer 77

✓ SNOMED

Question 78

The goal of the Recovery Audit Contractor program is A) recover payments made to health care facilities regardless of the payer B) audit health care records for incomplete documentation C) reimburse beneficiaries for payments made to them in error D) identify improper payments made on claims of health care services provided to medicare beneficiaries

Answer 78

D) identify improper payments made on claims of health care services provided to medicare beneficiaries

Question 79

Which of the following is true? a. Automated record systems can help to prevent drug interactions. b. Automated record systems have lower start-up costs than do manual systems. c. Secure electronic communications among patients and providers does not need to be present for communication to occur. d. In a manual patient record system, many users can access patient information at the same time.

Answer 79

a. Automated record systems can help to prevent drug interactions.

Question 80

The Joint Commission requires patient records to be completed ____ days after a patient is discharged. a. 25 b. 10 c. 15 d. 30

Answer 80

D 30

Question 81

The CPC, CPC-H, CPC-A and CPC-H-A certifications are sponsored by: A. AAPC B. AHIMA C. AMA D. ACMCS

Answer 81

A. AAPC

Question 82

Which of the following authorized the implementation of a PQRI that established a financial incentive for eligible professionals who participate in a voluntary quality reporting program A. Tax Relief and Health Care Act of 2006 B. Deficit Reduction Act of 2005 C. Patient Safety and Quality Improvement Act D. HITECH Act

Answer 82

A. Tax Relief and Health Care Act of 2006

Question 83

In relation to a hybrid record system, which of the following is false? a. It helps organizations make the transition to a fully electronic system. b. It totally eliminates paper record storage. c. Technical staff is needed. d. It improves readability in some sections of the record

Answer 83

b. It totally eliminates paper record storage.

Question 84

Ms. RHIT is writing a policy for filing alphabetic records. Which statement below should be included in the policy? a. When a patient is a senior or junior, file the record using senior or junior as the surname. b. Prefixes included as part of the patient's last name are filed alphabetically. c. Arrange patient names according to given name, then surname. d. When a hyphen is used in a patient's name, ignore the letters that follow the hyphen.

Answer 84

b. Prefixes included as part of the patient's last name are filed alphabetically.

Question 85

A disadvantage of the serial numbering system is that a. multiple locations must be accessed to retrieve patient records. b. computer software must be purchased to manage the system. c. previous folders must remain in the file system. d. staff training is difficult and time-consuming.

Answer 85

a. multiple locations must be accessed to retrieve patient records.

Question 86

Which of the following is a disadvantage of automated systems? a. Updates of information are not easy. b. Retrieval of customized information is difficult. c. Technical staff is needed to maintain the system. d. There is no downtime.

Answer 86

c. Technical staff is needed to maintain the system.

Question 87

Hillcrest Hospital is conducting research on Alzheimer's disease and wishes to obtain information from its state's registry. Which information below would be unavailable from the registry?

Answer 87

✓ patient names

Question 88

The early computerized medical record automation efforts focused on the: a. scanning of documents into imaging systems. b. development of RHIOs. c. development of alerts, medication administration records, and provider orders communication and notes. d. networking between the systems of separate facilities.

Answer 88

c. development of alerts, medication administration records, and provider orders communication and notes.

Question 89

each year the business office, ancillary departments, and HIM department update the changes and codes for all procedures, services, and supplies. This information is entered into the computer system to create a A) encounter form B) financial record C) superbill D) chargemaster

Answer 89

D) chargemaster

Question 90

James Jones is scheduled for outpatient surgery on July 15. He undergoes preoperative testing on July 3 and is assigned patient record number 234567. He undergoes outpatient surgery on July 15 and is assigned patient record number 334789. On October 10, he is admitted as an inpatient and assigned patient record number 435679. His record is filed in three different locations. The system being used is:

Answer 90

b. Serial Numbering

Question 91

Patients that undergo procedures that can be performed on an outpatient basis are categorized as A) ambulatory patients B) clinic outpatients C) observation patients D) ambulatory surgery patients

Answer 91

D) ambulatory surgery patients

Question 92

The purpose for which data is collected is known as:

Answer 92

a. Data Application

Question 93

Hillcrest Hospital uses terminal-digit numbering to file records and color codes only the primary number. Using the table below, what would be the color pattern for record number 39-09-15?

Answer 93

c. Red, Dark Green

Question 94

Which of the following is documented on the physical examination? a .Denies loss of hearing. b .Patient's lungs are congested. c. Zocar, 40 mg, daily d."I'm feeling very tired lately."

Answer 94

b. Patient's lungs are congested.

Question 95

Dr. Jones records the following information in the section of a patient's SOAP note: BP is 120/74. Temperature is 100 degrees examination, lungs are clear but patient has nasal congestion. ✓ b. Objective

Answer 95

✓ b. Objective

Question 96

Every report and every page/screen in a manual or computerized patient record must include a. patient name and identification number. b. patient name and date of birth. c. medical record number and Social Security number. d. medical record number and date of birth.

Answer 96

a. patient name and identification number.

Question 97

Which of the following will occur in an HIM department that has an electronic record system?

Answer 97

Notes that are not authenticated.

Question 98

Sue has just accepted a position at the National Library of Medicine to retrieve and process electronic biomedical information for health care universities. Her supervisor informs her that she will be receiving coding training for: A CMIT B CPT C UMLS D DSM-III

Answer 98

C UMLS

Question 99

A candidate for hospice care would be a patient who: A was diagnosed with cancer B has a nonhealing fracture C is a postsurgical patient D manages his high blood pressure at home

Answer 99

A was diagnosed with cancer

Question 99

A candidate for hospice care would be a patient who: A was diagnosed with cancer B has a nonhealing fracture C is a postsurgical patient D manages his high blood pressure at home

Answer 99

A was diagnosed with cancer

Question 100

Dr. Smith has 10 patient records that are delinquent. The action that could be taken by the hospital includes a. suspension of license. b. suspension of physician privileges. c. revoking the physician's license. d. denial of clinical privileges.

Answer 100

b. suspension of physician privileges.

Question 101

Hillcrest Hospital is writing a retention policy for the health information management (HIM) department. Which index must be retained permanently? A disease index B master patient index C procedure index D operative index

Answer 101

B master patient index

Question 102

Intravenous administration of chemical agents that have specific and toxic effects upon a disease - causing cell or organism. A hydration therapy B pain management C chemotherapy D drug therapy

Answer 102

C chemotherapy

Question 103

A formal recording of items, names, or actions is known as a A Chart B register C line graph D index

Answer 103

B register

Question 104

Hospital reimbursement based on a retrospective payment system that issues payment based on daily charges is called A) per diem B) RPS C) an 80/20 plan D) fee_for_service

Answer 104

A) per diem

Question 105

The exchange of data among multiple software products is known as: A data collection B data capture C computer interface D computer sharing

Answer 105

C computer interface

Question 106

Which of the following is an advantage of an automated systems? a. Low start-up costs. b. Requires untrained staff. c. User resistance is unlikely. d. Eliminates paper record storage.

Answer 106

d. Eliminates paper record storage.

Question 107

The process of translating data into information utilized for an application.

Answer 107

data analysis

Question 108

a group practice usually consists of

Answer 108

three or more physicians

Question 109

Which is a freestanding facility that provides radiographic services such as MRI and PET? A) imaging center B) satellite center C) clinical laboratory D) clinical center

Answer 109

A) imaging center

Question 110

Nurse flower is reviewing an electronic report of patient Katie's CBC and urinalysis, This report has most likely been generated as part of a ___ application A radiology B patient monitoring C pharmacy D laboratory

Answer 110

D laboratory

Question 111

a nursing home administrator places the following advertisement in a local newspaper: "Seeking a health care professional who has the ability to coordinate a program to ensure superior patient care, monitor and improve patient outcomes, monitor facility compliance with accreditation and regulatory standards, and coordinate preparation for survey's

Answer 111

quality manager

Question 112

The physicians at Sunny Valley Hospital have requested that all progress notes be organized with the most current progress note filed first, a type of filing order known as:

Answer 112

reverse chronological date order