HIM 1000 Flashcards
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.
- All entries should be documented and signed by the author.
- Complete only necessary entries on preprinted forms. Leave others blank.
- If other patient(s) are referenced in the record, document their name(s).
- All documentation should be entered in permanent black ink.
- 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
A: 2 and 3
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
A: physical examination
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.
C: The record needs to document evidence of appropriate informed consent.
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.
B: forms committee
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.
B: differential diagnoses
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.
A: 74-year-old readmitted for pneumonia seven days following discharge for this condition.
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
B: Ambulatory record
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
B: forms commitee
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.
c. All entries must be legible and complete.
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.
D: financial data
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.
A. Uniform Hospital Discharge Data Set.
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.
c. living will.
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
C: Health Resources and Services Administration
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
B: general
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
B: National Institutes of Health
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
D: staff model
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
C: AHRQ
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
B: AoA
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
A: American College of Surgeons
Medical assistants routinely perform which task?
A: completing insurance claims
B: writing prescriptions
C: examining and treating patients
D: documenting in patient records
A: completing insurance claims
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.
D: utilization manager.
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
D: nursing assessments
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
C: health data
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
C: clinical data repository
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
A: provisional diagnosis
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
C: report of consultation
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
A: master patient index
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
B: multiple locations must be accessed to retrieve patient records
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
D: unit numbering
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
C: shred the manual MPI within four weeks after the conversion
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
B: admissions and health information
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
C: master patient index
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
D: physician index
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
C: procedure index
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.
D: Progress notes were kept in the normal course of business.
PHI includes all of the following except:
A: patient’s name
B: patient’s date of birth
C: hospital address
D: medical record numbers
C: hospital address
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
B: res ipsa loquitur
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.
C: A nurse administers the wrong medication to a patient. The hospital is liable.
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
D: respondeat superior
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
A: CDT
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
C: diagnostic and therapeutic services with the same principal diagnosis code
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
D: Food and Drug Administration
A durable medical equipment company would classify medical equipment using:
A: CPT codes
B: CDT codes
C: HCPCS Level II codes
D: NDC codes
C: HCPCS Level II codes
The Joint Commission requires that a discharge summary be completed within ____ days of discharge.
a.25
b.15
c.30
d.20
C 30
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
D 1, 2, 4
