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A critical early step in designing an EHR is to develop a(n) _____ in which the characteristics of each data element are defined.
2 Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop _____.
3 In healthcare, data sets serve two purposes. The first purpose is to identify data elements to be collected about each patient. The second is to _____.
4 A health information technician has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is _____.
5 Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and UACDS?
B. They provide a complete and exhaustive list of data elements that must be collected. 6 A corporation is evaluating several health plans for its benefits package. The data set that provides comparison information about health plan performance is _____.
7 The name of the government agency that has led the development of basic data sets for health records and computer data bases is _____.
D. National Committee on Vital and Health Statistics 8 The primary purpose of a minimum data set in healthcare is to _____.
9 The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the _____.
B. Uniform Hospital Discharge Data Set 10 Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for _____.
A. Performance Improvement Programs 11 While the focus of inpatient data collection in the UHDDS is on principal diagnosis, the focus of outpatient data collection in the UACDS is on _____.
12 In long term care, the resident's care plan is based on data collected in the _____.
13 Reimbursement for home health services is dependent on data collected from _____.
14 Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for _____.
15 A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is _____.
A. Continuity of Care Record 16 The home health prospective payment system uses the _____ data set for patient assessments.
17 The government agency most closely involved in the development of healthcare data sets and information standards is _____.
D. National Centers for Health Statistics 18 The data set designed to organize data for public release about the outcomes of care is _____.
19 OASIS data are used to assess the _____ of home health services.
20 Which of the following indexes and databases includes patient-identifiable information?
C. Master Patient/Population Index 21 Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a POMR progress note would this notation be written?
22 A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written?
23 A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Duril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?
24 A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
25 The set of all terms that may be used in a language is referred to as a _____.
26 Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services?
B. Healthcare Common Procedure Coding System 27 Which of the following provides a detailed classification system for coding the histology, topography, and behavior of neoplasms?
C. International Classification of Diseases for Oncology, Third Edition 28 Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?
D. Systematized Nomenclature of Medicine Clinical Terminology 29 Which of the following provides a system for classifying morbidity and mortality information for statistical purposes?
D. International Classification of Diseases, Ninth Revision, Clinical Modification 30 Which of the following is not a knowledgeable source for users of the Unified Medical Language System?
31 Nosology can be defined the branch of medical science that deals with _____.
D. Classification Systems 32 Which of the following classifications is used exclusively for classifying cases of malignant disease?
33 Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
34 Which of the following provides a set of codes used for collecting data about substance abuse and mental health disorders?
35 Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
36 The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
37 The term used to describe expected data values is _____.
38 The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as carcinoma on the discharge summary. This is an example of a problem with:
39 Which of the following is a primary weakness of the paper-based health record?
A. Difficulty to Provide Availability to a Number of Providers at the Same Time 40 Which of the following elements is not a component of most patient records?
41 Which of the following is not a characteristic of high-quality healthcare data?
42 Which of the following represents an example of data granularity?
C. A Numerical Measurement Carried Out to the Appropriate Decimal Place 43 Which of the following is a primary purpose of the health record?
A. Document Patient Care Delivery 44 Which of the following best describes data accuracy?
45 Which of the following best describes data completeness?
C. Data Include All Required Elements 46 Which of the following best describes data accessibility?
B. Data Are Easy to Obtain 47 In which department/unit does the health record typically begin?
48 Identify where the following information would be found in the acute care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the upper left extremity was prepped and draped in the standard fashion."
49 Identify where the following information would be found in the acute care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."
A. Medical Laboratory Report 50 Identify where the following information would be found in the acute care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine."
51 The attending physician is responsible for which of the following types of acute care documentation?
52 A nurse is responsible for which of the following types of acute care documentation?
53 Which of the following is an example of clinical data?
54 Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
55 The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear?
56 The following is documented in an acute care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear?
57 The following is documented in an acute care record: "Admit to 3C. Diet: NPO, Meds: Compazine 10mg, IV Q 6 PRN." In which of the following would this documentation appear?
58 The following is documented in an acute care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the upper left extremity was prepped and draped in the standard fashion."
59 The following is documented in an acute care record: "CBC: WBC 12.0H, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93." In which of the following would this documentation appear?
B. Clinical Laboratory Report 60 The following is documented in an acute care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear?
61 The following is documented in an acute care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?
62 The following is documented in an acute care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear?
63 The following is documented in an acute care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: Referral. Case manager to meet with patient and family." In which of the following would this documentation appear?
64 Which of the following is not usually a part of quantitative analysis review?
C. Checking that every word in the record is spelled correctly. 65 Which of the following materials is not documented in an emergency care record?
C. Patient's complete medical history. 66 Which of the following provides macroscopic and microscopic information about tissue removed during an operative report?
67 Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in which of the following records?
68 In a problem-oriented medical record, problems are organized _____.
69 What is the defining characteristic of an integrated health record format?
D. Integrated health records components are arranged in strict chronological order. 70 Which of the following represents documentation of the patient's current and past health status?
71 Which of the following contains the physician's findings based on an examination of the patient?
72 What is the function of a consultation report?
B. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care. 73 What is the function of physician's orders?
C. Documents the physician's instructions to other parties involved in providing care to a patient. 74 What type of patient care record includes documentation of a family bereavement period?
75 Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of _____ review.
76 Which of the following is a secondary purpose of the health record?
77 Use of the health record by a clinician to facilitate quality patient care is considered _____.
A. A primary purpose of the health record. 78 Use of the health record to monitor bioterrorism activity is considered a _____.
B. A secondary purpose of the health record. 79 In designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions is the E1384 standard promulgated by the _____.
B. American Society for Testing and Measurement (ASTM) 80 The _____ mandated the development of standards for electronic medical records.
C. Health Insurance Portability and Accountability Act (HIPAA) of 1996 81 Messaging standards for electronic data interchange in healthcare have been developed by _____.
82 A statement or guideline that directs decision making or behavior is called a _____.
83 Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2?
D. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 84 Which organization originally published ICD-9?
D. World Health Organization (WHO) 85 Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?
B. Centers for Medicare and Medicaid Services (CMS) 86 At which level of the classification system are the most specific ICD-9-CM codes found?
D. Subclassification Level 87 What are five-digit ICD-9-CM diagnosis codes referred to as?
D. Subclassification Codes 88 What are four-digit ICD-9-CM diagnosis codes referred to as?
89 Which of the following ICD-9-CM codes are always alphanumeric?
90 Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?
91 Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
92 Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals?
A. Current Procedural Terminology (CPT) 93 Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals?
94 Which of the following is a standard terminology used to code medical procedures and services?
95 Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?
96 A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops to wound infections. In the DRG system, which of the following would be considered a comorbidity in this case?
97 A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?
C. Radiology Examinations 98 Given the information here, which of the following statements is correct?
<p>A. In each MS-DRG the geometric mean is lower than the arithmetic mean.</p> <br> 99 Given the following information, from which payer does the hospital proportionately receive the least amount of payment?
100 Given the following information, in which city is the GPCI the highest for practice expense?
101 What term is used for retrospective cash payments paid by the patient for services rendered by a provider?
102 Which of the following is the condition established after study to be the reason for hospitalization?
103 In which of the following payment systems is the amount of payment determined before the service is delivered?
104 Which of the following is a prospective payment system implemented for payment of inpatient services?
105 In the Inpatient Prospective Payment System assignment to a DRG begins with the _____.
106 Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
107 Diagnosis-related groups are organized into _____.
C. Case-Mix Classifications 108 MS-DRGs may be split into a maximum of _____ payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC; or no CC.
109 The purpose of the present on admission (POA) indicator is to _____.
A. Differentiate between conditions present on admission and conditions that develop during an inpatient admission. 110 The present on admission (POA) indicator for
A. Inpatient Medicare claims submitted by all hospitals. 111 Which of the following is associated with the Medicare fee schedule?
112 To assign SNF residents to the appropriate resource utilization group data are collected using the _____.
113 SNFs complete MDS assessments _____.
C. According to a schedule designed for Medicare payment. 114 In processing a Medicare payment for outpatient radiology exams a hospital outpatient services department would receive payment under which of the following?
115 Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?
B. Critical Access Hospitals 116 Fee schedules are updated by third-party payers _____.
117 Which of the following would a health record technician use to perform the billing function for a physician's office?
118 When a provider accepts assignment this means that the _____.
B. Provider accepts as payment in full whatever the payer reimburses. 119 A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
C. Counsel the coder and stop the practice immediately. 120 A health information technician is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?
B. Establishment of a hotline to receive complaints and adoption of procedures to protect whistle blowers from retaliation. 121 In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
122 The national Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for:
B. Part B Medicare Claims 123 When the CCI editor flags that a comprehensive code and a component code are billed together for the same beneficiary on the same date of service, Medicare will pay for:
B. The comprehensive code but not the component code. 124 CCI edit files contain code pairs called mutually exclusive edits which prevent payment for _____.
A. Services that cannot reasonably be billed together. 125 Which of the following issues compliance program guidance?
D. HHS Office of the Inspector General 126 The coordination of benefits transaction (COB) is important so that _____.
A. There is no duplication of benefits paid. 127 Which of the following is a written description of an organizations; formal position?
128 Community Hospital is launching a clinical documentation improvement (CDI) initiative because currently clinical documentation does not always adequately reflect the severity of illness of the patient and does not support optimal HIM coding quality and accuracy. Given this situation, which of the following would be the best action to provide improved documentation for patient care and coding.
D. Conduct qualitative analyses of inpatient records while the patient is hospitalized to identify opportunities to improve the documentation in the record. 129 A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
C. Mental or Behavior Problems 130 In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation would a doctor look for to substantiate the diagnosis of aspiration pneumonia?
B. Patient has history of inhaled food, liquid, or oil. 131 The HIM department is planning to scan non-electronic medical record documentation. The project includes the scanning of health record documentation such as history and physicals, physicians orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
132 The HIM department is planning to scan non-electronic medical record documentation. The project includes the scanning of health record documentation such as history and physicals, physicians orders, operative reports, and nursing notes will be scanned. Which of the following methods of scanning would be best so that critical patient health information is available electronically at the patient's bedside or in the physician portal?
133 The HIM department is planning to scan non-electronic medical record documentation. The project will include scanning of documents at the point of admission such as consents, drivers' licenses, and insurance cards, The project also includes that scanning of health record documentation such as history and physicals, physicians orders, operative reports, and nursing notes will be scanned. Which of the following methods of scanning would be most efficient to make intake documents such as consents, drivers' licenses, and insurance cards immediately available to the hospital's billing department?
134 The HIM department is planning to scan non-electronic medical record documentation. The project will include scanning of documents at the point of admission such as consents, drivers' licenses, and insurance cards, The project also includes that scanning of health record documentation such as history and physicals, physicians orders, operative reports, and nursing notes will be scanned. Which of the following methods of scanning would be the simplest to implement?
135 In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
B. Query the physician to determine if the condition was present on admission. 136 When coding a hydrocystoma of the eyelid, which of the following codes should be used?
137 When coding a benign neoplasm of skin of the vermilion border of the lip, which of the following codes should be used?
138 If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?
D. Diameter of the lesion as well as the margins excised as described in the operative report. 139 According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
140 The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this case?
141 A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?
142 An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case?
C. Query the physician to ask if the patient has septicemia because of the symptomology. 143 A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case?
C. Metastatic Carcinoma of the Brain 144 A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case?
B. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina. 145 A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastatic. Which of the following is the correct coding and sequencing for the current hospital stay?
C. Metastatic carcinoma of the brain; history of carcinoma of the prostate. 146 A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be:
A. Sequence either the pancreatitis or the noncalculus cholecystitis as principal diagnosis. 147 According to the UHDDS, which of the following is the definition of "other diagnoses"?
C. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring. 148 A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
C. Asthma with status asthmaticus 149 A coder might find which of the following on a patient's problem list if the medication list contains the drug Protonix?
150 A physician orders a chest x-ray for a patient who presents with fever, productive cough, and shortness of breath. The physician indicates in the progress notes: "Rule out pneumonia." What should the coder report for the visit when the results have not yet been received?
B. Fever, cough, shortness of breath 151 If another Status T procedure were performed, how much would the facility receive for the second Status T procedure?
152 Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered _____ from the database.
153 Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking.
154 Which of the following terms refers to the incidence of death?
155 Review of the disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?
156 Cancer registries receive approval as a part of the facility cancer program from which of the following agencies?
D. American College of Surgeons 157 Which of the following is a database from the National Health Care Survey that uses the patient health record as a data source?
B. National Ambulatory Medical Care Survey 158 Which of the following contains a list maintained in diagnosis code number order of patients discharged from a facility during a particular time period?
159 Which of the following contains a list maintained in a procedure code number order of patients discharged from a facility during a particular time period?
160 Case finding is a method used to _____.
A. Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry. 161 In a cancer registry, the accession number _____.
B. Is the number assigned to each case as it is entered into a cancer registry. 162 A population-based registry _____.
A. Includes information from more than one facility in a particular geopolitical area, such as a state or region. 163 Vital statistics include data on _____.
B. Births, deaths, fetal deaths, marriages, and divorces. 164 The most prevalent trend in the collection of secondary databases is _____.
C. Increased use of automated data entry. 165 A record is considered a primary data source when it _____.
A. Contains information about the patient that has been documented by the professionals who provided care to the patient. 166 The following data were derived from a comparative discharge database for hip and femur procedures. These data can best be described as:
167 Suppose there are six males in a class of 20 students. What term could be used to describe the comparison?
168 In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range?
169 What is the mean for the following frequency distribution:10, 15, 20, 25, 25?
170 What is the mode for the frequency distribution 10, 15, 20, 25, 25?
171 Suppose that five patients stayed in the hospital for a total of 27 days. Which term would be used to describe the result of the calculation 27 divided by 5?
A. Average Length of Stay 172 Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient?
C. Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services. 173 Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the mean?
174
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the mode?
175 What is (are) the format problems with the following table?
176 Mr. Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay of Mr. Jones?
177 Community Hospital discharged nine patients on April 1. The length of stay for each of the patients was as follows: for patient A; 1 day; for patient B; 5 days; for patient C; 3 days; for patient D; 3 days; for patient E; 8 days; for patient F; 8 days; for patient G; 8 days; for patient H; 9 days; for patient I; 9 days. What was the median length of stay?
178 Community Hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed five autopsies for the same period. What was the gross autopsy rate for the hospital for June?
179 Which national database includes data on all discharged patients regardless of payer?
A. Healthcare Cost and Utilization Project Look into this more 180 Which of the following is made up of claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities?
181 The Medicare Provider Analysis and Review file is made up of _____.
C. Medicare claims from acute care hospitals and skilled nursing facilities. 182 The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of _____.
B. Healthcare Integrity and Protection Data Bank 183 The Healthcare Cost and Utilization Project is a major initiative of which organization within the federal government?
A. Agency for Healthcare Research and Quality (AHRQ) 184 If you are interested in displaying the parts of a whole in graphic form, what graphic technique would you use?
185 Which rate describes the number of new cases of an illness for a specific time period?
186 Which term is used to describe the number of inpatients present at the census-taking time each day pus the number of inpatients who were both admitted and discharged after the census-taking time the previous day?
D. Daily Inpatient Census 187 Which unit of measure is used to indicate the services received by one inpatient in a 24-hour period?
188 Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges?
C. Gross Hospital Death Rate 189 Which rate is used to compare the number of calendar days that a patient is hospitalized?
190 Which rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths for the same period of time?
191 Which rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths minus unautopsied coroners' or medical examiners' cases for the same period of time?
192 What term is used for the number of calendar days of an inpatient hospitalization from admission to discharge?
193 What term is used for the number of inpatients present at any one time in a healthcare facility?
194 Several members of the hospital's quality performance improvement team arrive late for most team meetings. This practice hinders the efficiency of the team. Which of the following would be the best action to take to remedy the situation?
C. Develop team ground rules for meeting attendance. Look into further 195 What is the official count of inpatients taken at midnight called?
C. Daily Inpatient Census 196 What is the role of the case manager?
C. Coordinate medical care and ensure the necessity of the services provided to beneficiaries. 197 Which of the following is not a responsibility of a healthcare organization's quality management department?
C. Using medical peer review to identify patterns of care. 198 Which of the following statements best describes the purpose of universal precautions?
A. Prevent exposure to disease-causing agents. 199 Which of the following statements best defines utilization management?
B. It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. 200 Which of the following is NOT a type of utilization review?
D. Documentation Utilization Review 201 What role is not representative of the ombudsmen in patient advocacy?
202 The process that involves ongoing surveillance and prevention of infection so as to ensure the quality and safety of healthcare for patients and employees is known as:
203 Every healthcare organization's risk management plan should include the following components:
C. Objectives, key elements, responsibilities, methods, and areas of focus for the current year. 204 Which of the following is NOT one of the basic functions of the utilization review process?
205 A HIT professional who is following a process for abstracting information for a cancer registry would be engaging in what type of decision making?
206 Total quality management and continuous quality improvement are well-known _____.
A. Performance Improvement Models 207 Donabedian proposed three types of quality indicators: structure indicators, process indicators, and _____.
208 Many organizations and quality experts define quality as meeting or exceeding _____.
209 Teams generally go through the following stages as the develop: forming, _____, norming, and performing.
210 The man credited with revitalizing the Japanese economy are World War II was _____.
211 The individual whose principal responsibility is to facilitate the process of change is the _____.
212 Peter Senge believed that each individual within an organization must be committed to personal mastery and must always seek to _____.
213 The steps in Langley, Nolan, and Nolan's PDSA cycle are _____.
214 Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during performance improvement initiatives to facilitate _____.
215 Which of the following terms refers to the process of planning for change?
216 Which of the following is a data collection tool that records and compiles observations or occurrences?
217 According to the Pareto principle, _____.
A. 20 percent of the sources of a problem are responsible for 80 percent of its actual effects. 218 Change management is the process of planning for change. It concentrates on _____. Addressing employee resistance to changes in processes, procedures, and policies. Scheduling planned changes in processes, procedures, and policies. Implementing the technology required to execute planned changes. Managing the cost of implementing planned changes. A. Addressing employee resistance to changes in processes, procedures, and policies. 219 Which of the following statements does not represent a fundamental principle of performance improvement?
B. Systems are static and do not demonstrate variation. 220 Which of the following should be the first step in any decision-making process?
221 Which of the following is used to plot the points for two variables that may be related to each other in some way?
222 The HIM analytics professional is reviewing a chart on nosocomial infections presented by the hospital's infection control committee. The committee is reporting that the decrease in infection rate has accelerated over the past ten years. What comments should the data analytics professional make?
D. Request a new data chart be presented that accurately reflects the trend of infection rate.
223 Hospital A discharges 10,000 patients a year. Hospital B is located in the same town and discharges 5,000 patients per year. At a medical staff committee meeting a physician reports that he is concerned about the quality of care at Hospital A because Hospital A has double the number of deaths per year than Hospital B. The HIM director is attending the meeting in a staff position. Which of the following actions should the director take?
C. Suggest that the data be adjusted for possible differences in type and volume of patients treated. 224 A flu epidemic has occurred in a small-sized town. This resulted in 200 visits to the emergency department of the local hospital. Of the 200 emergency patients, 80 were subsequently admitted, and of those, 20 died. Based on the data, the local paper is reporting that the mortality rate area wide from the flu epidemic is 10 percent. How should the HIM data analytics professional respond to this conclusion?
C. Maintain that the true mortality rate for the area is unknown. 225 The Medical Record Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM director has compiled a report that shows that the records are delinquent for an average of 29 days after discharge. Given this information what can the Committee conclude?
D. Data are insufficient to determine if the hospital is in compliance. 226 The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes as average of six errors per day; Jane makes and average of five errors per day, and Bob and Susan each make an average of two errors per day. What action should the coding supervisor take given this information?
D. Take no action since not enough information is given to make a judgement. 227 Community Hospital has compared its 2003 and 2008 admission type patient profile data. From a performance improvement standpoint, which admission types should the hospital examine for possible changes in capacity handling?
228 As part of the clinic's performance improvement program, a HIM director wants to implement benchmarking for the transcription division at a large physician clinic. The clinic has 21 transcriptionists who average about 140 lines an hour. The transcription unit supports 80 physicians at a cost of 15 cents per line. What should be the first step that the supervisor takes to establish benchmarks for the transcription division?
A. Clearly define what is to be studied and accomplished by instituting benchmarks. 229 The following table compares Community Hospital's pneumonia length of stay (observed LOS) to the pneumonia length of similar hospitals (expected LOS). Given this data where might Community Hospital want to focus attention on its pneumonia LOS?
230 The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data?
B. Full-time coders are more productive than part-time coders. 231 Which one of the following is the largest healthcare standards-setting body in the world?
232 Patient care managers use the data documented in the health record to:
A. Evaluate the performance of individual patient care providers. 233 Which of the following use data from the MDS for Long-term Care?
A. Centers for Medicare and Medicaid Services (CMS) 234 What is the name of the federally funded program that pays the medical bills of the spouses and dependents of the persons on active duty in the uniformed services?
235 The primary goal of the Hospital Standardization Program established in 1918 by the American College of Surgeons was to _____.
A. Raise the standards of surgical practice. 236
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and use tracer methodology during survey visits?
237 Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?
B. Commission on Accreditation of Rehabilitation Facilities 238 What is the general name for Medicare standards impacting healthcare organizations?
A. Conditions of Participation 239 Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called _____.
A. Elements of Performance 240 The creation of the National Practitioner Data Bank was mandated by the _____.
D. Health Care Quality Improvement Act 241 Mr. Jones is a 67-year-old patient who only has Medicare's Part A insurance. Given the information here, if Mr. Jones used 36 lifetime reserve days, how many does the patient have left to be used at a later date?
242 Under outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Mr. Smith, who has paid his deductible for the year, was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case?
243 The number of days Medicare will cover SNF inpatient care is limited to which of the following?
244 Which of the following types of care is not covered by Medicare?
A. Long-Term Nursing Care 245 How many benefit periods are covered by hospital insurance during a Medicare beneficiary's lifetime?
246 What is the name of the program funded by the federal government to provide medical care to people on public assistance?
247 Some services are covered and paid by Medicare before Medicaid makes payments because Medicaid is considered which of the following?
248 Which of the following groups of healthcare providers contracts with an employer to provide healthcare services?
A. Preferred Provider Organization (PPO) 249 Which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered?
B. Prospective payment method 250 Which of the following payment methods reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness?
251 Which of the following apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?
252 Prospective payment systems were developed by the federal government to:
B. Manage Medicare and Medicaid Costs 253 Private health insurance is a type of _____ insurance.
254 Health insurance plans where providers give healthcare services to members of the plan at a discounted rate are called _____ plans.
255 Which of the following encourages subscribers to select providers from a prescribed network but also allow them to seek healthcare services from providers outside the network at a higher level of copay?
256 Title XVIII of the Social Security Act Amendment of 1965 is also known as:
257 Which of the following establish eligibility standards for enrollment in Medicaid?
258 This program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children.
259 Active armed services members and their qualified family members are covered by which of the following healthcare providers?
260 Dependents and survivors of permanently and totally disabled veterans are covered by which of the following healthcare programs?
261 Which of the following agencies is responsible for providing healthcare services to American Indians and Alaskan natives?
262 Which of the following insurance covers healthcare costs and lost income associated with work-related injuries?
263 A Medicare benefit period is defined as _____.
A. Beginning the day the Medicare patient is admitted to the hospital and ending when the patient has not been hospitalized for a period of sixty consecutive days. 264 Which of the following is an external user of data?
A. Public Health Department 265 Which of the following is the best definition of ambulatory surgery?
B. Any surgical procedure that does not require an overnight stay in the hospital. 266 Which of the following dictates how the medical staff operates?
267 Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building and effective executive management team?
B. Chief Executive Officer 268 What was the main result of the publication of the Flexner report?
A. Medical school standards were established. 269 _____ govern(s) the operation of a hospital medical staff.
270 Which of the following bears the ultimate responsibility for the quality of care in a hospital?
271 Ultimate responsibility for the operation of healthcare organizations lies with _____.
B. The Board of Directors 272 HIM professionals have been working with a multidisciplinary committee to identify the best solution that will allow hospital physicians coordinated access to all forms of incoming and outgoing messages including voice, fax, e-mail, and video mail. Currently physicians have to log in to various systems, using different IDs and passwords to retrieve all their messages, reducing effectiveness and efficiency. Which of the following would provide the best solution to the current problem?
273 Which of the following statements is true of decision making in an organization?
D. Decisions makers at different levels of the organization have different information needs, 274 Why was the American Medical Association established?
A. To represent the interests of physicians across the country. 275 The VA hospital system was established to provide hospital, nursing home, residential, and outpatient medical and dental care to the veterans of which war?
276 Which of the following refers to the organization of physicians according to clinical assignment?
A. Medical Staff Classifications 277 Which of the following statements regarding the nursing profession is true?
C. Both associate's and bachelor's degree nursing graduates qualify to become RNs. 278 Medical school students must pass a test before they can obtain a _____ to practice medicne.
279 The chief information officer is a senior-level executive who is responsible for _____.
D. Leading the organization's strategic IS planning process. 280 Law enacted by a legislative body is a(n) _____.
281 Which stage of the litigation process focuses on how strong a case the opposing party has?
282 Which of the following is NOT true of notices of privacy practices?
C. They must contain content that may not be changed. 283 Which of the following spells out the powers of the three branches of the federal government?
A. United States Constitution 284 Which document directs an individual to bring originals or copies of records to court?
<p>C. Subpoena Duces Tecum</p> <br> 285 To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within _____ days.
286 The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?
287 Which of the following statements if false?
C. An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations. 288 Which of the following statements is NOT true about a business associate agreement?
B. It allows the business associate to maintain PHI indefinitely. 289 Under HIPAA regulations, how many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHI is stored off-site?
290 Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?
A. Notice of Privacy Practices 291 Which of the following statements is true of the notice of privacy practices?
C. It must be provided to every individual at the first time of contact or service with the covered entity. 292 Which of the following statements about the directory of patients maintained by a covered entity is true?
A. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory.
293 What does the abbreviation PHI stand for?
B. Protected Health Information 294 Under HIPAA rules, when an individual asks to see hos or her own health information, a covered entity _____.
B. Can deny access to psychotherapy notes. 295 In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information?
C. When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual. 296 Which of the following statements is true in regard to responding to requests from individuals for access to their PHI?
B. A cost-based fee may be charged for making a copy of the PHI. 297 Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?
A. Notice of Privacy Practices 298 The legal health record (LHR) is a(n) _____.
A. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information. 299 Privacy can be defined as the _____.
B. Right of an individual to be left alone. 300 Confidentiality can be defined as the _____.
A. Limitation of the use and disclosure of private information. 301 Which of the following statements represents an example of nonmaleficence?
A. HITs must ensure that patient-identifiable information is not released unauthorized parties. 302 Which of the following terms means "treating others fairly"?
303 Which organization issues and maintains ethical standards for the health information management profession?
B. American Health Information Management Association 304 The hospital is revising its policy on completion of inpatient history and physical examination. The chairperson of the committee suggests that the history and physical examination be performed not more than 30 days before admission or later than 24 hours after admission. One of the committee members points out that if the history and physical is performed within 24 hours after admission, then the transcribed report should be documented in the patient's record within 48 hours of admission. How should the HIM director respond to this discussion?
C. Inform the committee that Joint Commission standards require the history and physical be placed in the medical record within 25 hours of admission. 305 During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens in order to access all the system modules. For example, they have to use one log on for CPOE and another log on to view laboratory results. One physicians suggests having a single sign on that would provide access to all the EHR systems components. However, the hospital administrator feels that one log on would be a security issue. What information should the HIM director provide?
C. Single sign on is less frustration for the end user and can provide better security. 306 To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee suggests using the copying fee established by the state. Another committee member feels that HIPAA will not allow for copying fees. What input should the HIM director provide?
C. Base charges on the cost of labor and supplies for copying and postage is copies are mailed. 307 The sister of a patient requests the HIM department to release copies of her brother's medical record to her. She states that because the doctor documented her name as her brother's caregiver that HIPAA regulations apply and that she may receive copies of her brother's medical record. In this case how should the HIM department proceed?
308 Community Hospital is discussing restricting the access that physicians have to electronic clinical records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available, while others maintain that HIPAA restricts access. The HIM director is part of the committee. Which of the following should the director advise the committee?
C. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role. 309 Which of the following is NOT a description of a hybrid record?
D. Includes an equal part of paper and electronically produced documents. 310 Which of the following is NOT a challenge in implementing a hybrid health record?
C. Creation of a pathway toward an EHR. 311 Incorporating a workflow function in an electronic information system would help support _____.
A. Tasks that need to be performed in a specific sequence. 312 To run an analysis on a large set of data from many patients, the best tool is a(n):
313 Which of the following would be the best course of action to take in order to ensure continuous availability of electronic data?
D. Use mirrored processing on redundant servers. 314 Which of the following would be considered discrete data?
315 Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
C. Electronic Document Management System 316 Which of the following technologies would be best for a hospital to use in order to manage data from its laboratory, pharmacy, and radiology information systems?
<p>B. Clinical Data Repository</p> <br> 317
Which of the following encourages patients to take an active role in collecting and storing their health information?
318 Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
319 Why is an ideal EHR system one that requires point-of-care charting?
D. Supports clinical decision making. 320 Which of the following is a transition strategy to achieve an EHR?
C. Electronic Document Management System 321 To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place?
C. Pharmacy Information System 322 Electronic prescribing is a special case of:
323 As part of an EHR system selection, due diligence should be done:
B. Before contracting for an EHR product. 324 Which of the following tasks may not be performed in an electronic health record system?
325 Which form of wireless technology is used to beam data between devices in close proximity to one another?
326 A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:
327 How are health plans incentivizing providers to use EHRs:
C. Paying for performance programs 328 Electronic systems used by nurses and physicians to document assessments and findings are called _____.
D. Electronic Patient Care Charting 329 A medical record that is part electronic and part paper is called a(n) _____.
330 A SNF wanting to collect MDS assessments in a database and transmit them in a standard CMS format would use which of the following data entry software?
331 What is the difference between data and information?
A. Data represent basic facts, while information represents meaning. 332 Data definition refers to _____.
Which of the following is a positive aspect of using employee self appraisal as a source of data for performance appraisal?Which of the following is a positive aspect of using employee self-appraisal as a source of data for performance appraisal? Employee self-appraisal provides the opportunity for the employee to keep the supervisor informed of accomplishments and issues.
Which of the following can assist managers with the task of monitoring productivity and forecasting budgets?Which of the following can assist managers with the tasks of monitoring productivity and forecasting budgets? Workload statistics can assist managers with the tasks of monitoring productivity and provide data regarding resources used, such as equipment, personnel, services, and supplies.
Which of the following has the ultimate responsibility for ensuring quality in a healthcare facility?HIT 216. Which of the following best describes the most important function of the health record group of answer choices?Which of the following best describes the most important function of the health record? Storing patient care documentation.
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