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130 Cards in this Set
- Front
- Back
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One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with - the HIPAA privacy rule - Conditions of Coverage rules - meaningful use requirements - Joint Commission standards |
meaningful use requirements |
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Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA privacy rules? - contact the patient to get permission to respond - honor the authorization since the patient obviously approves of the release - contact the attending physician for permission to respond - do not honor because the authorization is invalid |
do not honor because the authorization is invalid |
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You supervise five clerical employees who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for - 300 square feet of space for your clerical staff - 250 square feet of space for your clerical staff - 200 square feet of space for your clerical staff - 350 square feet of space for your clerical staff |
300 square feet of space for your clerical staff generally, allow 60 square feet per employee |
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The MS-DRG weight in a particular case is 2.0671 and the hospital's payment rate is $3,027. How much would the hospital receive as reimbursement in this case? - $3,027.00 - $6,257.11 - $960.00 - $5,094.10 |
$6,257.11 ($3,027 X 2.0671) |
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Your facility is engaged in a research project concerning patients newly diagnosed with type 2 diabetes. The researchers notice older patients have a longer length of stay than younger patients. They have seen a - homologous relationship between age and length of stay - negative correlation between age and length of stay - positive correlation between age and length of stay - causal relationship between age and length of stay |
positive correlation between age and length of stay |
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The protocol that allows a browser to connect to a server and authenticate identities for data transfer is known as a(n) _____ connection - application gateway - secure socket layer - public key - packet filter |
secure socket layer |
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In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing. The unnamed document in front of you includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. The document type you give to this form is - prenatal record - delivery room record - labor record - postpartum record |
postpartum record |
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A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to - ignore the request and advise you if it is repeated - comply with the request immediately - ask the patient to send the required fee prior to the release - contact the patient's attending physician before complying |
contact the patient's attending physician before complying |
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Release of information has increased its use of part-time prn clerical support in order to respond to increased requests for release of information. The budget variance report will reflect - neither the increased costs nor the increased revenue, as temporary changes are rarely reflected on variance reports - the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support - both the increases in revenue and increased costs for clerical support in ROI - the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area |
the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area |
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Employing the SOAP style of progress notes, choose the "assessment" statement from the following: - patient moving about very cautiously appears to be in pain - adjust pain medication; begin physical therapy tomorrow - sciatica unimproved with hot pack therapy - patient states low back pain with sciatica is as severe as it was on admission |
sciatica unimproved with hot pack therapy |
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SOAP style of progress notes |
S - subjective; records what the patient states is is the problem O - objective; records what the practitioner identifies through history, physical examination, and diagnostic tests A - assessment; combines the subjective and objective into a conclusion P - plan; what approach is going to be taken to resolve the problem |
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The file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. There are a total of 4,500 records in the main file. What is the area's accuracy rate? - 1.1% - 88.9% - 8.9% - 10.0% |
88.9% (400 / 450 X 100) |
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A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc). The quality improvement tool most likely to help collect these data would be - flowchart - check sheet - decision matrix - force field analysis |
check sheet |
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Identification of threats and vulnerabilities, security measures, and implementation priorities are part of a health care organization's - identity management plan - security plan - intrusion detection plan - risk management plan |
risk management plan |
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The CFO of your facility asks you to prepare a budget for the fiscal year based on the past volume and expected capacity for the coming year. This process is an example of using the "_____" budgeting method - zero-based budget - flexible or statistics budget - fixed budget - rolling budget |
fixed budget |
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Your facility is archiving scanned records for long-term storage on optical disk. The Disaster Recovery Committee has recommended that copies of the disks be stored
- in a clinic on the hospital campus - in a locked file maintained in the administrative offices - in a separate department within the facility - at a remote location |
at a remote location |
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Which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned? - single liveborn - occiput presentation - low forceps - episiotomy |
low forceps |
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A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section? - office or other outpatient consultations, new or established patient - office and other outpatient services, new patient - confirmatory consultations, new or established patient - office and other outpatient services, established patient |
office and other outpatient services, established patient - consultation codes can no longer be coded when the physician has taken an active part in the continued care of the patient |
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Postage charges in the Health Information Department have increased during the last quarter. The department director has seen metered envelopes in the mail bin that do not appear to be those used for departmental business. The best course of action for the director would be to - issue employee warnings at the next departmental meeting - assign responsibility for the postage meter to one employee - keep a watchful eye on the meter and who uses it - remove the postage meter from the department |
assign responsibility for the postage meter to one employee |
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As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with - recovery audit contractors - the OIG - QIO physicians -MEDPAR representatives |
recovery audit contractors |
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A technique that uncovers new information from existing information by probing data sets is known as - data mining - systems query language (SQL) - data warehousing - neural network analysis |
data mining |
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A patient was treated for meningitis at age 3 (15 years ago). The patient is now 18. The patient's attorney is requesting information on the admission. You tell the clerk the information is - available, but the patient's parents will have to sign a consent for you to release it - available, but the attorney will have to obtain a court order before you will release it - no longer available because the facility retains information for 10 years after the last patient visit - available, and the patient may sign consent to release the information in the record |
available, and the patient may sign consent to release the information in the record |
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The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that - the IRB focuses on patient care only, the Ethics Committee addresses both patient care and business practices - the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues - the IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary - the Ethics Committee reviews ethics complaints, and the IRB focuses on developing policies and procedures |
the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues |
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A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) - analyst - educator - reviewer - ambassador |
analyst |
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A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of: - res ipsa loquitur - stare decisis - respondeat superior - adjudicus res |
respondeat superior |
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The committee that is preparing your acute care hospital for an electronic health record is planning for an imaging system for record archiving in the immediate future. They are looking for a solution for data interfacing or integration of the imaging system into other computer systems. You recommend - Regional Health Information Organization guidelines - Health Level 7 standards - Joint Commission standards - data dictionary guidelines |
Health Level 7 standards |
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A number of key elements for your facility's computerized patient record are still input by clerical staff from handwritten data entry sheets. You are concerned about the transfer of data. If the vital signs stored in the database are not what were originally recorded, the impact on patient care could be severe. You are concerned about the - granularity of the data - stability of the data - validity of the data - timeliness of the data |
validity of the data |
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Johnston city was set upon by a swarm of killer bees. All 5,000 residents are at risk of a bee attack. If 25 residents were attacked by the bees, the incidence of bee attacks - is 5 in 5,000 - cannot be determined at this time - is 5 in 1,000 - is 25 in 1,000 |
5 in 1,000 |
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The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure - consistent criteria are used to evaluate the alternatives/vendors - the personalities of individual vendors will not influence the decision - the level of software support will be considered in the decision - all alternatives/vendors are evaluated subjectively |
consistent criteria are used to evaluate the alternatives/vendors |
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Reference checks are conducted on potential employees to help assess the applicant's fit with the position and also to - alert the past employer that the applicant is job hunting - get another opinion on the applicant's emotional stability - confirm the accuracy of information provided on the application - uncover skills the applicant may have neglected to report |
confirm the accuracy of information provided on the application |
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As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use - patient abstracts - patient index - accession register - follow-up files |
accession register |
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In order to perform their jobs, facility employees should have full and timely access only to the information they need to complete the task at hand. This is similar to HIPAA's provision for - an informed consent - a Notice of Privacy Practices (NOPP) - amending a record - accessing need to know information only |
accessing need to know information only |
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Everyone in the Health Information Department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not - salaried nonexempt employees - hourly employees - temporary employees - salaried exempt employees |
salaried exempt employees |
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A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? - the patient - the patient's parent or legal guardian - either of the patient's parents - the patient's wife |
the patient |
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The Hospital Value-Based Purchasing (Hospital VBP) Program adjusts a hospital's payments based on their performance in all of these domains except - the Outcomes Domain - the Patient Experience of Care Domain - the Patient Safety Domain - the Clinical Process of Care Domain |
the Patient Safety Domain |
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When checking the census data at South Beach Women's Center, you see that just yesterday, there were four sets of triplets, five sets of twins, and eight single births. Yesterday, South Beach Women's Center had - 17 deliveries - 25 deliveries - 39 deliveries - 30 deliveries |
17 deliveries - multiple births are still considered one delivery for statistical purposes |
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A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? - "U" - "W" - "N" - "Y" |
"N" |
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A clerk's work performance has diminished dramatically during the past 2 weeks. The supervisor initiates a discussion with the clerk, during which the clerk reveals that he recently accepted that he has an alcohol addiction. The clerk states an intention to quit drinking completely. The supervisor should - refer the clerk to the facility's Employee Assistance Program - suspend the clerk if alcohol has diminished the clerk's job performance - terminate the clerk if it can be proved that alcohol was used on the job - give the clerk a leave of absence until the problems can be resolved |
refer the clerk to the facility's Employee Assistance Program |
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A 19-year-old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the Army. The release of information clerk should - inform the young man that specific reports must be identified in his request - send a letter informing him that faxed requests are not correct - send the records as requested - deny the request |
send the records as requested |
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Which of the following scenarios identifies a pathologic fracture? - vertebral fracture with cord compression following a car accident - compression fracture of the vertebrae as a result of bone metastasis - greenstick fracture secondary to fall from a bed - compression fracture of the skull after being hit with a baseball bat |
compression fracture of the vertebrae as the result of bone metastasis
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In your job as Chief Security Officer, you are evaluating software programs that will support your policy on sound terminal controls within your facility. One of the features you include in your request for information to vendors is - unique identifier for log-on - voice recognition feature - auto log off - encryption |
auto log off |
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Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to - report sentinel events to the Joint Commission - decrease medication errors through CPOE systems - reduce clinical denials for medical necessity - increase patient engagement through patient portals |
reduce clinical denials for medical necessity - "decrease medication errors through CPOE systems" and "report sentinel events to Joint Commission" are more closely associated with patient safety programs than CDI programs - "increase patient engagement through patient portals" relates to HITECH goals for physician practices |
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As your meeting with the clerical staff on the stat report continues, one clerk suggests a possible reason for the delays is a lack of training concerning the nature of stat reports. On the cause and effect diagram, this would most appropriately be listed under - methods - personnel - materials - equipment |
personnel |
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A supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job - detail - analysis - description - process |
description |
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As a new HIM manager, you recognize that employee development is a necessary investment for the long-term survival and growth of the organization. Your goal is to design and implement a staff development program for your employees, so one of your first steps is to - implement training programs that emphasize teamwork - establish HIPAA training programs hospital-wide - survey the HIM employees to assess their need for new skills or knowledge - establish a budget for all hospital employee training |
survey the HIM employees to assess their need for new skills or knowledge |
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In order to prevent the accidental introduction of a virus into your facility's local area network, your facility has a policy that strictly prohibits - doing personal work on the computer system, even during personal time - sending or receiving e-mail from addresses that have not been authorized - sharing disks from one workstation to another within the facility - downloading executable files from electronic bulletin boards |
downloading executable files from electronic bulletin boards |
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During the work sampling of a file clerk's activity, it is noted that the employee is speaking on the telephone during 76 of 300 observations. How much of the employee's time is spent on the phone if the employee works 7 hours a day? - 1.77 hours - 3.94 hours - 3.28% - 9.2% |
1.77 76/30 = .253 .253 X 7 hours = 1.77 hours |
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As the Director of a Health Information Technology Program, you are reviewing the workforce development forecast for electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you need to regularly access the web site of which governmental agency? - CDC - CMS - ONC - OSHA |
ONC |
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Now that the EHR has been fully implemented, you are ready to move old records to basement storage. You are ordering shelving for those old paper files. You have 18,000 records. The files average is three files per filing inch. The shelf units you have selected have six shelves that will hold 34 inches per shelf. You will have to plan for a 20% expansion rate to accommodate miscellaneous paper records over the next 10 years. How many shelving units should you order? - 31 - 35 - 30 - 36 |
36 18,000 / 3 = 6,000 inches need for current records 6,000 x .2 = 1,200 inches projected expansion 6,000 + 1,200 = 7,200 total inches required 34 x 6 = 204 in per unit 7,200 / 204 = 35.29 filing units needed You can only purchase whole shelf units = 36 |
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As the Information Security Officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. Which of the following would you provide? - audit controls - chain-of-trust partner agreements - workstation use and location - entity authentication |
workstation use and location |
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Which of the following statements is true? - a surgical operation may include one or more surgical procedures - the term surgical procedure is an incorrect term and should not be used - the terms surgical operation and surgical procedure are synonymous - a surgical procedure may include one or more surgical operations |
a surgical operation may include one or more surgical procedures - a surgical operation is one or more surgical procedures performed at one time for one patient using a common approach or for a common purpose |
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Evidence-based management and decision making is an emerging model now used to make more informed decisions. The premise of this model is - using a decision tree with branches that show the alternatives - using an alternative that meets minimum requirements - using intuition based on previous experience - using the best clinical and research practices available |
using the best clinical and research practices available |
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The purpose of a Health Information Exchange (HIE) is to - link patient data to government agencies - build connectivity in rural areas - improve the interoperability of health care systems - improve health care delivery and information gathering |
improve health care delivery and information gathering |
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Your facility has decided to purchase an integrated patient information system. Your part in the initial work plan is to develop system specifications that will ultimately be sent out to vendors who will potentially submit a bid on your system. You are working on the systems specs that will become part of the - IRB - RFP - CRS - CPR |
RFP (request for proposal) |
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The census taken at midnight on January 1 showed 99 patients remaining in the hospital. On January 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on January 2 - 96 - 95 - 94 - 97 |
97 99 + 4 admissions - 7 discharges + 1 in and out same day fetal deaths and DOA have no impact on inpatient service days |
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The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign - no code for this condition - a code for an impending myocardial infarction - a code for the patient's symptoms - a code for a myocardial infarction |
a code for a myocardial infarction |
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You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM for billing purposes. You find this "theoretically" reasonable because DSM - codes are also valid ICD-10-CM codes - is a widely used and accepted classification system - codes are also valid CPT codes - is the industry standard for psychiatric billing systems |
codes are also valid ICD-10-CM codes |
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Which of the following employees would be considered exempt under the Fair Labor Standards Act? - the department secretary who is responsible for performing a variety of clerical and administrative tasks - the coding supervisor who has responsibility for three employees and performs analysis and coding 80% of the time - the sole employee in the physician's workroom who has responsibility for maintaining and tracking medical record deficiencies - the head of the Department of Health Information Services who is involved in decision making and planning 90% of the time |
the head of the Department of Health Information Services who is involved in decision making and planning 90% of the time |
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Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be - statutory requirements - space considerations - professional standards - provider preferences |
statutory requirements |
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In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to - larger facilities - nationally known facilities - facilities with superior performance - facilities within your corporation |
- facilities with superior performance |
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A clerical-level employee reports an incident in which the clerk felt the first-line supervisor discriminated on the basis of the clerk's gender. The best action for you to take at this time is to - thoroughly investigate the matter and document your findings - ask the clerk to provide objective evidence of the discrimination - talk with the first-line supervisor to determine what happened - ask the other clerical level staff if they have had similar experiences |
thoroughly investigate the matter and document your findings |
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The Pharmacy and Therapeutics Committee has asked you to find out more about a computerized order entry system that calculates drug dosages based on patient parameters (weight, age, etc.) and even suggests the best drug given the patient's diagnosis and current treatment. The committee is asking for information on a(n) - practice parameters system - clinical decision support system - application system - ordering system |
clinical decision support system |
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Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions - on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record - in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record - in the discharge summary - in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record |
in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record |
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A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on - affidavits - depositions - allocutions - interrogatories |
interrogatories |
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The hospital's strategic plan calls for having the entire health record content recorded in discrete form within the next 10 years. Which system will the HIM Director most likely recommend in the early stages of the project as a transition strategy? - speech recognition system - CPOE system - electronic document management system (EDMS) - clinical data repository system |
electronic document management system - many hospitals use the EDMS as a transition to support their EHR effort |
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A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that - you are opposed to the union - you need the names of those involved in union activities - a strike is inevitable if the union wins - wages will increase if the union is defeated |
you are opposed to the union |
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The state is considering the closure of the Arcadia Hospital. In reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? - daily census - inpatient service days - average length of stay - percentage of occupancy |
percentage of occupancy |
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You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that in 2015, sanctions for noncompliance began to appear in the form of - a mandatory action plan for implementing a meaningful use EHR - monetary fines up to $100,000 - downward adjustments to Medicare reimbursement - withdrawal of permission to treat Medicare and Medicaid pateints |
downward adjustments to Medicare reimbursement |
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In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the - prohibited use of any abbreviations - flagrant use of specialty-specific abbreviations - use of prohibited or "dangerous" abbreviations - use of abbreviations used in the final diagnoses |
use of prohibited or "dangerous" abbreviations - the Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form |
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Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for - Howard, who died within 24 hours after his admission - Fieldstone, who was admitted 15 days - Jackson, who was admitted for the replacement of a pacemaker battery - Babson, who delivered a healthy baby without complications for either mother or child and was discharged within 36 hours of admission |
Babson, who delivered a healthy baby without complications for either mother or child and was discharged within 36 hours of admission |
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Which of the following responsibilities would you expect to find on the job description of a facility's Chief Security Officer but NOT on the job description of Chief Privacy Officer? - cooperate with the Office of Civil Rights in compliance investigations - Oversee the patient's right to inspect, amend, and restrict access to protected health information - conduct audit trails to monitor inappropriate access to system information - monitory the facility's business associate agreements |
conduct audit trails to monitor inappropriate access to system information |
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There are 15 employees in your department. There were 21 working days last month. There were a total of 12 lost workdays last month due to absenteeism of all types. The absenteeism rate for your department last month was - 57% - 21% - 4% - 5% |
4%
15 x 21 = 315 total working days 12 / 315 x 100 = rate of absenteeism |
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An effective means of protecting the security of computerized health information would be to - install a system that would require fingerprint scanning and recognition for data access - develop clear policies on data security that are supported by the top management of the facility - write detailed procedures for the entry of data into the computerized information system - require all facility employees to change their passwords at least once a month |
develop clear policies on data security that are supported by the top management of the facility |
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Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of stay for the year, can you calculate the annual bed turnover rate? How? - yes, using the indirect method - yes, using the Joint Commission method - yes, using the direct method - no, there is insufficient data to complete the calculation |
no, there is insufficient data to complete the calculation - hospital bed turnover rate = number of discharges (including deaths) in a given time period / number of beds in the hospital during that same period - the number of discharges was not supplied |
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hospital bed turnover rate number of discharges (including deaths) in a given time period / number of beds in the hospital during that time period |
hospital bed turnover rate number of discharges (including deaths) in a given time period / number of beds in the hospital during that time period |
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Staging - refers to the monitoring of incidence and trends associated with a disease - designates the degree of differentiation of cells - is continued medical surveillance of a case - is a system for documenting the extent or spread of cancer |
is a system for documenting the extent or spread of cancer |
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In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post-surgery. There is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the - pathology report - lab report - nurses' notes - operative report |
lab report |
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Which of the following is coded as an adverse effect in ICD-10-CM - nonfunctioning pacemaker due to defective soldering - tinnitus due to allergic reaction after the administration of eardrops - mental retardation due to intracranial abscess - rejection of transplanted kidney |
tinnitus due to allergic reaction after administration of eardrops |
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As the Project Manager for the upcoming EHR implementation, you ask your assistant to develop a work breakdown structure (WBS). Critical to implementations and project success, the WBS - describes project responsibilities - lists steps needed to complete the project - determines dependencies among project tasks - defines the project's critical path |
lists steps needed to complete the project |
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You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time? - A - P - D - S |
P (plan) PDSA (plan-do-study-act) |
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As part of a team responsible for revenue analysis at your facility, you recommend a yearly review of which of the following? - CAHO requirements - the OIG Workplan - Blue Cross - Blue Shield beneficiary notices - the CMS Scope of Work |
the OIG Workplan |
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Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr. Jones approves a two-night leave of absence (LOA). Chances are Fred is a patient in - a long-term care facility; his LOA will increase the month's percentage of occupancy - a long-term care facility; his LOA will decrease the month's total inpatient service days - an acute care facility; his LOA will increase the month's total discharge days - an acute care facility; his LOA will decrease the month's average daily inpatient census |
a long-term care facility; his LOA will decrease the month's total inpatient service days |
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A common goal of the Office of the National Coordinator for Health Information Technology, HIEs, and a national infrastructure for information is - sharing information among providers - promoting telemedicine - translating images into a digital format - transferring health information within a hospital system |
sharing information among providers |
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Pareto principle |
states that, for many events, roughly 80% of the effects come from 20% of the causes |
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Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the - Federal Register - UHDDS - Coding Clinic - CMS Coding Guidelines |
UHDDS (Uniform Hospital Discharge Data Set) |
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Stage 1 of meaningful use focused on data capture and sharing. Which of the following best summarizes the focus of Stage 2? - advanced clinical processes - use CPOE for medication orders - establish critical pathways for complex, high-dollar cases - smoking cessation counseling for MI patients |
advanced clinical processes |
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The use of "public" and "private" keys is part of what type of data protection? - phishing - encryption - firewalls - biometrics |
encryption
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You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to - improve your department's processes - compare your department with another - make recommendations for improvement - implement your QI process |
improve your department's processes - benchmarking involves comparing your department to other departments or organizations known to be excellent in one or more areas. The success of benchmarking involves finding out how the other department functions and then incorporating their ideas into your department |
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benchmarking |
involves comparing your department to other departments or organizations known to be excellent in one or more areas. The success of benchmarking involves finding out how the other department functions and then incorporating their ideas into your department |
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As the Information Security Officer at your facility, you have been asked to provide examples of technical security safeguards adopted as a result of HIPAA legislation. Which of the following would you provide? - evidence of security awareness training - audit controls - workstation use and location - surge protectors |
audit controls |
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Many departments in your facility create and modify forms often. A major key to forms control in this setting is - consistent formatting of each page of each form - capturing every data item required by UHDDS - providing instructions when necessary for appropriate data fields - giving each form or view an identifiable name, number, and revision date |
giving each form or view an identifiable name, number, and revision date |
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Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gail has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's - CPOE - RHIO - expert system - EDMS system |
RHIO |
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CPOE |
computerized physician order entry (CPOE) a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care |
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RHIO
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regional health information organization (RHIO) a group of organizations within a specific area that share healthcare-related information electronically according to accepted healthcare information technology (HIT) standards |
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The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered - an inappropriate use of hospital resources - appropriate provided it is limited to a few days - the best utilization of the hospital's resources - a compassionate use of the hospital's resources |
an inappropriate use of hospital resources |
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In your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. When this occurs, who would be expected to authorize the release of the medical information documented in this episode of care to the patient's insurers? - the custodial parent of the patient - a court-appointed guardian on behalf of the patient - the patient's doctor on behalf of the patient - the patient |
the patient |
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Your HIM department is moving to a new location and in order to arrange your employees and functions for optimal work flow efficiency and to decide which employees need to be placed close to each other, the tool you decide to use is a - PERT chart - flow process chart - proximity chart or movement diagram - data flow diagram |
flow process chart |
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Which of these conditions are always considered "present on admission" (POA)? - congenital conditions - E codes - possible, probable, or suspected conditions - acute conditions |
congenital conditions |
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The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training. - the Joint Commission only expects involvement from clinical staff - this level of involvement is enough to meet Joint Commission standards - if you can talk him into training his staff, you can let him skip the training - this will not do because it violates Joint Commission standards and CQI philosophy |
this will not do because it violates Joint Commission standards and CQI philosophy |
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Which of the following are considered a late effect regardless of time? - poisoning - congenital defect - nonunion - nonunion fracture |
nonunion |
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You have been asked to reduce your department's operating budget by 20%. In order to do so, you will have to effect reductions in your largest budget line. You will have to make cuts in - personnel - supplies - equipment - contracts |
personnel |
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An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done? - the hospital should quickly seek a court-appointed guardian for the child - both patients can be treated under implied consent - nothing, until consent can be obtained from the nearest relative - the mother can be treated under implied consent but not the child |
both patients can be treated under implied consent |
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The final HITECH Omnibus Rule expanded some of HIPAA’s original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to - simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school - require written authorization from a custodial parent before disclosing proof of the child’s immunization to the school - allow the minor to authorize the disclosure of the proof of immunization to the school - allow school officials to authorize immunization disclosures on behalf of a child attending their school |
simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school - the “Disclosure of Student Immunizations to Schools” provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required. |
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In preparation for conversion to a computerized patient record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data - dictionary - reasonableness - edits - feasibility |
dictionary
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The most sophisticated level of interoperability of an EHR and other such systems is the _____ level - functional - exchange - basic - semantic |
semantic |
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You are providing an educational session to new hires at your hospital. You tell the new employees that hospital records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That is because the hospital record - is written rather than spoken - is accurate and complete - was kept in the regular course of business - has not been tampered with in any way |
was kept in the regular course of business |
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The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information you will consult the - hospital's Quality Management Plan - hospital bylaws, rules, and regulations - policy and procedure manual - data dictionary |
hospital bylaws, rules, and regulations |
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As a coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with - the Centers for Medicare and Medicaid Services - the Recovery Audit Contractor - the Office of Inspector General - the Office for Civil Rights |
the Recovery Audit Contractor |
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Sun City reported 12 cases of chronic heart disease in a population of 8,000 in 2008. In 2011, Sun City reported there were still 12 cases of chronic heart disease, but its population had decreased to 6,000. This represents an increase in the - reliability of reporting chronic heart disease in Sun City - incidence of chronic heart disease in Sun City - prevalence of chronic heart disease in Sun City - occurrence of chronic heart disease in Sun City |
prevalence of chronic heart disease in Sun City |
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You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The system you are likely referencing is - RUGS - MS-DRG - RBRVS - IPPS |
RBRVS |
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Generally, CMS requires the submission of a claim (CMS 1450) for inpatient services provided to a Medicare beneficiary for inpatient services. An exception to this requirement would be when - the physician furnishes a covered services to the beneficiary - an ABN was given to the beneficiary for services unlikely to be covered by Medicare - attempts are made to charge a beneficiary for a service that is covered by Medicare - the beneficiary refuses to authorize the submission of a bill to Medicare |
the beneficiary refuses to authorize the submission of a bill to Medicare - when a beneficiary refuses to authorize the submission of a bill to Medicare, the Medicare provider is not required to submit a claim to Medicare |
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Authentication is one of the components necessary to produce a legal document in an EHR. This means - identifying who created a document and when - creating audit trails |
identifying who created a document and when |
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A section of a job description states that the incumbent will handle day-to-day operations in the transcription and release of information areas. This section defines the - time required for each function - skills required to perform the job - scope of responsibility in the job - authority associated with the job |
scope of responsibility in the job |
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The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. This crisis manager is particularly weak in which management function? - organizing - planning - controlling - budgeting |
planning |
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A piece of objective data collected upon initial assessment of the patient is the - review of systems - vital signs - chief complaint - history of present illness |
vital signs |
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A run or line chart would be most useful for collecting data on - patient satisfaction with the food - waiting time in the Pediatrics Clinic - delays in scheduling elective surgical procedures - medication errors and their causes |
waiting time in the Pediatrics Clinic |
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A patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of - 46 days - 47 days - 45 days - 48 days |
47 days calculation: 31 - 14 + 28 + 2 = 47 days - the first day does not count, day of discharge does count |
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The purpose of CMS's National Correct Coding Initiative is to - increase fines and penalties for bundling services into comprehensive CPT codes - detect and prevent payment for improperly coded services - restrict Medicare reimbursement to hospitals for ancillary services - teach coders how to unbundle codes |
detect and prevent payment for improperly coded services |
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Access to radiologic images has been improved through the use of which of the following? - EDMS - LOINC - PACS |
PACS (picture archiving and communication systems) provide a means to store and rapidly access digitized file images |
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According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is - excisional - incisional - punch - percutaneous |
incisional |
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incisional biopsy vs excisional biopsy |
an incisional biopsy is a procedure in which a small area of tissue is taken to identify the composition (or make-up) of a lesion or abnormality an excisional biopsy is a more involved procedure where the entire abnormality or area of interest is removed |
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Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with - the UHDDS and information on where each data element is collected and/or verified in your facility - a copy of the facility coding guidelines, along with written information on improved documentation - feedback on specific instances when improved documentation would improve coding - regular in-service presentations on the importance of accurate clinical documentation and tips for improvement |
feedback on specific instances when improved documentation would improve coding |
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A major drug company wants to promote a fundraiser targeting patients with congestive heart failure. The drug company representative has requested a list of patients treated at your facility. As privacy and security officer, you tell them that - a prior authorization is required before any PHI can be released - you will need to confer with the medical director - if the fundraising was conducted by a business associate without authorization, and the funds were to benefit your facility (the covered entity), that you could disclose the information - they just need to send a written request for the list |
a prior authorization is required before any PHI can be released |
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The transcriptionists have collected data on the number and types of problems with the dictation equipment. The best tool to display the data they collected is a - Gantt chart - flowchart - PERT chart - Pareto chart |
Pareto chart |
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In preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be - the average readmission rate for the facility - the statute of limitations in your state - Joint Commission and AOA standards regarding minimum retention periods - the available options for inactive records |
the statute of limitations in your state |
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The new electronic system recently purchased at your physician practice allows for e-prescribing and the exchange of data to a centralized immunization registry, and lets your physicians report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing - a certified EHR - a functional EMR - an AMA-approved product - a Joint Commission-approved system |
a certified EHR |
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The 2014 AHIMA Foundation's “Clinical Documentation Improvement Job Description Summative Report” identified that most Clinical Documentation Improvement Specialists report directly to the - CEO - HIM Department - CFO - Quality Management Department |
HIM Department - although CDI programs differ in hierarchy, most CDS professionals report to the HIM Department |
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If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level, - only the chronic condition should be coded - they should both be coded, chronic sequenced first - only the acute condition should be coded - they should both be coded, acute sequenced first |
they should both be coded, acute sequenced first |
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ORYX is a program that was developed by - CMS to track Medicare costs - Joint Commission to link patient outcomes to accreditation - AMA to allow for rapid CPT updates - NIH to track communicable diseases |
Joint Commission to link patient outcomes to accreditation |
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Percutaneous placement of pacemaker lead. Identify the approach - percutaneous - external - via natural or artificial opening - percutaneous endoscopic |
percutaneous |
