Rhia Ahima Study Guide 7Th Edition

Front 1

Mildred Smith was admitted to a nursing facility with the following information : “Patient is being admitted for Organic Brain Syndrome.” Underneath the dx her medical information was listed along with a summary of the care already provided. This is known as a ______________.

Back 1

Transfer Record

Hint 1

These records are created whenever a patient is _________ from one facility to another.

Front 2

A 65 year old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and lab evaluation of CBC and UA. The X-ray revealed possible cholelithiasis, and the IA showed an increased white blood cell count. What is the chief complaint:

A: abdominal pain, B: cholelithiasis, C: exploratory laparoscopy, or D: ruptured appendix.

Back 2

Abdominal pain

Hint 2

Chief complaint or reason for the visit is the nature and duration of the symptoms that caused the patient’s illness and caused the patient to seek medical attention as stated in the patient’s own words. Mrs. Smth

Front 3

Mrs. Smith’s admitting data indicates that her DOB is March 21, 1948. On the discharge summary, Mrs. Smith’s DOB is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith’s health record?

A: data accuracy, B: data consistency, C: data accessibility, D: data comprehensiveness

Back 3

Data Consistency

Hint 3

Data quality needs to be consistent. A difference in the birth dates provides a good example of how the lack of consistency can lead to problems.

Front 4

Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data:

A: research, B: reference, C: coded, D: demographic

Back 4

Coded Data

Hint 4

Data that is translated into standard nonmenclature of classification so that it may be aggregated, analyzed, and compared.

Front 5

Which of the following is an acceptable means of authenticating a record entry?

A: the physician’s assistant signs for the physician

B: the HIM clerk stamps entries with the physician’s signature stamp

C: the charge nurse signs the physician’s name

D: the physician personally signs the entry

Back 5

the physician personally signs the entry

Hint 5

Authentication means to prove authorship and can be done in several ways.

Front 6

All documentation entered in the medical record relating to the patient's dx and tx are considered to be this type of data:

A: Clinical, B: Financial, C: Identification, D: Secondary

Back 6

Clinical Data

Hint 6

This type of data is collected and recorded during the intake process. From this data, the treating or admitting physician can provide the patient's preliminary dx and the reason the patient is seeking tx.

Front 7

In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):

A: Resident Assessment Protocols (RAPs), B: Resident Assessment Instrument (RAIs), C: Utilization Guidelines (UGs), D: Minimum Data Sets (MDS)

Back 7

Resident Assessment Protocols (RAPs)

Hint 7

This forms a critical link to decisions about care planning and help to provide guidance on how to create assessment information within a comprehensive assessment.

Front 8

Conducting an inventory of the hospital's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a:

A: Case mix index, B: master patient index, C: Health record matrix, D: Retention program

Back 8

Retention Program

Hint 8

DHIMs are typically responsible for this task. Some facilities/companies assemble a task force to implement and oversee this item.

Front 9

What is the principal function of health records?

A: Determine appropriate resource allocation, B: Serve as the repository of clinical documentation relevant to the care of individual patients, C: Provide information for performance improvement activities, D: Support billing and reimbursement processes

Back 9

Serve as the repository of clinical documentation relevant to the care of individual patients

Hint 9

Principal functions are related to specific healthcare encounters between providers and their patients.

Front 10

What type of information makes is easy for hospitals to compare and combine the contents of multiple patient health records?

A: administrative information, B: demographic information, C: progress notes, D: uniform data sets

Back 10

Uniform Data Sets

Hint 10

When clinical information from many patient records is combined, a _________ can facilitate the comparison of patient information from multiple sources.

Front 11

When defining the legal health record in a healthcare organization, it is best practice to establish a policy statement of the legal health record as well as a: A: case mix index, B: master patient index, C: health record matrix, D; retention schedule

Back 11

health record matrix

Hint 11

best practice to create this with LHR that identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR.

Front 12

Which of the following materials are required elements in an emergency care record?

A: patient's instructions at discharge and a complete medical history, B: time and means of the patient's arrival, tx rendered, and instructions at discharge, C: time and means of patient's arrival, patient's complete medical history, and instructions at discharge, D: tx rendered, instructions at discharge, and the patient's complete medical history

Back 12

Time and means of arrival, tx rendered, and instructions at discharge

Hint 12

Healthcare facilities required to do a pertinent history, including chief complaint and onset of illness or injury but not a complete medical history of the patient.

Front 13

In ICD-10-PCS, what value is used if there is a character that does not apply to a given code?

A: X, B: -, C: 0, D: Z

Back 13

Z

Hint 13

All ICD-10-PCS codes must be seven characters, and a character cannot be left blank.

Front 14

Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care?

A: case management, B: minimum data set, C: outcomes and assessment information set, D: core measure abstracting

Back 14

Minimum Data Set

Hint 14

This is a component of the resident assessment instrument and is used to collect information about the resident's risk factors and to plan the ongoing care and tx of the resident in the long-term care setting.

Front 15

Mr. Smith was admitted to University Hospital by Dr. Adams. Mr. Smith's hospital bill will be paid by BCBS. Upon discharge from the hospital, who owns the health record of Mr. Smith? A: Mr. Smith, B: Blue Cross, C: University Hospital, D: Dr. Adams

Back 15

University Hospital

Hint 15

Health record serves as both a medical document and a legal document that provides proof of care for business purposes.

Front 16

Documenting the full depth and breadth of data use in a healthcare entity requires:

A: identifying all of the data consumers, B: identifying the needs of data consumers, C: understanding all of the functionality requirements, D: performing a gap analysis.

Back 16

Identifying all of the data consumers

Hint 16

As a HIM professional, you must first understand who the data consumers are and what their needs are.

Front 17

Which part of the problem-oriented chart is used by many facilities that have adopted the whole problem-oriented format?

A: the problem list as an index, B: the initial plan, C: the SOAP form of progress notes, D: the database

Back 17

SOAP form of progress notes

Hint 17

These notes are part of the problem-oriented chart approach most commonly used by physicians and other health professionals. These notes are intended to improve the quality and continuity of patient services by enhancing communication among healthcare professionals.

Front 18

The insured party's member ID number is an example of this type of data:

A: demographic data, B: clinical data, C: certification data, D: financial data

Back 18

Financial Data

Hint 18

This includes details about the patient's occupation, employer, and insurance coverage and is collected at the time of tx.

Front 19

What is the data model that is most widely used to illustrate a relational database structure?

A: entity-relationship diagram (ERD), B: object model, C: relational model, D: unified medical language system (UMLS)

Back 19

Entity relationship model

Hint 19

Type of conceptual modeling. conceptual models are abstact and encourage high-level problem structuring; they help establish common ground for communication between users and developers.

Front 20

Which of the following is an example of M:M relationship?

A: patients to hospital admissions, B: patients to consulting physicians, C: patients to hospital health records, D: patients to physician to patients

Back 20

Patients to consulting physicians

Hint 20

Many-to-many relationship occurs only in data model developed at the conceptual level.

Front 21

Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:

A. Identification and demographic integrity, B. Authorship integrity, C. Statistical integrity, D. Auditing integrity

Back 21

origin of recorded information that is attributed to a specific individual or entity. Copy and paste make it easier to get documentation from one record to another.

Hint 21

A - Authorship Integrity

Front 22

The process by which a person or entity authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called:

A. Endorsement, B. Confirmation, C. Authentication, D. Consent

Back 22

An author is a person or system who originates or creates information that becomes part of the record.

Hint 22

C - Authentication

Front 23

The primary responsibility of a coder is to:

A. Ensure timely processing of coded data, B. Ensure accuracy of coded data, C. Avoid claims rejections by third-party payers, D. Ensure maximum reimbursement for the facility

Back 23

Accuracy is very important

Hint 23

B - ensure accuracy of coded data

Front 24

Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:

A. Authorization, B. Certificate of destruction, C. Informed consent, D. Continuity of care record

Back 24

Required by federal law.

Hint 24

B - Certificate of Destruction

Front 25

Anywhere Hospital has mandated that the SSN will be displayed in the xxx-xx-xxxx format for their patients. This is an example of the use of a:

A. Wildcard, B. Mask, C. Truncation, D. Data definition

Back 25

The use of this tells the database what format to use to display the number.

Hint 25

B- Mask

Front 26

Decision making and authority over data-related matters is known as:

A. Data management, B. Data admin, C. Data governance, D. Data modeling

Back 26

Emerging practice in the healthcare industry. Decision making and authority over data-related matters in _____. It is clear that any industry as reliant on data as healthcare needs a plan for managing this asset.

Hint 26

C - Data Governance

Front 27

A data element name is considered which of the following:

A. Master data, B. Metadata, C. Structured data, D. Unstructured Data

Back 27

Often referred to as “data about data”. Structured information used to increase the effective use of data.

Hint 27

B - Metadata

Front 28

The data elements in a patient’s automated lab result are examples of:

A. Unstructured data, B. Free-text data, C. Financial data, D. Structured data

Back 28

Commonly referred to data that are organized and easy to retrieve and to interpret by traditional databases and data models.

Hint 28

D - Structured Data

Front 29

Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication. Abbreviations in the health record:

A. Are not permitted by JC, B. Should have only one meaning, C. Enhance patient safety, D. Are critical to an EHR system

Back 29

Every healthcare entity should strive to limit or eliminate the use of abbreviations by developing an organization-specific abbreviation list so that only those abbreviations approved by the organization are used.

Hint 29

B - should have only one meaning.

Front 30

Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request of information.

A. It can exist in separate and multiple payer-base or electronic systems, B. The record is incomplete, C. Numerous physicians have not given consent to release the record, D. Risk management will not allow the legal record to be released.

Back 30

This complicates the process of pulling the entire LHR together in response to an authorized ROI to produce the complete patient record.

Hint 30

A. The documentation that comprises the LHR may physically exist in separate and multiple paper based or EHRs.

Front 31

Data Mapping is used to harmonize data sets or code sets. The code or data set from which the map originates is the:

A. Source, B. Target, C. Equivalent group, D. Solution

Back 31

Mapping is necessary as health information systems and their use evolves in order to link disparate systems and data sets.

Hint 31

A - Source

Front 32

Data that are collected on large populations of individuals and stored in databases are referred to as:

A. Statistics, B. Accession data, C. Aggregate data, D. Standards

Back 32

Used to develop information about groups of patients.

Hint 32

C - Aggregate Data

Front 33

Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:

A. Standardized data, B. Codified data, C. Aggregate data, D. Instructed clinical information

Back 33

_____ is entered into the patient record as text is not as easily automated due to the unstructured nature of the information.

Hint 33

D - Unstructured clinical information

Front 34

A significant challenge when handling hybrid records is complicated by the fact that:

A. Patients will continue to request paper records, B. Providers will continue to demand paper records, C. The requirements, regulations, and constrains to EHRs and paper records must be met, D. Only paper records can be used for legal purposes

Back 34

What is required for paper and electronic records is constantly changing.

Hint 34

C - the requirements, regulations, and constrains to EHRs and paper records must be met.

Front 35

According to JC accreditation standards, which document must be placed in the patient’s record before a surgical procedure may be performed?

A. Admission record, B. Physician’s order, C. Report of H&P exam, D. Discharge summary

Back 35

Must be completed no more than 7 days prior to surgery

Hint 35

C - H&P exam