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123 Cards in this Set
- Front
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In your facility it has become critical that information regarding patients who are transferred to the oncology unit to be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from _____ - disease index - R-ADT system - indicator monitoring program - generic screens used by record abstractors |
R-ADT system (registration-admission, dsicharge, and transfer system) |
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Discharge summary documentation must include _____ - a detailed history of the patient - a note from social services or discharge planning - correct codes for significant procedures - significant findings during hospitalization |
significant findings during hospitalization |
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Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS, would be _____ - principal diagnosis - cognitive patterns - persona identification - procedures and dates |
cognitive patterns |
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Joint Commission requires the attending physician to countersign health record documentation that is entered by _____ - business associates - interns or medical students - consulting physicians - physician partners |
interns or medical students |
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Stage I of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? - use CPOE for medication orders - establish critical pathways for complex, high-dollar cases - smoking cessation counseling for MI patients - appropriate use of HL-7 standards |
use CPOE for medication orders |
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abbreviation: CPOE |
computerized physician order entry |
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abbreviation: R-ADT system |
registration-admission, dsicharge, and transfer system |
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You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) _____ will be added to his health record. - advance directive - consultation report - interdisciplinary care plan - interval summary |
consultation report |
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abbreviation: COP |
conditions of participation - requires a consultation report on patients who are not a good surgical risk as well as those with obscure diagnoses, patients whose physicians have doubts as to the best therapeutic measure to be taken, and patients for whom there is a question of criminal activity |
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Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record? - delegated use of computer key by radiology secretary - a unique identification code entered by the person making the report - written signature of the provider of care - identifiable initials of a nurse writing a nursing note |
delegated use of computer key by radiology secretary |
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In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the _____ - uniform ambulatory core data - UHDDS - MDS - uniform clinical data set |
MDS (minimum data set) |
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abbreviation: MDS |
minimum data set |
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abbreviation: UHDDS |
uniform hospital discharge data set |
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abbreviation: OBRA |
omnibus budget reconciliation act (also known as federal nursing home reform act) |
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Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be _____ - cosigned by the attending physician within 4 hours of giving the order - accepted by charge nurses only - written within 24 hours of the patient's admission - recorded by persons authorized by hospital regulations and procedures |
recorded by persons authorized by hospital regulations and procedures |
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You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be: - medical staff bylaws - Joint Commission accreditation manual - medical staff rules and regulations - quality management plan |
medical staff rules and regulations |
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The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstance of the leave _____ - documented in an incident report and filed in the patient's health record - documented in both the progress notes and the discharge summary - reported as a potentially compensable event - reported to the Executive Committee |
documented in both the progress notes and the discharge summary |
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Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? - pharmacy consultation - medical consultation - emergency record - physical exam |
pharmacy consultation (required for elderly patients who typically take multiple medications. These consults review for potential drug interactions and/or discrepancies in medications given and those ordered) |
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Accreditation by Joint Commission is a voluntary activity for a facility and it is _____ - conducted in each facility annually - considered unnecessary by most health care facilities - required for state licensure in all states - required for reimbursement of certain patient groups |
required for reimbursement of certain patient groups |
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Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to _____ - use of box design - placement of hospital log - bar code placement - signature line for authentication |
bar code placement |
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The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding _____ - whether the severity of illness and/or intensity of service warranted acute level care - the quality of follow-up care - whether a postoperative infection occurred and how it was treated - the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed |
the presence or absence of such items are preoperative and postoperative diagnosis, description of findings, and specimens removed |
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A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data _____ - reliability - legibility - completeness - accessibility |
reliability |
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A primary focus of screen format design in a health record computer application should be to ensure that _____ - data fields can be randomly accessed - the user is capturing essential data elements - paper forms are easily converted to computer forms - programmers develop standard screen formats for all hospitals |
the user is capturing essential data elements |
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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 into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type that you are most likely to give to this form is _____ - operative report - discharge summary - pathology report - recovery room record |
pathology report |
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A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probably reasons for the fall. She would most likely find this information in the _____ - nurses' notes - incident report - integrated progress notes - doctors' progress notes |
incident report (factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record) |
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Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? - need for physician authentication of two verbal orders - x-ray report charted on the wrong record - discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist - missing discharge summary |
discrepancy between post-op diagnosis by the surgeon pathology diagnosis by the pathologist |
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Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets _____ - HL-7 standards - Joint Commission standards - NHIN standards - CMS standards |
CMS standards |
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abbreviation: NHIN |
nationwide health information network |
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abbreviation: HL-7 |
health level seven |
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You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? - operation index - master patient index - physician index - disease index |
operation index |
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Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every _____ - month - week - 90 days - 60 days |
60 days |
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In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain _____ - stop orders - standing orders - telephone orders - discharge order |
discharge orders |
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In creating a new form or computer view, the designer should be most driven by _____ - needs of the users - medical staff bylaws - QIO standards - flow of data on the page or screen |
needs of the users |
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abbreviation: QIO |
quality improvement organization - a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare |
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As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set? - UHDDS - MDS - DEEDS - ORYX |
DEEDS (data elements for emergency departments) |
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abbreviation: DEEDS |
data elements for emergency departments (recommended data set for hospital-based emergency departments) |
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What is ORYX? |
- not an acronym - Joint Commission performance measurement initiative |
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The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is _____ - 15-0000/00 - 15-0001/01 - 15-0001/00 - 15-0000/01 |
15-0001/00 ("15" represents the year that the patient first entered the database; "0001" indicates that this was the first case entered that year; "00" indicates that this patient has only one known neoplasm |
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The foundation for communicating all patient care goals in long-term care settings is the _____ - cognitive assessment - Uniform Hospital Discharge Data Set (UHDDS) - interdisciplinary plan of care - legal assessment |
interdisciplinary plan of care (the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved) |
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Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data _____ - comprehensiveness - accuracy - timeliness - security |
comprehensiveness |
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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 _____ - MEDPAR representatives - QIO physicians - recovery audit contractors (RACs) - the OIG |
recovery audit contractors |
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abbreviation: RAC |
recovery audit contractor |
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Ultimate responsibility for the quality and completion of entries in patient health records belongs to the _____ - attending physician - chief of staff - risk manager - HIM director |
attending physician |
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The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation? - impressions of a cardiologist asked to determine whether patient is a good surgical risk - interpretation of a radiologic study - technical interpretation of electrocardiogram - tissue examination done by the pathologist |
impressions of a cardiologist asked to determine whether patient is a good surgical risk |
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Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data _____ - precision - validity - timeliness - reliability |
precision |
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An example of a primary data source for health care statistics is the _____ - disease index - MPI - accession register - health record |
health record - disease index, accession register, and MPI are examples of secondary data sources |
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abbreviation: MPI |
master patient index |
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For inpatients, the first data item collected of a clinical nature is usually _____ - principal diagnosis - review of systems - expected payer - admitting diagnosis |
admitting diagnosis |
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For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the _____ - discharge summary - interdisciplinary patient care plan - transfer record - problem list |
problem list |
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In an acute care hospital, a complete history and physical may not be required for a new admission when _____ - a legible copy of a current H&P performed in the attending physician's office is available - the patient is readmitted for a similar problem within 1 year - the patient's stay is less than 24 hours - the patient has an uneventful course in the hospital |
a legible copy of a current H&P performed in the attending physician's office is available |
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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 _____ - use of prohibited or "dangerous" abbreviations - prohibited use of any abbreviations - flagrant use of specialty-specific abbreviations - use of abbreviations as the final diagnosis |
use of prohibited or "dangerous" abbreviations - JC requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4." Spelling out the unit is preferred |
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Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement? - yes, within 24 hours postsurgery - no, as long as it is done ASAP - yes, within 8 hours postsurgery - yes, prior to surgery |
yes, prior to surgery |
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In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the _____ - subjective review of systems - family history as related by the patient - chief complaint - general appearance as assessed by the physician |
general appearance as assessed by the physician |
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Which of the following services is least likely to be provided by a facility accredited by CARF? - vocational evaluation - brain injury management - palliative care - chronic pain management |
palliative care |
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abbreviation: CARF |
Commission on Accreditation of Rehabilitation Facilities |
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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 _____ - HIM Department - CFO - CEO - Quality Management Department |
HIM Department |
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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 index - patient abstracts - follow-up files - accession register |
accession register |
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Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? - progress notes - database - initial plan - problem list |
problem list |
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abbreviation: POMR |
problem-oriented medical record - there are four distinct components: the database contains the history and physical; the problem list includes titles, numbers, and dates of problems and serves as a table of contents of the record; the initial plan describes diagnostic, therapeutic, and patient education plans; the progress notes document the progress of the patient throughout the episode of care, summarized in a discharge summary or transfer note at the end of the stay |
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Engaging patients and their families in health care decisions is one of the core objectives for _____ - HIPAA 5010 regulations - the Joint Commission's National Patient Safety goals - establishing flexible clinical pathways - achieving meaningful use of EHRs |
achieving meaningful use of EHRs |
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As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult ____ - policy and procedure manual - federal register - hospital bylaws, rules, and regulations |
hospital bylaws, rules, and regulations |
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The health record states that the patient is female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case? - data accuracy - data granularity - data comprehensiveness - data precision |
data accuracy |
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As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the _____ - postpartum record - discharge summary - labor and delivery record - prenatal record |
prenatal record |
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Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of _____ - qualitative review - peer review - quantitative review - legal analysis |
qualitative review |
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In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of frequencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of records show _____ - missing discharge summaries - missing operative reports - absence of SOAP format in progress notes - missing signatures on progress notes |
missing operative reports |
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abbreviation: SOAP notes |
subjective, objective, assessment, plan |
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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 by 2015, sanctions for noncompliance began to appear in the form of _____ - a mandatory action plan for implementing a meaningful use EHR - the withdrawal of permission to treat Medicare and Medicaid patients - monetary fines up to $100,000 |
downward adjustments to Medicare reimbursement |
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You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? - Federal Register - Conditions of Participation - Uniform Hospital Discharge Data Set (UHDDS) - Minimum Data Set (MDS) |
Uniform Hospital Discharge Data Set (UHDDS) - the MDS is designed for use in long-term care facilities - the COP is the set of regulations that health care institutions must follow to receive Medicare reimbursement - the Federal Register is a daily government newspaper for publishing proposed and final rules of federal agencies |
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abbreviation: COP |
conditions of participation - the set of regulations that health care institutions must follow to receive Medicare reimbursement |
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The federally mandated resident assessment instrument used in long-term care facilities consist of three basic components, including the new care area assessment, utilization guidelines, and the _____ - DEEDS - MDS - UHDDS - OASIS |
MDS (minimum data set) - basic component of the long-term care RAI - UHDDS is used in acute care - OASIS Is used in home health - DEEDS is used in emergency departments |
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abbreviation: OASIS |
outcome and assessment information set (OASIS) - used in home health |
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In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the _____ - information security manager - clinical data specialist - health information manager - risk manager |
health information manager |
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Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? - when the record is taken to a physician's office for a follow-up patient visit post discharge - when the patient is brought to the hospital ED following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated ED at another hospital - when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court - when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record |
when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court |
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As the Compliance Office for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling _____ - EMTALA - Health Care Quality Improvement Act - ARRA - HIPAA |
ARRA (American Recovery and Reinvestment Act) |
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abbreviation: ARRA |
American Recovery and Reinvestment Act |
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The minimum length of time for retaining original medical records is primarily governed by _____ - readmission rates - state law - medical staff - Joint Commission |
state law |
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Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that _____ - tampering too often occurs with this method of authentication - it is too easy to delegate use of computer passwords - evidence cannot be provided that the physician actually reviewed and approved each report - electronic signatures are not acceptable in every state |
evidence cannot be provided that the physician actually reviewed and approved each report |
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You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's _____ - physician's index - disease index - number control index - patient index |
disease index |
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Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following: - adjust pain medication; begin physical therapy tomorrow - patient moving about very cautiously, appears to be in paint - patient states low back pain is as severe as it was on admission - sciatica unimproved with hot pack therapy |
patient states low back pain is as severe as it was on admission |
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Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the _____ - Office of Inspector General - Office for Civil Rights - FBI - Department of Recovery Audit Coordinators |
Office for Civil Rights (OCR) |
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abbreviation: OCR |
office for civil rights - ensures equal access to certain health and human services and protects the privacy and security of health information |
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The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate _____ - adverse effects and contraindications of drug utilized during hospitalization - quality of care through the use of preestsablished criteria - potentially compensable events - the overall quality of documentation in the record |
the overall quality of documentation in the record |
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As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman _____ - Joint Commission standards do not allow copies of any kind in the original record - that you apologize for not noticing the H&P she provided - the H&P copy is acceptable as long as she documents any interval changes - a new H&P is required for every inpatient admission |
the H&P copy is acceptable as long as she documents any interval changes |
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Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda 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 - expert system - EDMS system - RIO |
RIO |
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abbreviataion: CPOE |
computerized provider order entry system |
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abbreviation:EDMS |
electronic data management system |
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abbreviation: RIO |
regional health information organizations |
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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 _____ - meaningful use requirements - Conditions of Coverage rules - the HIPAA privacy rule - Joint Commission standards |
meaningful use requirements |
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In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing _____ - interdisciplinary treatment plans - integrated progress notes - SOAP notes - source-oriented records |
integrated progress notes |
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One of the Joint Commission National Patient Safety Goals (NSPGs) requires that healthcare organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would not be considered part of a preoperative verification process? - mark the surgical site - confirm the patient's true identity - follow the daily surgical patient listing for the surgery suite if the patient has been sedated - review the medical record and/or imaging studies |
follow the daily surgical patient listing for the surgery suite if the patient has been sedated |
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One record documentation requirement shared by both acute care and emergency departments is ______ - problem list - advance directive - time and means of arrival - patient's condition on discharge |
patient's condition on discharge |
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In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the _____ - Joint Commission accreditation manual - Federal Register - CARF manual |
Federal Register |
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abbreviation: NSPGs |
National Patient Safety Goals |
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abbreviation: CARF |
commission on accreditation of rehabilitation facilities |
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The best example of point-of-care service and documentation is _____ - using an automated tracking system to locate a record - using occurrence screens to identify adverse events - nurses using bedside terminals to record vital signs - doctors using voice recognition systems to dictate radiology reports |
nurses using bedside terminals to record vital signs |
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Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is _____ - beta blocker at discharge - early admission of aspirin - discharged on antithrombotic - blood culture before first antibiotic received |
blood culture before first antibiotic received |
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abbreviation: HCQIP |
Health Care Quality Improvement Program (HCQIP) |
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The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing _____ - clinical pertinence review - quantitative record review - point-of-care documentation - concurrent record analysis |
point-of-care documentation |
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As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm the necessary documents such as x-rays or medical records are available. They must also develop and use a process for _____ - apprising the patient of all complications that might occur - marking the surgical site - including the surgeon in the preanesthesia assessment - including the primary caregiver in surgery consults |
marking the surgical site |
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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) _____ - educator - ambassador - analyst - reviewer |
analyst |
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abbreviation: CDS |
clinical documentation specialist |
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Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? - procedure index - pediatric census sheet - disease index - patient register |
disease index |
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A data item to include on a qualitative review checklist of newborn inpatient health records that need not be included on adult records would be _____ - condition on discharge - time and means of arrival - chief complaint - APGAR score |
APGAR score |
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Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization joint a _____ - data warehouse - regional health information organization - data retrieval portal group - continuum of care |
regional health information organization |
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As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document _____ - past and current activities, such as smoking and drinking habits - subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant - objective symptoms observed by the physician - a chronological description of patient's present condition from time of onset to present |
subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant |
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As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the _____ - facility's data dictionary - glossary of health care terms - UHDDS - MDS |
facility's data dictionary |
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A key data item you would expect to find recorded on an ER record but would probably not see in an acute care record is the _____ - instructions for follow-up care - time and means of arrival - lab and diagnostic test results - physical findings |
time and means of arrival |
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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 _____ - allow the minor to authorize the disclosure of the proof of immunization to the school - 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 - refuse to disclose any information regarding child immunizations |
simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school |
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Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the _____ - peer review organization - Health Plan Employer Data and Information Set - risk manager - National Practitioner Data Bank |
National Practitioner Data Bank |
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Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record - Baby Boy Hiltz's mother admitted 1/5/2016, C-section delivery, and discharged 1/7/2016 - Baby Boy Doe admitted 1/3/2016, died 1/4/2016 - Baby Boy Hiltz, born 1/5/2015, maintained normal status, discharged 1/7/2015 - Patient admitted with COPD 1/4/2016 and discharged 1/7/2016 |
Baby Boy Hiltz, born 1/5/2015 |
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The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the _____ - CARF manual - medical staff bylaws, rules, and regulations - Joint Commission manual - Conditions of Participation for Rehabilitation Facilities |
CARF manual |
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A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n) _____ - analyst - ambassador - auditor - reviewer |
auditor |
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abbreviation: CDI |
clinical documentation improvement |
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The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choose a(n) _____ - AMA-approved product - certified EHR - functional EHR - Joint Commission-approved system |
certified EHR |
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As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the web site of this government agency: - ONC - CDC - OSHA - CMS |
ONC |
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abbreviation: ONC |
Office of the National Coordinator for Health Information Technology - the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and electronic exchange of health information |
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A qualitative review of health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates _____ - compliance with Medicare regulations - compliance with Joint Commission standards - noncompliance with Joint Commission standards - compliance with Joint Commission standards for nonsurgical patients |
noncompliance with Joint Commission standards (H&Ps must be completed within 24 hours) |
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Improving clinical documentation 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 _____ - reduce clinical denials for medical necessity - increase patient engagement through patient portals - decrease medication errors through CPOE systems - report sentinel events to the Joint Commission |
reduce clinical denials for medical necessity |
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abbreviation: UM |
utilization management |
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During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? - quantitative review - qualitative review - utilization review - legal review |
qualitative review |
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What is the difference between quantitative and qualitative analysis? |
Quantitative analysis involves checking for the presence or absence of necessary reports and/or signatures, while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record |
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The standards for the history and physical exam documentation time period for completion should be set at _____ - 12 hours after admission - 12 hours after admission or prior to surgery - 24 hours after admission - 24 hours after admission or prior to surgery |
24 hours after admission or prior to surgery |
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When is a recommendation for improvement from the Joint Commission indicated? |
If the number of delinquent records is greater than 50% or if the percentage of records with delinquent records due to missing H&Ps exceeds 2% of the average monthly discharge. |
