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Essentials in Health Records Management > Assignment 3 > Flashcards

Assignment 3 Flashcards

1
Q

True/False: Indexes and registers allow health information to be maintained and retrieved for the purpose of education, planning and research

A

True

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2
Q

True/False: An index is an organized system for the collection and dissemination data set of information on individual persons who have a particular disease

A

False

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3
Q

True/False: An automated master patient index consists of a computerized database of identification data about patients who have received health care services from a facility

A

True

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4
Q

True/False: A manual master patient index (MPI) is less expensive to purchase compared with an automated MPI

A

True

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5
Q

True/False: Information should be entered in a master patient index by various departments to ensure accuracy and to avoid the creation of duplicate records

A

False

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6
Q

True/False: The physician index is organized primarily by disease codes of patients admitted by physicians

A

False

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7
Q

True/False: A registry is a system for the collection, storage, retrieval, and circulation of information on individuals that have a particular disease

A

True

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8
Q

True/False: A data dictionary is a standard method for collecting and reporting individual data elements

A

False

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9
Q

True/False: To avoid fraudulent behaviors, healthcare providers must develop compliance plans and develop internal controls

A

True

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10
Q

True/False: Most hospital statistics are collected using automated computer systems

A

True

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11
Q

True/False: Data is reliable if it is consistent throughout the systems in which it is stored, processed, and/or retrieved

A

True

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12
Q

True/False: The process of translating data into information utilized for an application is data warehousing

A

False

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13
Q

True/False: The numer of inpatients present at census taking time is called the daily census count

A

True

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14
Q

True/False: Registers are primary sources of patient information

A

False

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15
Q

True/False: Case mix analysis is the study of the types of patients treated in a facility

A

True

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16
Q

True/False: Data Mining is a collection of data elements

A

False

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17
Q

True/False: Civil law deals with relationships between individuals and government

A

False

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18
Q

True/False: Discovery is the legal process lawyers use to obtain information about all aspects of law

A

False

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19
Q

True/False: Administrative law includes regulations created by administrative agencies of government

A

True

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20
Q

True/False: Stare decisis is Latin for “to stand by things decided”

A

True

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21
Q

True/False: Res gestae is Latin for “things done”

A

True

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22
Q

True/False: Medical negligence results when a health care provider acts in an improper way

A

False

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23
Q

True/False: All states/provinces have enacted comprehensive laws to deal with issues raised by the computerization of patient records

A

False

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24
Q

True/False: Vital Statistics are compiled for events, including births, deaths including fetal death, marriages and divorces

A

True

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25
Q

True/False: Length of stay data represents the number of calendar days that a patient was an inpatient

A

True

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26
Q

True/False: To calculate discharge data statistics divide the number of times something happened by the number of times something could happen

A

True

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27
Q

True/False: Patients are allowed to obtain copies of their records and to request ammendments be made to their records

A

True

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28
Q

True/False: A statue of limitations refers to the time period after which a lawsuit cannot be filed

A

True

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29
Q

True/False: A breach of confidentiality occurs when patient information is disclosed to others that do not have the right to access the information

A

True

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30
Q

True/False: Confidentiality is the process of keeping privileged information secret; and means that information cannot be released without a patient’s authorization

A

True

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31
Q

True/False: Each province/state establishes a list of reportable events for which providers must submit patient information to appropriate agencies

A

True

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32
Q

True/False: Continuous quality improvement plays a role in data quality in an organization and includes elements of data applications, collections, warehousing, and analysis

A

True

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33
Q

True/False: A qualified protective order permits the use or disclosure of protected health information for any purpose

A

False

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34
Q

True/False: A public health office must obtain a patient’s consent prior to requesting information from their medical chart

A

False

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35
Q

True/False: Electronic records are not admissible in court

A

False

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36
Q

True/False: A medical nomenclature organizes diseases and procedures into numeric and alphabetic characters

A

False

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37
Q

True/False: ICD-10-CA is the medical classification system used in Canada

A

True

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38
Q

True/False: The standard classification for mental disorders is CPT

A

False

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39
Q

True/False: An individual who brings a lawsuit is called the arbitrator

A

False

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40
Q

True/False: Workers compensation is a federally mandated insurance program that reimburses health care costs and lost wages for employees injured on the job

A

False

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41
Q

True/False: Critical pathways usually focus on one discipline and provide guidelines for standards of care

A

False

42
Q

True/False: A medical nomenclature is a vocabulary of clinical and medical terms

A

True

43
Q

True/False: A subscriber is a health plan enrollee

A

True

44
Q

True/False: CPT is the abbreviation for current procedural terminology

A

True

45
Q

The quality improvement (QI) department needs to obtain a list of patients discharged within the last three months with a diagnosis of diverticulitis. This information can be obtained from the

a. disease index
b. master patient index
c. procedure index
d. physician index

A

a. disease index

46
Q

The chief of surgery wants to determine the number of cholecystectomies performed using a scope and as an open surgery for the last six months. This information may be obtained from the

a. disease index
b. master patient index
c. procedure index
d. physician index

A

c. procedure index

47
Q

Dr. James is completing a report for a medical staff committee. He needs to determine the number of patients admitted by Dr. Tops for the month of July with the diagnosis of anemia. The best source for this information would be the

a. disease index
b. master patient index
c. procedure index
d. physician index

A

d. physician index

48
Q

The process of translating data into information utilized for an application is

a. data application
b. data collection
c. data analysis
d. data warehousing

A

c. data analysis

49
Q

Hillcrest Hospital is writing a retention policy for the health information department. Which index must be retained permanently?

a. disease index
b. master patient index
c. procedure index
d. physician index

A

b. master patient index

50
Q

During the month of May there were 130 births, of which 127 were full term births and three were premature births. There were five newborn deaths. The newborn death rate is

a. 2.3%
b. 3.8%
c. 5.4%
d. 7.2%

A

b. 3.8%

51
Q

Based on your review of statstics in the table, the total number of outpatient surgical procedures from 2001 through 2003 has

a. decreased
b. increased
c. remain the same
d. stayed constant

A

b. increased

52
Q

Based on your review of statstics in the table, the total number of inpatient surgical procedures from 2001 through 2003 has

a. decreased
b. increased
c. remain the same
d. stayed constant

A

a. decreased

53
Q

Based on your review of statistics in the table, the total number of outpatient surgical procedures from 2001 through 2003 was

a. equal to the total number of inpatient procedures
b. greater than the total number of inpatient procedures
c. less than the total number of inpatient procedures
d. the same as the total number of inpatient procedures

A

c. less than the total number of inpatient procedures

54
Q

Based on your review of statistics in the table, which unit had the shortest average length of stay (LOS) during the month of July?

a. 1
b. 2
c. 3
d. 4

A

a. 1

55
Q

Based on your review of statistcis in the table, which unit had the greatest increase in the average length of stay (LOS) from June through July?

a. 1
b. 2
c. 3
d. 4

A

c. 3

56
Q

Based on your review of statstics in the table, which unit had the greatest decrease in the average length of stay (LOS) from June through July

a. 1
b. 2
c. 3
d. 4

A

b. 2

57
Q

Based on your review of statistics in the table, which unit had the greatest number of patients in a single month?

a. 1
b. 2
c. 3
d. 4

A

b. 2

58
Q

The medical staff at Hillcrest Hospital reviewed the table. The medical director commented “The surgical unit had the longest length of stay (LOS) for both June and July.” Which unit was the surgical unit?

a. 1
b. 2
c. 3
d. 4

A

d. 4

59
Q

Based on your review of statistics in the table, which unit had the greatest total length of stay (LOS) for June?

a. 1
b. 2
c. 3
d. 4

A

d. 4

60
Q

DSM IV is a classification system of

a. Topology
b. Edidemiolgy
c. Pathology
d. Mental Disorders

A

d. Mental Disorders

61
Q

The director of the health information department at Sunny Valley Hospital needs to prepare a presentation for the finance committee to convince them to fund an automated master patient index system. Which statement would best support her argument?

a. an automated MPI is less expensive than a manual master patient index
b. an automated MPI will allow for rapid retrieval of patient information
c. Staff training time is decreased when an automated MPI is implemented
d. The security in information is increased when an automated MPI is implemented

A

b. An automated MPI will allow for rapid retrieval of patient information

62
Q

Sally Jones presents to the emergency room (ER) with lower left abdominal pain. The ER Physician asks the ER clerk to determine if the patient was previously seen in the facility. The quickest way for the ER clerk to obtain this information is to reference the

a. disease index
b. emergency department log
c. master patient index
d. patient’s record

A

c. master patient index

63
Q

The health information director is writing a policy to ensure the accuracy of an automated master patient index. The two departments that should be allowed to enter or update information in the master patient index are

a. admissions and nursing
b. admissions and health information management
c. health information and nursing
d. health information and medical staff

A

b. admissions and health information management

64
Q

Calculating health care statistics is a function of the

a. health care finance department
b. quality department
c. health information management department
d. risk management department

A

c. health information management department

65
Q

Hillcrest Hospital and Endwell Hospital are merging. The new health information director for both hospitals needs to ensure that the two master patient indexes are accurately merged. Each hospital currently uses manual MPIs, and they will convert to one automated MPI. Which activity below should the director avoid?

a. establish a merger plan for the hospital MPIs
b. perform manual aphabetic search to identify duplicate MPI files
c. shred the manual MPI within four weeks after the conversion
d. Use sofwatre to identify and correct errors in the automated MPI

A

c. Shred the manual MPI within four weeks after the conversion

66
Q 
Hillcrest Hospital is conducting research on Alzheimer's disease and wishes to obtain information from its states registry. Which information below would be unavailable from the registry?
a. incidence of disease
b. number of cases
c patient names
d. types of patients
A

c. patient names

67
Q

The health information department is responsible for generating reports and statistics on the types of patients treated by the facility. This function is called

a. case mix analysis
b. patient record abstracting
c. quality management
d. utilization review

A

a. case mix analysis

68
Q

Civil law deals with the legal rights and responsibilities of private individuals and includes

a. contracts
b. criminal acts
c. contracts and torts
d. daily census count

A

c. contracts and torts

69
Q

The number of inpatients present at census taking refers to

a. daily inpatient census
b. discharged data statistics
c. average daily census
d. daily census count

A

d. daily census count

70
Q

Which of the following would not be considered a health information custodian?

a. Law office
b. Health care practitioners
c. Hospitals
d. Behavioral Facilities

A

a. Law office

71
Q

Which of the following terms do not reflect the concept of data quality?

a. data application
b. data validity
c. data integrity
d. data reliability

A

a. data application

72
Q

Disease, procedure and physician indexes contain data abstracted (selected) from

a. computerized databases
b. data sets
c. patient records
d. registers and registries

A

c. patient records

73
Q

Mark Jones is receiving traction in the physical therapy department at Happy Hospital. The therapist sets the traction at a higher level than ordered and Mark is injured. The hospital is liable for the negligent act under the doctrine of

a. res gestae
b. res ipsa loquitur
c. res judicata
d. respondeat superior

A

d. respondeat suprior

74
Q

Which, in the following list, is NOT an acceptable phone request option for release of medical information (ROI)

a. patient calls ROI department and requests their recent MRI be faxed to their family doctor
b. Legal office calls the ROI office to confirm that Margaret Smith has records at the hospital, prior to sending their request
c. Physician’s office calls ROI department to see if EMG result is on file yet
d. patient’s family calls ROI to find out how to request their records

A

b. Legal office calls the ROI office to confirm that Margaret Smith has records at the hospital, prior to sending their request

75
Q

The doctrine of respondeat superior would apply in which of the following situations

a. an ambulance company documents incorrect information on an ambulance report. The hospital is liable
b. an x-ray tehchnician prepares the wrong patient for a CT scan. The supervisor is liable
c. A nurse administers the wrong medication to a patient. The hospital is liable
d. A release of insurance specialist sends a patient’s information to the wrong facility. The director of health records is liable

A

c. a nurse administers the wrong medication to a patient. The hospital is liable

76
Q

Public law deals with relationships between individuals and the government and includes

a. criminal law and torts
b. contracts and torts
c. criminal law and regulations
d. contracts and regulations

A

c. criminal law and regulations

77
Q

An authorization to disclose personal health information is NOT required when

a. a patient’s new employer wishes to verify his past medical history
b. Dr. Jones releases records to Dr. Smith for continuity of patient care
c. Happy Hospital identifies a patient as a cancer survivor in their newsletter
d. a police officer comes into the release of information department looking for information to support a case

A

b. Dr. Jones releases records to Dr. Smith for continuity of patient care

78
Q

Anna, a release of information specialist, releases information to ABC Legal firm with the consent of a patient. Within the chart was an item from another patient’s chart. This is considered

a. subpoena duces tecum
b. Res gestae
c. contempt of court
d. a breach of confidentiality

A

d. a breach of confidentiality

79
Q

Jane Mo, a release of information specialist at Sunnyside Hospital, receives a call from Princess Grace Hospital requesting information for a patient that is being seen in the emergency department of their hospital. Select what be done next

a. obtain the patient information on the phone and fax the information with the fax number given
b. request that they mail a consent directed to Sunnyside Hospital prior to releasing the information to Princess Grace Hospital
c. do not respond to the request as they should not be requesting information via the phone
d. request the name of the person calling, the main number of the hospital and their extension. Call the number given, verify that it is a hospital and then ask for the patient name and date of birth. Also ask of them to send a request in writing on their letterhead so that this request may be filed in the patient chart for future reference

A

d. request the name of the person calling, the main number of the hospital and their extension. Call the number given, verify that it is a hospital and then ask for the patient name and date of birth. Also ask of them to send a request in writing on their letterhead so that this request may be filed in the patient chart for future reference

80
Q

Protected health information includes all of the following EXCEPT

a. patient’s name
b. patient’s date of birth
c. hospital address
d. medical record numbers

A

c. hospital address

81
Q

Which is not an example of acceptable phone requests for medical information

a. general info on privacy and release of information
b. may be asking that medical tests be sent to their family physician
c. insurance firm asking confirmation if their client was a patient in the facility
d. may want reports sent automatically to physicians

A

c. insurance firm asking confirmation if their client was a patient in the facility

82
Q

Which of the following correctly describes a patient record?

a. the patient has the right to extract information from the chart that they perceive as incorrect
b. all states have the same rules and laws requiring legality of patient records
c. medical documentation is technically considered hearsay
d. medical records are only admissible to court with a judge’s order

A

c. medical documentation is technically considered hearsay

83
Q

Susie Smith wants to obtain a copy of her medical report. She can obtain a copy of all reports EXCEPT for the

a. admission history and physical
b. dental record
c. incident report
d. treatment plan

A

c. incident report

84
Q

Summaries of a set of data using charts, graphs, and tables are referred to as

a. aggregate data
b. comparative data
c. descriptive statistics
d. patient centric data

A

c. descriptive statistics

85
Q

The organization that reviews and revises ICD is

a. ADA
b. AMA
c. CMS
d. WHO

A

d. WHO

86
Q

Which is a standard classification of mental disorders published by the APA?

a. CPT
b. DSM
c. ICIDH
d. NDC

A

b. DSM

87
Q

Which of the following is typically NOT the way that requests flow into the release of information department?

a. walk-in
b. courier
c. email
d. mail

A

c. email

88
Q

The average number of inpatient’s treated during a given time period such as weekly, monthly, or annually is known as

a. daily census count
b. daily mean
c. daily inpatient census
d. average daily census

A

d. average daily census

89
Q

Barb is completing a report for the hospital governing board. They want to review the types and categories of patients treated. Barb should use which data to prepare the report?

a. case mix
b. coding
c. inpatient census
d. severity of illness scores

A

a. case mix

90
Q

Interdisciplinary guidelines developed by hospitals to facilitate the management and delivery of quality clinical care is called

a. hospital pathways
b. critical pathways
c. MQ pathways
d. quality pathways

A

b. critical pathways

91
Q

The process by which data elements are accumulated is known as data

a. application
b. collection
c. warehousing
d. analysis

A

b. collection

92
Q

Data ________ is the reliability of data regardless of the way in which data was stored

a. accessibility
b. comprehensiveness
c. consistency
d. precision

A

c. consistency

93
Q

The _____ links a patient’s medical record with common identification data elements

a. smartcard
b. master patient index
c. face sheet
d. consistency

A

b. master patient index

94
Q

Indexes, registers and registries are considered ______ sources of information

a. primary
b. secondary
c. tertiary
d. standard

A

b. secondary

95
Q

An admission/discharge/transfer system is used to input patient ______information, which creates an automated master index database

a. registration
b. records
c. abstract
d. family

A

a. registration

96
Q

Failure to obey a subpoena constitutes ______

a. contempt of court
b. negligence
c. fraud
d. a tort

A

a. contempt of court

97
Q

The type of law based on judicial decisions and precendent rather than statutes is called _______

a. case law/common law
b. tort
c. administrative law
d. statutory law

A

a. case law/common law

98
Q

Patients have the right to _____ of protected information

a. maintenance
b. confidentiality
c. access
d. breach

A

b. confidentiality

99
Q

Facilities need to have in place a ____ in the event of an emergency that damages systems containing personal health information

a. test model
b. contingency plan
c. secondary procedure
d. second copy

A

b. contingency plan

100
Q

Health information departments maintain a ______ to document patient information release to authorized requesters

a. data base
b. release of information log
c. plan
d. procedure

A

b. release of information log

Essentials in Health Records Management (4 decks)

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