Chapter Quizes

Question 1

Health care delivery in Canada and the United States has been greatly impacted by escalating costs, resulting in medical necessity requirements (to justify acute care hospitalizations), review of appropriateness of admissions, and requirement for administration of quality and effective treatments. Which was implemented as a direct results of current health care methods?

a. Health care consumers demand higher quality, more costly health care, and the focus on primary and preventative care
b. patients routinely undergo preadmission testing on an outpatient basis instead of being admitted as a hospital inpatient
c. Tertiary-care level services provided by specialized hospitals equiped with diagnostic and treatment facilities are offered in all communities
d. the performance of outpatient testing and surgiccal procedures has decreased due to advances in technology

Answer 1

b. patients routinely undergo preadmission testing on an outpatient basis instead of being admitted as a hospital inpatient

Question 2

Ultimate legal authority and responsibility for the hospital’s operation is the responsibility of the

a. administration
b. department chairpersons
c. governing board
d. medical staff

Answer 2

c. governing board

Question 3

An internist sees a patient with an unusual blood condition and then refers the patient to a specialist. This is an example of

a. continuity of care
b. primary care
c. secondary care
d. tertiary care

Answer 3

a. continuity of care

Question 4

Many of the physicians in a teaching hospital are interns and residents who work under the superivision of senior staff physician. A resident has

a. a medical degree and is continuing training immediately following completion of the four year medical curriculum
b. been granted active medical staff status by the health care facility
c. completing an internship and is engaged in a program of advanced specialized training
d. not yet written the state licensing exam to become a physician (e.g. MD)

Answer 4

c. completing an internship and is engaged in a program of advanced specialized training

Question 5

Medical staff policies that delineate medical staff responsibilities are called

a. bylaws
b. procedures
c. regulations
d. rules

Answer 5

a. bylaws

Question 6

Coders assign ICD-10-CM procedure codes to which of the following cases?

a. emergency room
b. inpatient
c. outpatient
d. physician office

Answer 6

b. inpatient

Question 7

The purpose of abstracting patient cases is to

a. classify diagnoses and procedures for facilities
b. generate statistical reports and disease/procedure indexes
c. identify deficiencies in the discharged patient record
d. process reimbursement for inpatient and outpatient care

Answer 7

b. generate statistical reports and disease/procedure indexes

Question 8

If a facility adopts the universal chart order, this means that

a. after a patient is discharged from the health care facility, the record is assembled in chronological date order
b. discharged patient records are maintained in chronological date order to eliminate the patient record assembly task
c. inpatient reports are filed in strict chronological order within each section of the patient records
d. the discharged patient record is organized in the same order as when the patient was on the nursing floor

Answer 8

d. the discharged patient record is organized in the same order as when the patient was on the nursing floor

Question 9

Cancer registries collect cancer data from a variety of sources and report cancer statistics to government and health care agencies. The primary responsibility of the Cancer Registrar is to:

a. assign code numbers to all diagnoses, services, and procedures, based on patient record documentation
b. ensure the timely, accurate, and complete collection and maintenance of cancer data
c. organize, analyze, and maintain patient information to ensure the delivery of quality health care
d. review health related claims to determine whether the costs are reasonable and medically necessary, based on the patient’s diagnosis

Answer 9

b. ensure the timely, accurate, and complete collection and maintenance of cancer data

Question 10

A coding specialist ensures that all diagnosis, services and procedure documents in patient records are coded accurately to

a. ensure the delivery of quality healthcare
b. determine whether the costs are reasonable and medically necessary, based on the patient’s diagnosis
c. ensure reimbursement, and for research and statistical purposes
d. plan, direct, coordinate, and supervise the delivery of health care

Answer 10

c. ensure reimburseent and for research and statistical purposes

Question 11

Patient data is organized, analyzed, and maintained by health information managers to

a. ensure the delivery of quality health care
b. ensure the timely, accurate, and complete collection and maintenance of cancer data
c. plan, direct, coordinate, and supervise the delivery of health care
d. verify claims against third-party payer guidelines

Answer 11

a. ensure the delivery of quality health care

Question 12

Health Insurance Specialists verify health claims against third-party payer guidelines to

a. authorize appropriate payment or refer the claim to an investigator for more thorough review
b. determine whether the costs are reasonable and medically necessary, based on the patients diagnosis
c. ensure reimbursement and for research an statistical purposes
d. ensure the delivery of quality health care

Answer 12

a. authorize approprate payment or refer the claim to an investigator for more thorough review

Question 13

Health services managers plan, direct, coordinate, and supervise the delivery of health care. They include specialists who:

a. complete physician credentialing
b. coordinate a health care facility’s quality improvement
c. direct clinical departments or services
d. perform routine administrative and clinical tasks

Answer 13

c. direct clinical department or services

Question 14

Medical assistants perform routine administrative and clinical tasks, which include

a. answer telephones, greeting patients, and arranging outpatient laboratory tests
b. ensure the timely, accurate, and complete collection and maintenance of cancer data
c. examining, diagnosis, and treating patients under the direct supervision of a physician
d. managing the physician credentialing process

Answer 14

a. answer telephones, greeting patients, and arranging outpatient laboratory tests

Question 15

Medical staff coordinators usually report directly to the health care facility’s administrator, and they are responsible for managing the medical staff office and complying with medical staff bylaws, which means they manage the (U.S.)

a. the physician credentialing and re-credentialing process
b. the privacy of patient health information
c. professional and general liability incidents, claims and lawsuits
d. quality improvement program

Answer 15

a. the physician credentialing and re-credentialing process

Question 16

A privacy officer oversees the development, implementation, and maintenance of, and adherence to an organization’s policies and procedures covering privacy of and access to patient health information in compliance with

a. federal and state laws
b. federal laws only
c. state laws only
d. federal laws, regardless of whether state laws superseded federal laws (US/Canada)
- in Canada, it is governed by provincial laws

Answer 16

a. federal and state laws

Question 17

A quality manager coordinates a health care facility’s quality improvement program to

a. analyze actual and potential risks to the health care facility
b. conduct accreditation surveys
c. identify liability incidents, claims, and lawsuits
d. improve patient’s outcomes

Answer 17

d. improve patient’s outcomes

Question 18

A risk manager investigates incidents to

a. ensure they are filed in the patient’s record
b. prepare patient’s for testimony against the facility
c. provide copies to the plaintiff’s attorney
d. recommend appropriate corrective action

Answer 18

d. recommend appropriate corrective action

Question 19

The hospital’s quality management department has determined that 10% of the medical staff is noncompliant regarding documentation issues related to appropriate assignment of diagnosis and procedure codes. Which professional would be best to provide in-service training in this area?

a. cancer registrars
b. coding specialist
c. medical staff coordinator
d. quality manager

Answer 19

b. coding specialist

Question 20

Mrs. Petrie enters the physician’s office for her appointment and signs in at the reception area. Which professional initially greets Mrs. Petrie and updates her registration information in the computer system

a. coding specialist
b. health insurance specialist
c. health services manager
d. medical assistant

Answer 20

d. medical assistant

Question 21

An acute care facility is a hospital that provides health care services to patients who have serious, sudden, or acute illness and/or who need certain surgeries. What is an accurate statement about an ACF

a. a quality manager closely monitors patients care for medical necessity
b. inpatient stays are typically lengthy (more than 30 days)
c. services are limited to emergency and critical care
d. they provide a full range of health care services

Answer 21

d. they provide a full range of health care services

Question 22

Hospitals have an organized medical and professional staff, and inpatient beds are available on a 24 hour basis. The primary function of hospitals is to provide inpatient medical and nursing services

a. along with other services (e.g. outpatient)
b. exclusively as single hospitals, where the facility is not part of a larger organization
c. to nonsurgical patients, along with other services (e.g. outpatient)
d. to surgical and nonsurgical patients, but no other services

Answer 22

a. along with other services (e.g. outpatient)

Question 23

A consideration when discussing hospital organization is to identify the population served by a health care facility. This means that health care is provided to specific groups of peple. Which is a true statement

a. a facility that specializes in the treatment of inpatient children is called a pediatric hospital
b. facilities that serves as “mini-intensive care units” are called emergency facilities
c. the hospital’s longest length of stay determines whether the hospital is classified as short- or long-term
d. the inpatient bed size licensed by the state determines whether the hospital is general or specialize

Answer 23

a. a facility that specializes in the treatment of inpatient children is usually called a pediatric hospital

Question 24

To calculate an inpatient length of stay, count the day of admission but not the day of discharge. A patient admitted on July 25 and discharged on August 3 has which LOS

a. 7 days
b. 8 days
c. 9 days
d. 10 days

Answer 24

c. 9 days

Question 25

Physicians who spend most of their time in a hospital setting admitting patients to their inpatient services from local primary care providers are called a. attending physicians b. hospitalist c. internist d. residents

Answer 25

b. hospitalist

Question 26

Outpatients are treated and released the same day and do not stay overnight in the hospital. Their length of stay is a maximim of a. 11 hours, 59 minutes, 59 seconds b. 23 hours, 59 minutes, 59 seconds c. 24 hours, 00 minutes, 00 seconds d. 24 hours, 59 minutes, 00 seconds

Answer 26

b. 23 hours, 59 minutes, 59 seconds

Question 27

Ambulatory surgery patients undergo certain procedures that can be performed on an oupatient basis, which means the patient is a. considered an inpatient b. receive subacute care c. treated and released the same day d. treated for urgent problems

Answer 27

c. treated and released the same day

Question 28

Which is an example of durable medical equipment that patients would use in their home a. daily living activities b. home infusion care c. inpatient bed d. wheelchair

Answer 28

d. wheelchair

Question 29

Hospice care provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families. The goal of hospice is to provide a. long-term care b. palliative care c. respite care d. therapeuitc care

Answer 29

b. palliative care

Question 30

Long-term care services that provide assistance with activities of daily living are associated with a. custodial care b. intermediate care c. managed care d. skilled care

Answer 30

a. custodial care

Question 31

Preadmission certification is defined as a form of utilization management that a. controls health care costs by reviewing cases for appropriateness b. includes a review of patient cases to determine that quality health care is provided c. involves the review for medical necessity of inpatient care prior to inpatient admission d. requires the documentation of services needed for diagnosis or treatment of a medical condition

Answer 31

c. involves the review for medical necessity of inpatient care prior to inpatient admission

Question 32

Which is the goal of both manual and electronic patient records a. documentation of patient care b. medicolegal protection of providers c. reimbursement of health care services provided d. research and education

Answer 32

a. documentation of patient care

Question 33

Which is most important for medicolegal purposes a. discharge summary b. entire record c. nurses notes d. progress notes

Answer 33

b. entire record

Question 34

Although hospital inpatient records have traditionally served as the documentation source and business record for patient care information, a. all patient records contain similar content and format features b. alternate care facilities records serve as the best documentation source for patient care information c. patient identification information must be captured by the physician's office that treats the patient d. the definition and purpose of the patient record is supported only by the financial record

Answer 34

a. all patient records contain similar content and format features

Question 35

Information capture is the process of recording respresentation of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care. Which is an example of information capture a. analyzing patient information b. constructing a health care document (paper or digital) c. formatting and/or structuring captured information d. generating images through x-rays

Answer 35

d. generating images through x-rays

Question 36

The primary purpose of the patient record is to provide continuity of care, which means a. documenting services so others have a source from which to base care b. evaluating the quality of inpatient care c. providing information to third-party payers for reimbursement d. service the medicolegal interest of the patient, facility, and providers of care

Answer 36

a. documenting services so others have a source from which to base care

Question 37

Which of the following statements is accurate a. the medical record is the property of both the provider and patient b. the medical record is the property of the provider c. the patient owns the documents in the medical record d. the provider owns the information in the medical record

Answer 37

b. the medical record is the property of the provider

Question 38

Mrs. Wright is a long standing patient of Dr. Bartron's medical practice. Mrs. Wright also happens to be a credentialed health information personnel, and she comes to the physicians office to request access to her medical record. She wants to make sure that the recent history that was documented by Dr. Bartron accurately reflects statements about her recent car accident. The receptionist has Mrs. Wright sign an authorization to release information and arranges to supervise Mrs. Wright's review of the record. Upon review, Mrs. Wright determines that there is an error in the documentation of the record and she approaches the medical assistant to request that it be corrected. How should the medical assistant respond? The medical assistant informs Mrs. Wright that a. because the receptionist shouldn't have let Mrs. Wright review the record in the first place, her request for correction is denied. b. Dr. Bartron does not correct entries in the medical record, but Mrs. Wright can write a letter clarifying the information, which will be filed in the record c. medical record entries can be corrected only after Mrs. Wright submits a letter that clarifies the information that she wants changed d. She has the right to access the contents for review and to request the physician to amend the record to correct inaccurate information

Answer 38

d. she has the right to access the contents for review and to request the physician to amend the record to correct inaccurate information

Question 39

The hospital inpatient record documents the care and treatment received by a patient admitted to the hospital. Where is the paper-based record stored while the patient is in the hospital a. all patient records are stored in the health information department b. each record is housed in the location specified in the physician's order c. the inpatient record is typically located at the nursing station d. the record is placed in a locking wall desk at the nursing station

Answer 39

c. the inpatient record is typically located at the nursing station

Question 40

Since the early 1980s, provision of outpatient services has steadily increased due to cost savings associated with providing health care on an ambulatory instead of inpatient basis. This shift from inpatient to outpatient care has also resulted in hospital health information departments managing a(n) a. decreasing volume of outpatient information b. equal volume of inpatient and outpatient information c. fluctuating volume of outpatient information d. increaseing volume of outpatient information

Answer 40

d. increasing volume of outpatient information

Question 41

Patient health care services received in a physician's office are documented in the physician office record, which includes both administrative and clinical data. Generally, physicians who practice independently use a(n) ______ used by physicians in a group practice a. less structured office record versus a more structured office record b. more structured office record versus a less structured office record c. office record that is very similar in comparison to the hospital inpatient's record d. structured office record similar to that

Answer 41

a. less structured office record versus a more structured office record

Question 42

One of the statements below is an interpretation of the familiar phrase "if it wasn't documented, it wasn't done" in the following care: Dr. White performed a thyroid biopsy procedure at the patient's bedside. He didn't document it in the patient record. Which statement is correct? a. the health care facility should reprimand Dr. White and possibly suspend his privileges b. The patient has no legal recourse to bring a malpractice suit against the physician c. the physician is not allowed to add documentation of the procedure after the fact d. upon review of the record, the third-party payer can refuse to pay for the procedure

Answer 42

d. upon review of the record, the third-party payer can refuse to pay for the procedure

Question 43

Health care services rendered must be documented to prove that care was provided and that good medical care is supported by patient record documentation. Therefore, inadequate patient record documentation may indicate a. an illegible entry should be rewritten by it's author b. enhanced continuity of care c. poor health care delivery d. the need to adopt an auto authentication policy

Answer 43

c. poor health care delivery

Question 44

Dr. Broad dictated a discharge summary on July 15, which was transcribed and placed in the patient record later the next day. Upon review of the report, Dr. Broad decided not to authenticate it and redictate it. He told the medical transcriptionist the reason was that, when he originally dictated the report, he had been ill with the flu; the report was incomplete and doesn't flow properly. Dr. Broad drew one line across each page of the report, wrote "re-dictated" on it, and dated and signed the notation. After the transcriptionist transcribes the new dictations, what action should the file clerk take? The file clerk should a. insert the newly transcribed report after the old report b. place the newly transcribed report on top of the other report c. remove the original report from the record and insert the newly transcribed report d. use a permanent marker to redact the old report, and file the new report

Answer 44

b. place the newly transcribed report on top of the other report

Question 45

A technical control mechanism created by an electronic health record system that consists of a listing of all transaction and activities that occurred, along with date, time, and user who performed the transaction is called a(n) a. addendum b. amended record c. audit trail d. indexed record

Answer 45

c. audit trail

Question 46

Preadmission testing incorporates patient registration, testing, and other services into one visit prior to a. ancillary services b. emergency care c. inpatient care d. urgent care

Answer 46

c. inpatient care

Question 47

X-ray films are consered a ______ of patient information a. primary source b. secondary source

Answer 47

a. primary source

Question 48

The original patient record is a ____ of information a. primary source b. secondary source

Answer 48

a. primary source

Question 49

EKG/ECGs are ____ of patient information a. primary source b. secondary source

Answer 49

a. primary source

Question 50

Indexes and registers are a _________ of patient information a. primary source b. secondary source

Answer 50

b. secondary source

Question 51

An incident report is a ____ of patient information a. primary source b. secondary source

Answer 51

b. secondary source

Question 52

The inpatient record format that is organized according to sections is called the a. electronic record b. integrated record c. problem-oriented record d. source-oriented record

Answer 52

d. source-oriented record

Question 53

In what order is the source oriented record usually arranged for permanent filing purposes a. by sections, chronological date order b. by sections, reverse chronological date order c. in the problem oriented fashion d. integrated, reverse chronological date order

Answer 53

a. by sections, chronological date order

Question 54

The problem oriented record's data base a. acts as a table of contents for the patient's record because it is filed at the beginning of the record and it contains a list of the patient's problems. b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data c. describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure

Answer 54

b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data

Question 55

The problem oriented record's problem list a. acts as a table of contents for the patient's record because it is filed at the beginning of the record and it contains a list of the patient's problems. b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data c. describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure

Answer 55

a. acts as a table of contents for the patient's record because it is filed at the beginning of the record and it contains a list of the patient's problems

Question 56

The problem oriented record's initial plan a. acts as a table of contents for the patient's record because it is filed at the beginning of the record and it contains a list of the patient's problems. b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data c. describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure

Answer 56

c. describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient

Question 57

The problem oriented record's progress notes a. acts as a table of contents for the patient's record because it is filed at the beginning of the record and it contains a list of the patient's problems. b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data c. describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure

Answer 57

d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure

Question 58

SOAP is the abbreviation for a. Source, Objective, Assessment, Problem b. Subjective, Objective, Analysis, Plan c. Subjective, Objective, Assessment, Plan d. Subjective, Objective, Assessment, Problem

Answer 58

c. Subjective, Objective, Assessment, Plan

Question 59

The SOAP format is commonly used by physicians to document progress notes, the subjective portion is the a. documentation of patient physical examination b. patient's problem in his or her own words c. physician orders for treatment of the patient d. physician's terminology that describes the patient's problems

Answer 59

b. patient's problem in his or her own words

Question 60

Which would be performed as part of a quantitiative analysis a. abstracting information from the patient record into a computer software program b. review of the face sheet and patient record to locate a diagnosis missing from the face sheet c. review of the patient record for inconsistent documentation d. review of the record to ensure that each document is present and authenticated

Answer 60

d. review of the record to ensure that each documet is present and authenticated

Question 61

Qualitative analysis involves the review of the patient record for a. inaccurate documentation b. patient identification on each patient c. presence of authentication by providers d. reports that are missing

Answer 61

a. inaccurate documentation

Question 62

The best way to mark authentication deficiencies in the patient's record is to a. call each physician and leave a message as to the number of chart deficiencies b. complete a deficiency form and place it in the physician's mailbox c. use a red marking pen to enter a check mark next to the documentation that needs authentication d. use pressure sensitive coloured tags to flag missing signatures

Answer 62

d. use pressure sensitive coloured tags to flag missing signatures

Question 63

From 1970 to 1980 the term _______ was used to describe early attempts at medical record automation a. automated medical records b. computerized medical record c. patient health record d. personal health record

Answer 63

b. computerized medical record

Question 64

Maria Jones' medical record includes records from different episodes of care, providers, and facilities, which are linked to form a view, over time of her health encounters. This type of medical record is called a a. comprehensive patient record b. computer based patient record c. longtiduinal patient record d. patient historical record

Answer 64

c. longtiduinal patient record

Question 65

Which of the following is a DISADVANTAGE of manual medical records a. low start up costs b. record linkage c. simplified staff training d. timely caputre of information

Answer 65

d. timely capture of information

Question 66

The electronic or paper based medical record that is maintained and updated by an individual for personal use is called a a. patient health record b. patient medical record c. personal health record d. personal medical record

Answer 66

c. personal health record

Question 67

Samantha Smith, HIM manager, is transitioning a manual patient record system to an electronic health record system by capturing existing paper record images in an electronic storage media. The most effective approach to accomplish this would be to a. entirely recreate the manual health information in the electronic health information system b. exclude manual patient records information from the electronic health record system c. keyboard all manual patient record system data into the electronic health record d. scan existing paper record images using a scanner to create an electronic record

Answer 67

d. scan exisiting paper record images using a scanner to create an electronic record

Question 68

The standards development organization that creates electronic health record standards under the direction of the U.S. department of health and human services is called a. AHIMA b. AMA c. CMS d. HL7

Answer 68

d. HL7

Question 69

Which of the following statements are false? a. electronic health health records systems are advantageous because there is no requirement for downtime b. facilities need to clearly define their legal record so as to respond to various requests for an entire patient's record when an electronic health record system is implemented c. implementation of each electronic health record system is based on information needs, budget, existing automated systems, and other factor unique to the organization d. no two facilities have the same electronic health record system

Answer 69

a. electronic health records systems are advantageous because there is no requirement for downtime

Question 70

Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds are called a. characters b. data c. fields d. information

Answer 70

b. data

Question 71

Which of the following is NOT an administrative application of the electronic health record system? a. admission/discharge/transfer and registration b. business and financial functions c. medication administration record documentation d. payroll applications

Answer 71

c. medication administration record documentation

Question 72

The functions of electronic health record (EHR) _____ applications include ordering x-ray tests, creating MRI/CT images, and reporting x-ray test results a. laboratory b. nursing c. pharmacy d. radiological

Answer 72

d. radiological

Question 73

Which of the following statements is true? a. a record contains more data than a file b. information is data that has been given meaning c. information is raw facts d. the first letter of a person's last name represents a field

Answer 73

b. information is data that has been given meaning

Question 74

A pathology report is required a. at the discretion of the pathologist b. at the discretion of the surgeon c. only in predefined cases where tissue is removed d. whenever tissue (or other material) is removed

Answer 74

d. whenever tissue (or other material) is removed

Question 75

A provisional diagnosis is also known as a a. comorbidity b. final diagnosis c. principal diagnosis d. tentative diagnosis

Answer 75

d. tentative diagnosis

Question 76

The tissue report is the written report of findings on surgical specimens and is documented by the a. attending physician b. pathologist c. radiologist d. surgeon

Answer 76

b. pathologist

Question 77

Major sections of the history include a. family and past history, mental and neuro-psychiatric exams, personal exams, and physical exams b. past history, family history, social history, review of systems, impression, and lab data c. past history, social history, chief complaint, present illness, and review of systems d. social and family history, past history, present illness, physical exam, and system review

Answer 77

c. past history, social history, chief complaint, present systems, impression, and lab data

Question 78

A graphic record documents a. the amount of medicine given per dose b. the number of times a patient is visited by his doctor c. the total number of times a patient has been in the hospital d. vital signs throughout the patient's stay

Answer 78

d. vital signs throughout the patient's stay

Question 79

Who provides the patient's admitting diagnosis for an inpatient stay? a. admitting office b. attending physician

Answer 79

b. attending physician

Question 80

An operative record should contain a a. description of the procedure b. history of the anesthesia reactions c. post-anesthesia status d. vital signs

Answer 80

a. description of the procedure

Question 81

The history of present illness a. describes the patient's current illness b. is a review of symptoms by body systems c. is a statement about the patient's life d. summarizes the patient's past illnesses

Answer 81

a. describes the patient's current illness

Question 82

Where is the fact that a patient smokes cigarettes documented a. family history b. physical examination c. review of systems d. social history

Answer 82

d. social history

Question 83

Laboratory tests are ordered by the a. laboratory technician b. medical technologist c. pathologist d. responsible physician

Answer 83

d. responsible physician

Question 84

An "impression" is most likely to be found on the a. advances directive b. discharge summary c. face sheet d. physical exam

Answer 84

d. physical exam

Question 85

The review of systems is found on the a. history b. physical examination

Answer 85

a. history

Question 86

A patient is admitted on May 1 and discharged on May 2. The diagnosis is tonsillectomy, and the patient underwent routine tonsillectomy. Which applies? a. A discharge note must be documented in the progress note b. a discharge summary must be dictated c. a short stay record may be documented d. an internal history and physical can be documented

Answer 86

c. a short stay record may be documented

Question 87

If the physician wants to determine how her patient reacted to a new medication administered during the night, she would review the a. anciallary data b. medication administration record c. nurses notes d. physician orders

Answer 87

c. nurses notes

Question 88

Inpatient progress notes are documented a. according to federal government mandates b. as the patient's condition warrants c. at least on a daily basis d. more than one a day, as a minimum

Answer 88

b. as the patient's condition warrants

Question 89

The face sheet is also known as admission/discharge a. record b. register

Answer 89

a. record

Question 90

The condition established after the study to be chiefly responsible for occasioning the admission of the patient to the hospital for care is the diagnosis a. principal b. principle

Answer 90

a. principal

Question 91

Which type of inpatient procedure is usually sequenced first? a. diagnostic procedure to treat a complication b. diagnostic procedure to treat the reason for admission after study c. therapeuitc procedure to treat a complication d. therapeutic procedure to treat the reason for admission after study

Answer 91

d. therapeutic procedure to treat the reason for admission after study

Question 92

A coexisting condition is a a. comorbidity b. complication

Answer 92

a. comorbidity

Question 93

The best method of communication for members of the health care team caring for a hospital inpatient is the a. consultation report b. discharge summary c. physicians report d. progress report

Answer 93

d. progress report

Question 94

The description of surgical tissue analysis is found on the a. autoposy report b. laboratory report c. operative report d. pathology report

Answer 94

d. pathology report

Question 95

The choice of anesthesia to be administered during surgery is documented by the anesthesiologist on the a. operative record b. pre-anesthesia evaluation note c. preoperative note d. recovery room record

Answer 95

b. pre-anesthesia evaluation note

Question 96

Progress notes are a chronological report of the patient's hospital course and reflect changes of the patient's a. data entries that direct patient treatment during an inpatient stay b. documentation of patient examination and review of the patient's record c. evidence that sufficient treatment was rendered to justify the stay d. the only basis upon which the patient or payer is billed for the hospital stay

Answer 96

c. evidence that sufficient treatment was rendered to justify the stay

Question 97

Which is an ancillary service form? a. flow sheet b. laboratory report c. medical administration record d. nursing discharge summary

Answer 97

b. laboratory report

Question 98

Which statement would be documented in a physical examination? a. admitted because of sharp epigastric pain b. had cholecystectomy three years ago c. HEAD: occasional headache d. negative bowel sounds

Answer 98

d. negative bowel sounds

Question 99

Which filing system houses all patient records in one department a. centralized b. decentralized

Answer 99

a. centralized

Question 100

Terminal digit filing is also called reverse numerical filing becase a. deceased patient records are filed according to this system b. the last two numbers of the patient number are considered primary

Answer 100

b. the last two numbers of the patient number are considered primary

Question 101

When a patient is assigned a new number at each admission to the hospital and a seaparte record is generated for the patient, which numbering system is being utilized a. phonetic b. serial c. serial unit d. unit

Answer 101

b. serial

Question 102

Which system is used when a patient receives a number on his first admission and retains it for all subsequent admissions a. phonetic b. serial c. serial unit d. unit

Answer 102

d. unit

Question 103

When filing patient number 38-47-23 according to terminal digit, the digits, "23" would be considered a. primary b. principal c. secondary d. tertiary

Answer 103

a. primary

Question 104

Within one primary section, which represents records filed in terminal digit order a. 00-00-52, 01-00-52, 02-00-52, 03-00-52 b. 00-00-52, 01-00-53, 02-00-54, 03-00-55 c. 00-00-52, 01-40-53, 02-40-54, 03-35-55 d. 05-00-52, 02-00-53, 01-00-54, 06-00-54

Answer 104

a. 00-00-52, 01-00-52, 02-00-52, 03-00-52

Question 105

Six patients were admitted to the hospital between 9:00 and 10:00 a.m. on January 1. The following patient numbers were entered, one after another, in the admission register: 9010, 2053, 9011, 9012, 3155, 0381 Which numbering system does the hospital use? a. pseudo numbering b. serial-unit c. serial unit d. unit

Answer 105

d. unit

Question 106

How does the serial unit system differ from the serial system a. serial unit records on the same patient are filed in one location in the health information department files, while serial records on the same patient are filed in multiple locations b. there is no difference; both the serial and serial unit filing systems follow the same number assignment guidelines as well as filing procedures in the filing system

Answer 106

a. serial unit records on the same patient are filed in one location in the health information department files, while serial records on the same patient are filed in multiple locations

Question 107

The file system requires 2,000 file guides, which pattern of guides will appear in the terminal digit files a. 00-00-00, 00-05-00, 00-10-00 b. 00-00-00, 00-00-05, 00-00-10 c. 00-00-00, 00-50-00, 01-00-00 d. 00-00-00, 00-00-05, 00-00-10

Answer 107

a. 00-00-00, 00-05-00, 00-10-00

Question 108

An outguide is typically used within the health record filing system to a. identify convenient units of patient record folders b. indicate that a patient record has been removed c. separate files by department d. show that a record has been lost

Answer 108

b. indicate that a patient record has been removed

Question 109

Loose filing usually involves a. filing reports in the record that are generated after a patient is discharged b. filing reports that have been previously misplaced c. leaving space available in a file system to allow additional records to be file d. stapling together reports that are loose in a folder

Answer 109

a. filing reports in the record that are generated after a patient is discharged

Question 110

In a terminal digit filing system, if the number is 64 79 36, the tertiary numbers is a. 36 b. 64 c. 79 d. 936

Answer 110

b. 64

Question 111

The hospital assigned patient numbers using the serial numbering system. Which number was most assigned by admissions a. 44 10 74 b. 56 00 96 c. 76 02 82 d. 89 03 76

Answer 111

d. 89 03 76

Question 112

Which numbering system is typically used when a hospital assigns pseudonumbers as patient numbers a. family b. serial c. serial-unit d. unit

Answer 112

d. unit

Question 113

A jukebox is a component of a. automated record tracking b. microfilming c. optical imaging d. transcribing dication

Answer 113

c. optical imaging

Question 114

The medical center has adopted the unit numbering system to assign patient numbers. The number that will be assigned to the next admission is 201562. Patricia Sloan's number on her last admission 010921. What number is assigned to Miss Sloan today as she is registered for outpatient care? a. 010921 b. 010922 c. 201562 d. 201563

Answer 114

a. 010921

Question 115

The primary purpose of color coding the file system is to a. flag deficiencies b. guide files c. indicate missing records d. reduce misfiles

Answer 115

d. reduce misfiles

Question 116

How many secondary sections does each primary section have in terminal digit filing? a. 50 b. 100 c. 1000 d. 10 000

Answer 116

b. 100

Question 117

Open shelf filing is preferred over file cabinets because a. filing is more hazardous b. it is more attractive c. it is required by JCAHO d. less floor space is required

Answer 117

d. less floor space is required

Question 118

Alfred State Medical Centre has a total of 20,000 records in their filing systems and plans to place a guide every 100 records. How many guides will they need? a. 50 b. 100 c. 200 d. 400

Answer 118

c. 200

Question 119

Which system requires extra digits in front of (at the end of) the patient numbers to signify placement of the individual in the household a. family numbering b. pseudonumbering c. social security numbering d. unit numbering

Answer 119

a. family numbering

Question 120

What type of filing units are mounted on tracks a. lateral b. movable files c. open shelf files d. visible files

Answer 120

b. moveable files

Question 121

Which allows for ease in the expansion of a file folder a. actvity legend b. fasteners c. color coded d. scoring

Answer 121

d. scoring

Question 122

The review of a filing system to locate misfiles is called a. auditing b. colour coding c. guiding d. requistioning

Answer 122

a. auditing

Question 123

When a record is removed from the filing system, what is left in its place? a. file guide b. incomplete record c. loose file d. outguide

Answer 123

d. outguide

Question 124

When the length of time a record remains active has passed, the record is processed for a. destruction b. microfilm c. retention d. storage

Answer 124

a. destruction

Question 125

When using the straight numeric filing methodology, which would be filed first a. 11320 b. 12465 c. 62374 d. 73912

Answer 125

a. 11320

Question 126

A formal or official recording of items, names or actions is called a a. register b. registry

Answer 126

a. register

Question 127

An organized system for the collection, storage, retrieval, analysis, and dissemination of information on individuals who have either a particular disease, a condition that predisposes to the occurrence of a health related event, or prior exposure to substances (or circumstances) known or suspected to cause adverse health effects is called a a. register b. registry

Answer 127

b. registry

Question 128

Soundex is a phonetic a. filing system b. numbering system

Answer 128

a. filing system

Question 129

Ideally, the master patient index (MPI) (CPI) is retained by the facility a. according to state statute b. as established by medical staff bylaws c. in accordance with federal law d. permanently

Answer 129

d. permanently

Question 130

The master patient index is filed a. alphabetically b. chronologically c. numerically d. reverse numerically

Answer 130

a. alphabetically

Question 131

Which is the key for locating patient's records filed by numbers a. admission/discharge register b. discharge log c. master patient index d. patient registry

Answer 131

b. discharge log

Question 132

If more than one person with the same surname and first name has been admitted to hospital, the master patient index cards are being arranged by a. date of birth b. date of discharge c. middle name d. patient number

Answer 132

c. middle name

Question 133

The main advantage of phonetic filing of master patient index cards is a. emphasis is placed on foreign language b. keyboarding errors are eliminated c. names that sound alike are filed together d. spelling accuracy is insured

Answer 133

c. names that sound alike are filed together

Question 134

Which statement is true about filing master patient index cards a. a married woman's MPI card is filed under her husband's first name b. a surname particle, such as da in daVinci, is not considered when filing MPI index cards c. Titles that precede an individual's name, such as Doctor or Sister, are considered when filing MPI index cards d. When the patient's legal name has an initial first, such as T Berry Bracelton, the intitial is considered when filing and precedes all full first names

Answer 134

d. when the patient's legal name has an initial first, such as T Berry Bracelton, the initial is considered when filing and preceds all full first names

Question 135

Before the case abstracting process can begin, a standard method for collecting and reporting individual data elements must be established so data can be easily compared. This is called a a. data dictionary b. data set

Answer 135

b. data set

Question 136

Which is an example of descriptive statistics a. narrative report b. run chart

Answer 136

b. run chart

Question 137

Data ______ is accurate, complete, consistent, up to date and the same no matter where the data is recorded a. integrity b. quality c. reliability d. validity

Answer 137

a. integrity

Question 138

A technique that uses software to search for patterns and trends and to produce data content relationships a. analysis b. collection c. mining d. warehousing

Answer 138

c. mining

Question 139

Limited two dimensional structures that do not allow for complete trend analysis are called a. online analytical processing servers b. relational databases

Answer 139

b. relational databases

Question 140

The date of a patient's authorization to release information is generally acepted a. according to established facility policy b. at any time regardless of the date c. as long as it contains an expiration date d. in accordance with federal regulations

Answer 140

a. according to established facility policy

Question 141

Alcohol or drug abuse records may be released via a. court order b. subpoena duces tecum c. tort d. interrogatory

Answer 141

a. court order

Question 142

A subpoena duces tecum requires the a. completion of a list of written questions by the party served b. despondent to answer certain questions, obtained as a sworn statement c. patient to produce his records in court and testify d. witness to come to court with specified documents

Answer 142

d. witness to come to court with specified documents

Question 143

A patient demands to see his medical records. How would you proceed a. advise him to request records through his attorney b. advise the patient of the procedure for access of information c. allow him to view the records immediately because HIPAA requires you to do so d. tell him that he cannot view his records because the law does not allow it

Answer 143

b. advise the patient of the procedure for access of information

Question 144

Mildred is transferred from the Alfred State Medical Center to the Community Nursing Facility. Two weeks later, the charge nurse from the nursing facility calls the medical center to request a copy of the discharge summary. How would you proceed a. contact the patient to obtain her autorization to release information b. require patient authorization before sending the information c. send the information d. use the "call back method" to verify the request for information

Answer 144

c. send the information

Question 145

Documentation regarding release of information to outside agencies is usually kept in the a. accession register b. admission/discharge register c. correspondence log d. master patient index

Answer 145

c. correspondence log

Question 146

A court order is signed by the a. attorney b. court clerk c. judge d. patient

Answer 146

c. judge

Question 147

Rule of conduct passed by a legislative body that is enforced by the gvernment and results in penalities when violated is called a(n) a. civil law b. contract c. statute d. tort

Answer 147

c. statute

Question 148

Which deals with the legal rights and relationships of private individuals and includes torts and contracts? a. civil law b. criminal law c. public law d. statutory law

Answer 148

a. civil law

Question 149

Any wrongful act for which a civil suit can be brough is called a(n) a. tort b. contract c. deposition d. interrogatory

Answer 149

a. tort

Question 150

Which deals with relationships between individuals and government and includes criminal law and regulations a. civil law b. criminal law c. public law d. statutory law

Answer 150

c. public law

Question 151

Published rules that interpret laws are called a. administrative laws b. cases c. depositions d. regulatory terms

Answer 151

d. regulatory terms

Question 152

The individual who initiates a civil complaint and has the burden of proof is called the a. administrator b. attorney c. defendant d. plaintiff

Answer 152

d. plaintiff

Question 153

The individual against whom the complaint is brought is called the a. attorney b. claimant c. defendant d. plaintiff

Answer 153

c. defendant

Question 154

Which is the legal process lawyers use to obtain information about all aspects of a case a. disposition b. discovery c. interrogatory d. trial

Answer 154

b. discovery

Question 155

Which is a form of discovery that includes a list of written questions that must be answered by the party upon which it is served a. disposition b. discovery c. interrogatory d. trial

Answer 155

c. interrogatory

Question 156

Which is a form of discovery used to obtain a sworn statement from a witness a. deposition b. discovery c. interrogatory d. trial

Answer 156

a. deposition

Question 157

Which is based on judicial decisions and precedent rather than on statutes a. administrative law b. case law c. civil law d. public law

Answer 157

b. case law

Question 158

For HIV related information request from an insurance company an authorization is a. required b. not required

Answer 158

b. not required

Question 159

For public health activities, an authorization is a. required b. not required

Answer 159

b. not required

Question 160

For patient or patient representative requests for information, an authorization is a. required b. not required

Answer 160

a. required

Question 161

For health care providers who do not render care to the patient, an authorization is a. required b. not required

Answer 161

a. required

Question 162

A vocabulary of clinical and medical terms is called a a. coding system b. medical nomenclature

Answer 162

b. medical nomenclature

Question 163

Which organizes a medical nomenclature according to similar conditions, diseases, procedures, and services and establishes numeric and alphanumeric characters for each a. classificiation system b. medical nomenclature

Answer 163

a. classification system

Question 164

Which is used to report diagnoses a. ABC b. CPT c. HCPCS d. ICD

Answer 164

d. ICD

Question 165

A third party payer is an organization that a. acts on behalf of insurance companies to process insurance claims b. processes claims for remibursement covered by a health care plan

Answer 165

b. processes claims for reimbursement covered by a health care plan

Question 166

Health care facilities analyze their case mix to a. determine whether a facility is serving caseloads that inlude disproportionate shares of patients with above-average (or below average) care needs b. forecast health care trends unique to their individual settings, ensure that they continue to provide appropriate services to their patient populations, and recognize that different patients require different resources for care

Answer 166

b. forecast health care trends unique to their individual settings, ensure that they continue to provide appropriate services to their patient populations, and recognize that different patients require different resources for care

Question 167

Severity of illness is the physiologic complexity that comprises the extent and interactions of a patient's disease as presented to medical presonnel. Severity of illness scores are based on a. ICD codes b. physiologic measures and ICD codes

Answer 167

b. physiologic measures and ICD codes