Chapter Quizes Flashcards
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
b. patients routinely undergo preadmission testing on an outpatient basis instead of being admitted as a hospital inpatient
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
c. governing board
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
a. continuity of care
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)
c. completing an internship and is engaged in a program of advanced specialized training
Medical staff policies that delineate medical staff responsibilities are called
a. bylaws
b. procedures
c. regulations
d. rules
a. bylaws
Coders assign ICD-10-CM procedure codes to which of the following cases?
a. emergency room
b. inpatient
c. outpatient
d. physician office
b. inpatient
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
b. generate statistical reports and disease/procedure indexes
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
d. the discharged patient record is organized in the same order as when the patient was on the nursing floor
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
b. ensure the timely, accurate, and complete collection and maintenance of cancer data
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
c. ensure reimburseent and for research and statistical purposes
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
a. ensure the delivery of quality health care
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
a. authorize approprate payment or refer the claim to an investigator for more thorough review
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
c. direct clinical department or services
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
a. answer telephones, greeting patients, and arranging outpatient laboratory tests
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
a. the physician credentialing and re-credentialing process
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
a. federal and state laws
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
d. improve patient’s outcomes
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
d. recommend appropriate corrective action
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
b. coding specialist
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
d. medical assistant
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
d. they provide a full range of health care services
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
a. along with other services (e.g. outpatient)
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
a. a facility that specializes in the treatment of inpatient children is usually called a pediatric hospital
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
c. 9 days
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
b. hospitalist
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
b. 23 hours, 59 minutes, 59 seconds
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
c. treated and released the same day
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
d. wheelchair
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
b. palliative care
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
a. custodial care
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
c. involves the review for medical necessity of inpatient care prior to inpatient admission
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
a. documentation of patient care
Which is most important for medicolegal purposes
a. discharge summary
b. entire record
c. nurses notes
d. progress notes
b. entire record
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
a. all patient records contain similar content and format features
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
d. generating images through x-rays
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
a. documenting services so others have a source from which to base care
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
b. the medical record is the property of the provider
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
d. she has the right to access the contents for review and to request the physician to amend the record to correct inaccurate information
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
c. the inpatient record is typically located at the nursing station
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
d. increasing volume of outpatient information
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
a. less structured office record versus a more structured office record
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
d. upon review of the record, the third-party payer can refuse to pay for the procedure
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
c. poor health care delivery
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
b. place the newly transcribed report on top of the other report
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
c. audit trail
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
c. inpatient care
X-ray films are consered a ______ of patient information
a. primary source
b. secondary source
a. primary source
The original patient record is a ____ of information
a. primary source
b. secondary source
a. primary source
EKG/ECGs are ____ of patient information
a. primary source
b. secondary source
a. primary source
Indexes and registers are a _________ of patient information
a. primary source
b. secondary source
b. secondary source
An incident report is a ____ of patient information
a. primary source
b. secondary source
b. secondary source
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
d. source-oriented record
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
a. by sections, chronological date order
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
b. contains minimum information collected on every patient, such as chief complaint, present conditions and diagnoses, social data
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
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
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
c. describes actions that will be taken to learn more about the patient’s condition and to treat and educate the patient
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
d. includes one or more problems and notes documented for each using a subjective, objective, assessment, and plan structure
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
c. Subjective, Objective, Assessment, Plan
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
b. patient’s problem in his or her own words
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
d. review of the record to ensure that each documet is present and authenticated
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
a. inaccurate documentation
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
d. use pressure sensitive coloured tags to flag missing signatures
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
b. computerized medical record
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
c. longtiduinal patient record
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
d. timely capture of information
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
c. personal health record
