CPXE

Question 1

The federally mandated resident assessment instrument used in long term care facilities consists of three basic components, including the new care area assessment, utilization guidelines,and the

Answer 1

MDS.

p. 24

Question 2

The foundation for communicating all patient care goals in long-term care settings is the

Answer 2

Interdisciplinary plan of care. Page 24

Question 3

The best example of point of care service and documentation is:
A. Using an automated tracking system to locate a record
B. Using occurrence screens to identify adverse events.
C. Doctors using voice recognition systems to dictate radiology reports.
D. Nurses using bedside terminals to record vital signs

Answer 3

D. Nurses Using bedside terminals to record vital signs.

Page 25

Question 4

The health record states that the patient is female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?
A. Data comprehensiveness
B. Data granularity
C Data precision
D Data accuracy

Answer 4

D. Data accuracy

Page 26

Question 5

In determining your acute care facility’s degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Answer 5

Federal register

Page 27
CMS publishes both proposed and final rules for the conditions of participation for hospitals in the daily federal register.

Question 6

You have been appointed has chair of the health record committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the joint commission and the Medicare conditions of participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

Answer 6

24 hours after admission or prior to surgery

Page 30 number 48

Question 7

During a retrospective review of RoseHunter’s in patient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

Answer 7

Qualitative review
Page 32 number 55

Note: quantitative analysis involves checking for the presence or absence of necessary Reports and/or signatures, while qualitative analysis may involve checking documentation consistency, such as comparing a patients pharmacy drug profile with the administration record.

Question 8

As a new HIM manager of an acute care facility, you have been asked to update the facility’s policy for physician’s verbal orders in accordance with joint commission standards and state law. Your first area of concern is the qualifications of those in your facility who have been authorized to record verbal orders. For this information, you will consult the

Answer 8

hospital bylaws, rules, and regulations

Page 34 number 65

Question 9

As supervisor of the cancer registry, you report the registry’s annual caseload to administration.

The most efficient way to retrieve this information would be to use

Answer 9

Accession register

Page 35 number 70
the accession register is a permanent log of all cases entered into the database. Each number assigned is preceded by the accession year, making it easy to assess annual workloads