Domain 1 Flashcards
During a retrospective review of Rose Hunter’s inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?
- Utilization Review
- Quantitative Review
- Legal Review
- Qualitative Review
Qualitative Review
Which of the following is least likely to be identified by a deficiency analysis technician?
• Discrepancy between post up diagnosis by the
surgeon and pathology diagnosis by the
pathologist
• Missing discharge summary
• Need for physician authentication of two verbal
orders
• X-ray report charted on the wrong record
Discrepancy between post up diagnosis by the surgeon and pathology diagnosis by the pathologist
The Conditions of Participation require that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered consultation?
• tissue examination done by the pathologist
• impressions of a cardiologist asked to determine
whether patient is a good surgical risk
• interpretation of a radiologic study
• technical interpretation of electrocardiogram
impressions of a cardiologist asked to determine whether patient is a good surgical risk
The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding
• The presence or absence of such items as
preoperative and postoperative diagnosis,
description of findings, and specimens removed
• whether a postoperative infection occurred and
how it was treated
• the quality of follow-up care
• whether the severity of illness and/or intensity of
service warranted acute level care
The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed
In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing
- integrated progress notes
- interdisciplinary treatment plans
- source-oriented records
- SOAP notes
integrated progress notes
Which of the following services is LEAST likely to be provided by a facility accredited by CARF?
- Chronic pain management
- palliative care
- brain injury management
- vocational evaluation
palliative care
Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?
• Written signature of the provider of care
• identifiable initials of a nurse writing a nursing note
• a unique identification code entered by the person
making the report
• delegated use of computer key by radiology
secretary
delegated use of computer key by radiology secretary
As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?
- DEEDS
- UHDDS
- MDS
- ORYX
DEEDS
As a new HIM manager of an acute care facility, you have been asked to update the facility’s policy for a physicians verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the
- Consolidated Manual for Hospitals
- Federal Register
- Policy and Procedure Manual
- Hospital Bylaws, Rules, and Regulations
Hospital Bylaws, Rules, and Regulations
Reviewing a medical record to ensure that all diagnosis are justified by documentation throughout the chart is an example of
- Peer review
- quantitative review
- qualitative review
- legal analysis
qualitative review
Accreditation by Joint Commission is a voluntary activity for a facility and it is
• considered unnecessary by most health care
facilities
• required for state license in all states
• conducted in each facility annually
• required for reimbursement of certain patient
groups
required for reimbursement of certain patient groups
Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record
- database
- problem list
- initial plan
- progress notes
problem list
As a supervisor of the cancer registry, you report the registry’s annual caseload to administration. The most efficient way to retrieve this information would be to use
- patient abstracts
- patient index
- accession register
- follow-up files
accession register
Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record
• Patient admitted with COPD 1/4/2016 and
discharged 1/7/2016
• Baby Boy Hiltz, born 1/5/2016, maintained normal
status, discharged 1/7/2016
• Baby Boy Hiltz’s mother admitted 1/5/2016, C-
section delivery, and discharged 1/7/2016
• Baby Boy Doe admitted 1/3/2016, died 1/4/2016
Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016
Based on the following Documentation in an acute care record, where would you expect this excerpt to appear?
“ Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKG’s remained unchanged. Patient will be discharged and followed as an outpatient.”
- discharge summary
- physical exam
- admission note
- clinical laboratory report
discharge summary
The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking our specific voluntary accreditation standards and guidelines is the
• Conditions of participation for Rehabilitation
Facilities
• Medical Staff Bylaws, Rules, and Regulations
• Joint Commission Manual
• CARF manual
CARF manual
Which of the following is a secondary data source that would be used to quickly gather the health record of all juvenile patients treated for diabetes within the past 6 months.
- disease index
- patient register
- pediatric census sheet
- procedure index
disease index
As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with
- The OIG
- MEDPAR representatives
- QIO physicians
- Recovery audit contractors
Recovery audit contractors
Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data
- timeliness
- accuracy
- comprehensiveness
- security
comprehensiveness
In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represent the most serious pattern of delinquencies? Fifteen percent of delinquent records show
- missing signatures on progress notes
- missing discharge summaries
- absence of SOAP format in progress notes
- missing operative reports
missing operative reports
A primary focus of screen format design in a health record computer application should be to ensure that
• programmers develop standard screen formats for
all hospitals
• the user is capturing essential data elements
• paper forms are easily converted to computer forms
• data fields can be randomly accessed
the user is capturing essential data elements
A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captures on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data
- reliability
- accessibility
- legibility
- completeness
reliability
Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be
• written within 24 hours of the patient’s admission
• accepted by charge nurse only
• cosigned by the attending physician within 4 hours
of giving the order
• recorded by persons authorized by hospital
regulations and procedures
recorded by persons authorized by hospital regulations and procedures
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave
• documented in an incident report and filed in the
patient’s health record
• reported as a potentially compesable event
• reported to the Executive Committee
• documented in both the progress notes and the
discharge summary
documented in both the progress notes and the discharge summary
Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely ch3eck to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and re-certify the patient as appropriate. The time frame for requiring this summary is at least every
- week
- month
- 60 days
- 90 days
60 days
You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be
- medical staff bylaws
- quality management plan
- Joint Commission accreditation manual
- medical staff rules and regulations
medical staff rules and regulations
A quarterly review reveals the following data for Spring field Hospital:
Springfield Hospital Quarterly Statistics
Average monthly discharges 1,820
Average monthly operative procedures 458
Number of incomplete records 1,002
Number of delinquent records 590
What is the percentage of incomplete records during this quarter?
- 55%
- 54%
- 33%
- 32%
55%
Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital
- 55%
- 32%
- 33%
- 54%
32%
Still referring to the information in the table related to Springfield Hospital, would the facility be out of compliance with Joint Commission standards?
- Yes
- No
No
In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the
- Information security manager
- clinical data specialist
- health information manager
- risk manager
health information manager
For inpatients, the first data item collected of a clinical nature is usually
- principle diagnosis
- expected payer
- admitting diagnosis
- review of symptoms
admitting diagnosis
Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare’s Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is
- beta blocker at discharge
- blood culture before first antibiotic received
- early administration of aspirin
- discharge on antithrombotic
blood culture before first antibiotic received
One record documentation requirement shared by BOTH acute care and emergency departments is
- patient’s condition on discharge
- time and means of arrival
- advance directive
- problem list
patient’s condition on discharge
In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain
- standing orders
- telephone orders
- stop orders
- discharge order
discharge order
As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how “review of systems” differs from “physical exam,” you explain that the review of systems is used to document
• objective symptoms observed by the physician
• past and current activities, such as smoking and
drinking habits
• a chronological description of patient’s present
condition from time of onset to present
• subjective symptoms that the patient may have
forgotten to mention or that may have seemed
unimportant
subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant
Based on the following documentation in an acute care record, where would you expect this excerpt to appear:
“The patient is alert and in no acute distress, Initial vital signs: T98, P102, and regular, R 20 and BP 120/69…”
- physical exam
- past medical history
- social history
- chief complaint
physical exam
Which one of the following is NOT a step in developing a health record retention schedule?
- conducting an inventory of the facility’s records
- determining the format and location of storage
- assigning all records the same retention period
- destroying records that are no longer needed
assigning all records the same retention period
Information found in which of the following would not be considered secondary data?
- disease index
- implant registry
- health record
- National Practitioner Data
health record
Under the Patient Self-Determination Act of 1990, evidence of advance directives
• are required to be documented in the health
record
• are not required to be documented in the health
record
• require a doctor’s approval
• must be prepared by an attorney
are required to be documented in the health record
A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be take?
• Return inactive records to each individual patient
• Destroy records of all deceased patients
• Destroy inactive records that exceed the statute of
limitations
• Maintain the records indefinitely in hard copy
Destroy inactive records that exceed the statute of limitations
