Domain 3

Question 1

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.  You must name each form for bar coding and indexing into a document management system.  The unnamed document in front of you includes a microscopic description of tissue excised during surgery.  The document type you are most likely to give to this form is: 
A. Pathology report
B. Operative report
C. Discharge summary
D. Recovery room record

Answer 1

A. Pathology report
Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description

Question 2

In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission’s national patient safety goals, the focus has shifted to:
A. use of prohibited or “dangerous” abbreviations
B. Prohibited use of any abbreviations
C. Use of abbreviations used in the final diagnosis
D. Flagrant use of specialty-specific abbreviations

Answer 2

A. Use of prohibited or “dangerous” abbreviations

Question 3

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?
A. MDS
B. DEEDS
C. UHDDS
D. ORYX

Answer 3

B. DEEDS
Is intended for use by individuals and organizations responsible for maintaining or improving record systems in 24 hour, hospital-based emergency departments. DEEDS is designed to provide uniform specifications for data elements that decision makers may choose to retain, revise, or add to their ED record systems

Question 4

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets 
A. Joint Commission standards
B. HL-7 standards
C. CMS standards
D. NHIN standards

Answer 4

C. CMS standards,

MDS data are reported directly to the Centers for Medicare and Medicaid Services and must conform to agency standards

Question 5

When operating under the Health Insurance Portability and Accountability act of 1996 (HIPAA), what is a basic tenet in information security for health care professionals to follow:
A. The information system encourages mass copying, printing, and downloading of patient records.
B. Security training is provided to all levels of staff.
C. Patients are not educated about their right to confidentiality of health information
D. When paper-based records are no longer needed, they are bundled and sent to a recycling center

Answer 5

B. Security training is provided to all levels of staff.

Question 6

Medicare’s Conditions of Participation for Hospitals requires that patient health records be retained for at least \_\_\_\_\_\_\_\_\_\_years unless a longer period is required by state or local laws. 
A. Seven
B. Five
C. Three
D. Ten

Answer 6

C. Five

Medical records must be retained in their original or legally reproduced form for a period of at least five years

Question 7

Which of the following responsibilities would you expect to find on the job description of a facility’s Information Security Officer but NOT on the job description of Chief Privacy Officer?
A. Monitor the facility’s business associate agreements
B. Conduct audit trails to monitor inappropriate access to system information
C. Cooperate with the Office of Civil Rights in compliance investigations
D. Oversee the patients right to inspect, amend, and restrict access to protected health information

Answer 7

B. Conduct audit trails to monitor inappropriate access to system information
The other three answers deal with privacy, not internal security

Question 8

What is the best resource to reference for recent certification standards to determine your acute facility’s degree of compliance with prospective payment requirements for Medicare?
A. CARF manual
B. Joint Commission accreditation manual
C. Federal register
D. Hospital bylaws

Answer 8

C. The Federal register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal register

Question 9

Which index is used by the HIM department to link the patients name and number in relation to access and retention of the clinical record?
A. Master patient index
B. Physician index
C. Disease index
D. Operation index

Answer 9

A. Master patient index (MPI)
Is an electronic medical database that holds information on every patient registered at a healthcare organization. It may also include data on physicians, other medical staff and facility employees

Question 10

Part of the responsibilities of the Health Infomation Manager (HIM) is:
A. Secure the data records for the hospital
B. Perform background checks on new employees
C. Educate physicians regarding proper documentation policies and standards
D. Make sure each employee has the proper certification for their department

Answer 10

C. Educate physicians regarding proper documentation policies and standards

Question 11

In a manual record tracking system, no record should be removed from the file without being replaced by a(n)
A. Outguide
B. 8 1/2 x 11 inch charge-out slip
C. Paddle
D. Empty file folder

Answer 11

A.outguide
When a file is removed or checked out, an outguide is used in its place to alert personnel that the file is being used or has been removed

Question 12

AHIMA recommends that patient health information for minors be retained for at least how long?
A. Ten years after the age of majority
B. Ten years after the most recent encounter
C. Age of majority plus statute of limitation
D. Permanently

Answer 12

C. Age of majority plus statute of limitation

Unless state or federal laws require longer time periods

Question 13

The steps in developing a record retention program include all but which one of the following
A. Destroying records that are not longer needed
B. Notifying the courts of the destruction
C. Assigning each record a retention period
D. Determining the format and location of storage

Answer 13

B. notifying the courts of the destruction

The courts do not have to be notified of the record destruction

Question 14

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 represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show:
A. Absence of SOAP format in progress notes
B. Missing signatures on progress notes
C. Missing operative reports
D. Missing discharge summaries

Answer 14

C. Missing operative reports
Institutions are given a Type 1 recommendation when 2% of delinquent records are due to missing history and physicals or operative reports. The remaining choices are incorrect and defined as follow: absence of SOAP format in progress notes= the SOAP format is not a requirement of Joint Commission. Missing signatures on progress notes = both signature omissions and discharge summary reports may be captured after discharge, but history and physicals should be on the chart within 24hrs of the patient’s admission

Question 15

According to AHIMA’s recommended retention standards, which one of the following types of health information does NOT need to be retained permanently?
A. Register of deaths
B. Register of surgical procedures
C. Register of births
D. Physician index

Answer 15

D. Physician index

A physician index does not have to be retained permanently

Question 16

Accreditation of Joint Commission is a voluntary activity for a facility and it is:
A. Required for reimbursement of certain patient groups
B. Required for state licensure in all states
C. Considered unnecessary by most health care facilities
D. Conducted in each facility annually

Answer 16

A. Required for reimbursement of certain patient groups
The remaining choices are incorrect and explained as follows:
Required for state licensure in all state= state licensure is required for accreditation but not the reverse; considered unnecessary by most health cere facilities=advantages of accreditation are numerous and include financial and legal incentives; conducted in each facility annually = Joint Commission conducts unannounced on-site surveys approximately every three years

Question 17

Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be \_\_\_\_\_\_\_\_\_\_\_\_\_
A. Provider preferences
B. Professional standards
C. Statutory requirements
D. Space considerations

Answer 17

C. Statutory requirements

Question 18

Engaging patients and their families in health care decisions is one of the core objectives for:
A. Joint Commissions National Patient Safety goals
B. Achieving meaningful use of EHRs
C. HIPAA 5010 regulations
D. Establishing flexible clinical pathways

Answer 18

B. Achieving meaningful use of EHRs

There are several core objectives for achieving meaningful use. Engaging patients and their families is one

Question 19

What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program?
A. 80%
B. 90%
C. 100%
D. 70%

Answer 19

B. 90%
The commission on Cancer (CoC) of the American College of Surgeons (ACoS) requires approved cancer programs to meet or exceed the target rate of 90 percent successful follow-up. SEER cancer registries must meet or exceed 95% successful follow-up. The follow-up rate is calculated on all eligible patients, both living and dead

Question 20

In which registry would you expect to find an Injury Severity Score (ISS)?
A. Birth Defects Registry
B. Cancer Registry
C. Transplant Registry
D. Trauma Registry

Answer 20

D. Trauma Registry
The injury severity Score (ISS) is an established medical score to assess trauma severity. It correlates with mortality, morbidity, and hospitalization time after trauma. It is used to define the term major trauma

Question 21

In 1987, OBRA helped shift the focus in long-term care to patient outcomes.  As a result, core assessment data elements are collected on each Skilled Nursing Facility resident as defined in the \_\_\_\_\_\_\_\_\_\_
A. Uniform Ambulatory Core Data
B. MDS
C. UHDDS
D. Uniform Clinical Data Set

Answer 21

B. MDS
OBRA mandates comprehensive functional assessments of long-term care residents using the Minimum Data Set for long-term care.

Question 22

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?
A. Delegated use of computer key by radiology secretary
B. Identifiable initials of a nurse writing a nursing note
C. A unique identification code entered by the person making the report
D. Written signature of the provider of care

Answer 22

A. Delegated use of computer key by radiology secretary.
Written signatures, identifiable initials, unique computer codes and rubber stamp signatures may all be allowed as legitimate means of authenticating an entry. However, the use of codes and stamped signatures MUST be confined to the owners and they are never to used by anyone else.

Question 23

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 ___________
A. The quality of follow-up care
B. The presence of absence of such items as pre operative and postoperative Diagnosis, description of findings, and specimens removed
C. Whether the severity of illness and/or intensity of service warranted acute level care.
D. Whether a postoperative infection occurred and how it was treated

Answer 23

B. The presence of absence of such items as preoperative and postoperative Diagnosis, description of findings, and specimens removed
The following choices are incorrect and defined as follows: the quality of follow-up care=represents the clinical care evaluation process rather than the review of quality documentation; whether the severity of illness and/or intensity of service warranted acute level care=this is a function of the utilization review program; whether a postoperative infection occurred and how it was treated=this represents an appropriate job for the infection control officer

Question 24

Your state regulations require records to be kept for a statute of limitations period of seven years. Federal law requires records to be retained for five years. The minimum retention period for health records in your facility should be
A. Five years
B. Seven years
C. Either five or seven years as determined by the facility
D. Ten years

Answer 24

B. Seven years

The facility must match the steps statute of limitations period of seven years

Question 25

Stage 1 of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?
A. Establish critical pathways for complex, high dollar cases
B. Appropriate use of HL-7 standards
C. Use CPOE for medication orders
D. Smoking cessation counseling for MI patients

Answer 25

C. Use CPOE for medication orders.

See all objectives for stage 1 of meaningful use on the www.health it.gov website