Module 2

Question 1

A patient record serves as a business record for the patient encounter and contains administrative data.

Answer 1

T

Question 2

The medical record is the property of the provider.

Answer 2

T

Question 3

Administrative data includes demographic, socioeconomic, and financial information

Answer 3

T

Question 4

A consultation report, history and physical exam, and operative reports are all types of administrative dat

Answer 4

F

Question 5

The legibility of patient care record entries impacts patient care

Answer 5

T

Question 6

Inpatient record creation may begin prior to admission when preadmission testing is performed

Answer 6

T

Question 7

Most facilities organize the patient record according to reverse chronological order during inpatient hospitalization.

Answer 7

T

Question 8

Clinical data includes all patient medical information

Answer 8

T

Question 9

Source oriented records consist of a database, problem list and initial plan and progress notes.

Answer 9

F

Question 10

A potentially compensable event is an accident or medical error that results in personal injury or loss of property.

Answer 10

T

Question 11

The electronic health record facilitates the creation of a longitudinal patient record.

Answer 11

T

Question 12

Patients do not have the right to access or review contents of their records

Answer 12

F

Question 13

Continuity of care includes documentation of patient care services so that others that treat the patient have a source of information on which to provide additional care and treatment.

Answer 13

T

Question 14

A living will is a written document that informs a health care provider of a patient’s desires regarding life sustaining treatment.

Answer 14

T

Question 15

A delinquent record can result in suspension of a physician’s medical staff privileges

Answer 15

T

Question 16

The history of the present illness is the patient’s description of his current medical condition in his own words

Answer 16

F

Question 17

Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record

Answer 17

T

Question 18

A physician’s order can be considered a “prescription” for care.

Answer 18

T

Question 19

A Preoperative note is a progress note documented by the surgeon prior to surgery

Answer 19

T

Question 20

EKG reports include a graphic printout of measurements of the activity of the brain

Answer 20

F

Question 21

The appearance of an outpatient to a hospital department to receive an ordered service, test or procedure is called an encounter.

Answer 21

F

Question 22

The role of a forms committee is to review all proposed forms to be used in the patient record

Answer 22

T

Question 23

An autopsy must be authorized by the deceased’s next of kin, except when it is a coroner’s case.

Answer 23

T

Question 24

The patient history documents the patient’s chief complaint, history of the present illness, past/family/social history and review of systems.

Answer 24

T

Question 25

Electronic Health records will improve care and reduce medical mistakes and costs

Answer 25

T

Question 26

The use of a serial numbering system does not need computer software to track the assignment of patient numbers.

Answer 26

T

Question 27

Patient records are filed in one location in the filing system when a unit or serial unit numbering system is used.

Answer 27

T

Question 28

In a unit numbering system, each time a patient is registered, a new patient number is assigned.

Answer 28

F

Question 29

A unit numbering system requires the retrieval of a patient’s record from multiple locations in the filing system when previous records are requested by a physician.

Answer 29

F

Question 30

Terminal digit numbers are usually written with a hyphen separating each part of the number.

Answer 30

T

Question 31

Patients have the right to have their record amended if they disagree with its content, or have a letter

which clarifies their view attached to the record.

Answer 31

T

Question 32

An assisted living facility is a combination of housing and support services

Answer 32

T

Question 33

Color-coding allows misfiles to be easily identified

Answer 33

T

Question 34

Chart tracking systems help to control the file area and facilitate accurate tracking.

Answer 34

T

Question 35

A patient monitoring system includes systems that collect demographic information

Answer 35

F

Question 36

Births, deaths, fetal deaths, marriages and divorces are examples of vital statistics

Answer 36

F?

Question 37

In consecutive numeric filing, records are filed in chronological order according to the patient’s birth date.

Answer 37

F

Question 38

A summary of a set a data using charts graphs and tables is referred to as descriptive statistics

Answer 38

T

Question 39

39. Which is an example of clinical data?
    a. date of birth c. patient name
    b. diagnosis d. social security number

Answer 39

B

Question 40

40. An admission clerk enters “right lower abdominal pain” as the admission diagnosis on the face sheet. This information is known as
    a. administrative data. c. demographic data.
    b. clinical data . d. financial data.

Answer 40

B

Question 41

41. An Inpatient record is typically between _______ in length.
    a. 30 and 50 pages c. 60 and 100 pages
    b. 40 and 60 pages d. 125 and 175 pages

Answer 41

C

Question 42

42. Since the early 1980’s, the number of outpatients treated by hospitals has
    a. decreased c. remained the same
    b. increased d. stayed constant

Answer 42

B

Question 43

43. If the order of a patient record reads like a diary, the forms are in
    a. chronological date order c. discharged record order
    b. reverse chronological order d. integrated date order

Answer 43

A

Question 44

A form of authentication by an individual in addition to the signature by the original author is known as a(n)

a. auto authentication		c fax signature
b. countersignature			d. rubber stamp signature

Answer 44

B

Question 45

45. When Janey Smilth, a health record technician, reviews a patient chart and looks for items that are incomplete or incorrect, she is doing a _____ on a chart.
    a. record assembly
    b. qualitative analysis
    c. quantitative analysis
    d. concurrent analysis

Answer 45

B

Question 46

46. An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the:
    a. preadmission testing c. principal procedure
    b. primary provider d. provisional diagnosis

Answer 46

D

Question 47

47. Which filing order saves time in processing discharged records?
    a. chronological order c. reverse chronological order
    b. date order d. universal chart order

Answer 47

D

Question 48

48. Tom Smith, a patient at Sunny View Hospital, fell out of bed during his inpatient admission. At the time of the fall an incident report was completed. He is now suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility.

Determine which of these actions should NOT have occurred.

A. The incident report was filed in the risk management office.
B. A note was entered in the patient record stating that an incident report was completed.
C. A copy of the incident report was filed in the patient’s record.
D. Defense attorneys for the health care facility reviewed the incident
report to prepare for the case.

a. A and B				c. B and C
b. A and C				d. B and D

Answer 48

C

Question 49

Disadvantages of automated record systems include all EXCEPT which of the following:

a. increased start-up costs
b. difficulty abstracting patient information
c. need for technical staff to maintain system
d. time consuming staff training

Answer 49

B

Question 50

50. A group of characters forms a(n):a. data item
    b. field
    c. information field
    d. paragraph

Answer 50

B

Question 51

Sunny Valley Hospital has an electronic health record system. The HIM department has been asked by the quality management department to monitor the number of times that providers make corrections to inpatient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?

a. audit trail c. digital signature log
b. independent database files d. public key cryptography

Answer 51

A

Question 52

Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient’s record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the data recorded in the record.

a. clinical c. financial
b. epidemiological d. socioeconomic

Answer 52

D

Question 53

Dan Smith has recently moved to a new town and he calls Dr. Jones office to make an appointment for an annual history and physical. It is the policy of Dr. Jones office to have all new patients request information from their previous health care providers and forward copies to his office prior to their first treatment.
Dr. Jones reviews Dan’s medical information that includes anxiety, depression, and documentation of therapy and treatment.
This information would most accurately be referred to as:

a. ambulatory care information c. case conference information
b. behavioral health information d. social work information

Answer 53

B

Question 54

Pre- and post-anesthesia evaluations would be found in a(n) record.

a. ambulatory care			c. long term care
b. behavioral health care		d. surgical care

Answer 54

D

Question 55

When a (PCE) potentially compensable event occurs the report should 
                 be filed in

a. The health record c. risk managers office
b. The health record manager’s office d. privacy officer’s office

Answer 55

C

Question 56

56. Steve Blue fell while he was transferred from his bed to a wheelchair. This would be documented on a (n)
    a. compliance report c. incident report
    b. fall report d. safety report

Answer 56

C

Question 57

57. The third set of digits in this Terminal digit number (02 08 41) is considered
    to be the

a. terminal digit c. secondary
b. primary d. tertiary

Answer 57

B

Question 58

58. The primary reason for completing medical records in a fashion consistent with
    medical staff policies and procedures is to

a. document risk management activities
b. comply with accreditation requirements
c. generate revenue from third party payers.
d. provide continuity of care to patients

Answer 58

D

Question 59

59. Sally Jones is responsible for analyzing, organizing and presenting information based on patient records. This is a function of
    a. data capture c. Information generation
    b. information capture d. report generation

Answer 59

D

Question 60

60. Tom Jones performs analysis of patient records and had identified several records without final diagnosis and procedures recorded on the face sheet. The type of analysis performed is
    a. deficiency c. quantitative
    b. qualitative d. statistical

Answer 60

B

Question 61

61. A collection of related fields is called a:a. character set
    b. field
    c. record
    d. information set

Answer 61

C

Question 62

62. Which of the following observations would be found in the physicals examination report?
    a. Has smoked two packs of cigarettes daily for the past 30 years.
    b. Needs assistance to perform activities of daily living.
    c. Abdomen soft and tender with no rebounding tenderness.
    d. Review of systems negative for hydration and diabetes.

Answer 62

C

Question 63

63. The physicians at Sunny Valley Hospital have requested that all progress notes be organized with the most current progress note filed first. This type of filing is known as
    a. chronological date order c. reverse chronological date order
    b. date order d. reverse date order

Answer 63

C

Question 64

At times a physician may have to document a change in one of their previous reports to clarify a statement made previously or to enter a late entry. This is
known as a

   a. correction report		c.   Addendum    b. checklist 			d.   audit report

Answer 64

C

Question 65

Automated chart completion management software can assist health information departments in managing retrospective analysis by discharging patient records by generating all of these options except:

a. credit reports
b. suspension letters
c. customized reports
d. deficiency reports

Answer 65

A

Question 66

Ada Nosic is using an electronic health record system that collects and monitors a patient’s vital signs. This is a :

a. patient clinical system
b. patient monitoring system
c. vital signs data system
d. vital signs information system

Answer 66

B

Question 67

Which statement regarding the patient record is true?

a. All entries must be legible and complete.
b. An alias cannot be used in a patient record
c. Only the front page of a two page document must contain patient identification.
d. The author of each entry does not have to sign the note if another supervising professional has signed it

Answer 67

A

Question 68

The diagnosis that documents the condition or disease for which the
patient is seeking treatment is the

a. discharge diagnosis.		c. provisional diagnosis.
b. final diagnosis.			d preoperative diagnosis

Answer 68

C

Question 69

Preexisting conditions that cause an increase in the patient’s length of
stay by at least one day in 75% of the cases is known as a(n)

a. chief complaint.		c. comorbidity.
b. complication.		d. principal diagnosis.

Answer 69

C

Question 70

Every report and every page/screen in a manual or computerized patient record must include

a. medical record number and date of birth.  
b. patient name and address.  
c. medical record number and social security/insurance number.
d. patient name and medical record number or date of birth.

Answer 70

D

Question 71

A patient is admitted for congestive heart failure and hypertension. During the admission the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a

a. complication  			c. principal condition.
b. comorbidity  			d. principal diagnosis

Answer 71

B

Question 72

A document that informs a health care provider of a patient’s desire regarding various life-sustaining treatment is a

a. do not resuscitate order.  	c. living will. 
b. health care proxy.	 	 d. organ donation card.

Answer 72

C

Question 73

Sally Smith is admitted to Sunny Valley Hospital wearing a diamond
ring. This should be documented on the

a. face sheet.  			c. patient property form.
b. financial record. 			d. nursing assessment

Answer 73

C

Question 74

Dr. Jones completes an admission history and physical on Bob Lot, who states, “When I walk up stairs I have difficulty breathing.” This statement is known as the patient’s

a. chief complaint.  			c. past history
b. history of the present illness  	d. patient complaint.

Answer 74

A

Question 75

Progress notes should be written

a. daily	 			c. on admission and discharge 
b. weekly  				d. as the patient’s condition warrants.

Answer 75

D

Question 76

An APGAR score is documented in the

a. admission history and physical  c. newborn record
b. autopsy report 			 d. nursing assessment

Answer 76

C

Question 77

Information concerning the mother’s condition after delivery is
documented in the

a. antepartum record. c. labor record.
b. delivery record d. postpartum record.

Answer 77

D

Question 78

The use of electronic health records can accomplish all EXCEPT which of the following:

a. decreased lengths of stay
b. improved health care quality
c. reduced health care costs
d. reduced medical errors

Answer 78

A

Question 79

The diagnosis, determined after the evaluation and documented by the
attending physician upon discharge from the facility is known as the

a. final diagnosis 		c. comorbidity 
b. admitting diagnosis.  	d. complication .

Answer 79

A

Question 80

Sunny Valley Hospital has adopted the following as part of their patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices.

a.
1. All entries should be documented and signed by the author.
2. Complete only necessary entries on preprinted forms. Leave others blank.
3. If other patient (s) are referenced in the record, document their name (s).
4. State facts about patient care and treatment; avoid documenting opinions.
5. Be sure to document specific information and to avoid vague entries.

a. 1 and 2  				c. 2 and 5
b. 1 and 4 	 			d. 2 and 3

Answer 80

D

Question 81

81. Review the following patient record entry, and determine in which report it would be documented.
    Skin No jaundice reveals pale, cool, and moist surface.
    Chest Respirations normal.
    Lungs Clear on inspection, percussions, and auscultation.
    Abdomen No tenderness, guarding, or rigidity.
    Extremities No significant findings
    Genitalia Normal
    Rectal Deferreda. chief complaint c. physical examination
    b. history of present illness d. review of systems

Answer 81

C

Question 82

82. A paper or computer based assessment of the patient’s body system is a
    a. physical examination c. consultation
    b. history of present illness d. social history

Answer 82

A

Question 83

A patient’s record contains the following order: “Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No
medications given and no restrictions. She can be released home in the
morning. To be seen in my office in two weeks.” This is an example of a

a. discharge order 			c. postoperative note. 
b. post-anesthesia note.  		d. risk management review

Answer 83

A

Question 84

Dr. Smith documents in a patient’s record that the patient may be released from the recovery room. This would be documented as part of the

a. operative report. 		 	c. postoperative note.
b. post-anesthesia note.  		d. case management note

Answer 84

B

Question 85

Which of the following statements would be found as part of a pre-anesthesia note?

1. Patient denies any previous reactions to anesthesia.  
2. Anesthesia to be used-genera
3. Patient had no reaction to current surgery.
4. Patient is at risk due to smoking history.

a. 1 and 2 	 			c. 1, 2, and 3
b. 2 and 3  				d. 1, 2, and 4

Answer 85

D

Question 86

Dr. Jones reviews the following information located in the patient
record.
Determine in which report the information is documented.
Date 1/2YYYY 1/3/YYYY 1/4/YYYY 1/5/YYYY 1/6/YYYY 1/7/YYYY
Blood Pressure 130/75 128/78 120/75 130/80 135/80 130/78
Temperature 99.3 99.5 99.8 99.5 99.8 99.9
Weight 139 139 137 137 136 138

a. history of present illness  	c. nursing care plan
b. physical examination 		d. vital signs record

Answer 86

D

Question 87

The following note is written by Dr. Balby: “Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.” This information would be documented as part of the

a. ante partum record. 	   	c. prenatal record. 
b. labor and delivery record.  	d. postpartum record.

Answer 87

B

Question 88

Sally Jones assembles a patient record and organizes the following
documents into a separate section of the record: advance directives, informed consent, and patient property form.
This separate section of the record would be considered.

a. administrative data c. financial data.
b. clinical data. d. miscellaneous data.

Answer 88

A

Question 89

The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as day of discharge. This information can be located on the

a. discharge summary.  		c. intake/output record
b. graphic sheet.  	      		d. nursing progress notes.

Answer 89

B

Question 90

Dr. Sharp, a surgeon, has designed a new form that he wants to use when he completes cataract surgery. Final approval of the form would be given by the

a. executive board.   		c. medical staff.
b. forms committee  		 d. surgery committee.

Answer 90

B

Question 91

Sally Smith is completing analysis of a patient’s record and finds original incident report in the record. Which action should she take?

a. File the original incident report in the patient record.  
b. make a copy of the incident report for the patient’s record and send the 	original to the risk manager. 
c. Make a copy of the incident report for the risk manager and file the 	original in the record.   
d. Send the original incident report to the risk manager’s office.

Answer 91

D

Question 92

Dr. Cook records the following as part of a history and physical examination: “Patients presents with abdominal pain of seven days’ duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon.” The diagnoses recorded are

a. admission diagnoses.  		c. primary diagnosis
b. differential diagnosis.  		d. secondary diagnosis

Answer 92

B

Question 93

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary’s chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the

a. discharge summary  		c. report of consultation
b. interval history and physical 	d. review of systems.

Answer 93

C

Question 94

A report that describes gross findings, organs examined and techniques for surgery is

a. operative discharge report c. pathology report
b. anesthetic record d. operative record

Answer 94

D

Question 95

What is not a part of an antepartum record?

a. Health history of the mother

b Pregnancy risk factors

c. diagnostic reports and other care during the pregnancy
d. fetal strips.

Answer 95

D

Question 96

96 . Which of the following is not documented as a part of a consultation report?

a. consulting physician’s signature  c. recommendations and opinions.
b. diagnosis and findings  		   d. family physician’s name

Answer 96

D

Question 97

97. As Ms. RHIT assembles and analyzes a discharged obstetrical patient’s record, she finds the forms listed below. Which should be pulled from the discharged patient’s record?

	Face Sheet
	Admission history and physical exam
	Consents 
	Patient’s property record
	Insurance claim
	Laboratory reports
	Antepartum record (copy) 
	Labor and delivery record 
	Incident report
	Postpartum record

a. antepartum record (copy) 
b. antepartum record (copy), insurance claim, and incident report
c. incident report and antepartum record (copy) 
d. incident report and insurance claim.

Answer 97

D

Question 98

A Patient was admitted with COPD on April 15 (this year). The patient has an exacerbation of COPD and was readmitted on June 1 (this year). The physician needs to document a(n)

a. history and physical examination
b. interval history and physical examination
c. progress note discussing patient’s condition since april 15
d. short form history and physical examination.

Answer 98

A

Question 99

99. Which of the following is documented on the physical examination?
    a. “I’m feeling very tired lately.” c. Denies loss of hearing.
    b. Patient’s lungs are congested d. Zocar, 40 mg, q.d

Answer 99

B

Question 100

With alphabetic filing, which name is filed first?

a. B. Polly Kim 	 			c. Barbara Polly Kim 
b. B. Kim  					d. Brenda Polly Kim

Answer 100

B