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Health Records Management > Module 3 > Flashcards

Module 3 Flashcards

1
Q

Indexes and registers allow health information to be maintained and
retrieved for the purpose of education, planning and research.

A

T

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2
Q

An index is an organized system for the collection and dissemination data set of information on individual persons who have a particular disease

A

F

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3
Q

An automated master patient index consists of a computerized database of identification data about patients who have received health care services from a facility.

A

T

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4
Q

A manual master patient index (MPI) is less expensive to purchase compared with an automated MPI.

A

T

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5
Q

Information should be entered in a master patient index by various department to ensure accuracy and to avoid the creation of duplicate records.

A

F

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6
Q

The physician index is organized primarily by disease codes of
patients admitted by Physicians.

A

F

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7
Q

A registry is a system for the collection, storage, retrieval, and circulation of information on individuals that have a particular disease.

A

T

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8
Q

A data dictionary is a standard method for collecting and reporting
individual data elements.

A

F

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9
Q

To avoid fraudulent behaviors, healthcare providers must develop compliance plans and develop internal controls

A

T

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10
Q

Most Hospital statistics are collected using automated computer
systems.

A

T

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11
Q

Data is reliable if it is consistent throughout the systems in which it is stored, processed, and/or retrieved.

A

T

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12
Q

The process of translating data into information utilized for an
application is data warehousing.

A

F

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13
Q

The number of inpatients present at census taking time is called the
daily census count.

A

T

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14
Q

Registers are primary sources of patient information.

A

F

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15
Q

Case mix analysis is the study of the types of patients treated in a
facility.

A

T

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16
Q

Data Mining is a collection of data elements.

A

F

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17
Q

Civil laws deals with relationships between individuals and

government.

A

F

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18
Q

Discovery is the legal process lawyers use to obtain information about
all aspects of law.

A

F

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19
Q

Administrative law includes regulations created by administrative agencies of government.

A

T

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20
Q

Stare decisis is Latin for “to stand by things decided”.

A

T

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21
Q

Res gestae is Latin for “things done.”

A

T

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22
Q

Medical negligence results when a health care provider acts in an
improper way.

A

F

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23
Q

All states/provinces have enacted comprehensive laws to deal with
issues raised by the computerization of patient records.

A

F

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24
Q

Vital Statistics are compiled for events, including births, deaths Including fetal death), marriages and divorces

A

T

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25
Q

Length of stay data represents the number of calendar days that a patient was an inpatient.

A

T

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26
Q

To calculate discharge data statistics divide the number of times something happened by the number of times something could happen.

A

T

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27
Q

Patients are allowed to obtain copies of their records and to request
amendments be made to their records.

A

T

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28
Q

A statute of limitations refers to the time period after which a lawsuit cannot be filed.

A

T

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29
Q

A breach of confidentiality occurs when patient information is disclosed to others that do not have the right to access the information.

A

T

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30
Q

Confidentiality is the process of keeping privileged information secret; and means that information cannot be released without a patient’s authorization.

A

T

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31
Q

Each Province/state establishes a list of reportable events for which providers must submit patient information to appropriate agencies.

A

T

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32
Q

Continuous quality improvement plays a role in data quality in an
organization and includes elements of data application, collection,
warehousing, and analysis.

A

T

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33
Q

A qualified protective order permits the use or disclosure of protected
health information for any purpose.

A

F

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34
Q

A public health office must obtain a patient’s consent prior to requesting information from their medical chart.

A

F

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35
Q

Electronic records are not admissible in court.

A

F

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36
Q

A medical nomenclature organizes diseases and procedures into
numeric and alphabetic characters.

A

F

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37
Q

ICD-10-CA is the medical classification system used in Canada.

A

T

38
Q

The standard classification for mental disorders is CPT.

A

F

39
Q

An individual who brings a lawsuit is called the arbitrator.

A

F

40
Q

Workers compensation is a federally mandated insurance program that reimburses health care costs and lost wages for employees injured on the job.

A

F

41
Q

Critical pathways usually focus on one discipline and provide guidelines for standards of care.

A

F

42
Q

A medical nomenclature is a vocabulary of clinical and medical terms.

A

T

43
Q

A subscriber is a health plan enrollee

A

T

44
Q

CPT is the abbreviation for current procedural terminology

A

T

45
Q
  1. The quality improvement (QI) department needs to obtain a list of patients discharged within the last three months with a diagnosis of diverticulitis. This information can be obtained from the
    a. disease index c. procedure index
    b. master patient index d. physician index
A

A

46
Q

The chief of surgery wants to determine the number of cholecystectomies performed using a scope and as a open surgery for the last six months. This information may be obtained from the

a. disease index			c. procedure index
b. master patient index		d. physician index
A

C

47
Q

Dr James is completing a report for a medical staff committee. He needs to determine the number of patients admitted by Dr. Tops for the month of July with the diagnosis of anemia. The best source for this information would be the:

a. disease index			c. procedure index
b. master patient index		d. physician index
A

D

48
Q
  1. The process of translating data into information utilized for an application is
    a. data application c. data analysis
    b. data collection d. data warehousing
A

C

49
Q

Hillscrest Hospital is writing a retention policy for the health information department. Which index must be retained permanently?

a. disease index			c. procedure index
b. master patient index		d. physician index
A

B

50
Q

During the month of May there were 130 births, of which 127 were full term births and three were premature births. There were five newborn deaths. The newborn death rate is

	a. 2.3%				c 5.4%
	b. 3.8%				d. 7.2%
A

B

51
Q
  1. Based on your review of statistics in the table, which unit had the greatest number of patients in a single month?

Hillcrest Medical Center length of stay: June to July

Month of June	Unit No.	Total LOS	Total #of patients discharged(including deaths	Average LOS
	1	457	135	3.39
	2	549	125	4.39
	3	358	112	3.20
	4	630	130	4.85
Month Of July	Unit No.	Total Los	Total #of patients discharged(including deaths	Average LOS
	1	396	120	3.30
	2	536	140	3.83
	3	325	85	3.82
	4	657	128	5.13

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

A

B

52
Q
  1. DSM IV is a classification system of:
  • Topology c. Pathology
  • Edidemiology D Mental disorders
A

D

53
Q
  1. The director of the health information department at Sunny Valley Hospital needs to prepare a presentation for the finance committee to convince them to fund an automated master patient index system. Which statement would best support her argument?
  • An automated MPI is less expensive than a manual master patient index
  • An automated MPI will allow for rapid retrieval of patient information
  • Staff training time is decreased when an automated MPI is implemented.
  • The security in information is increased when an automated MPI is implemented.
A

B

54
Q
  1. Sally Jones presents to the emergency room (ER) with lower left abdominal pain. The ER physician asks the ER clerk to determine if the patient was previously seen in the facility. The quickest way for the ER clerk to
    obtain this information is to reference thea. disease index c master patient index
    b. emergency department log d. patient’s record
A

C

55
Q
  1. The health information director is writing a policy to ensure the accuracy of an automated master patient index. The two departments that should be allowed to enter or update information in the master patient index are.a. admissions and nursing
    b. admissions and health information management
    c. health information and nursing
    d. health information and medical staff
A

B

56
Q
  1. Calculating health care statistics is a function of thea. health care finance
    b. quality department
    c. health information management department
    d. risk management department
A

C

57
Q
  1. Hillcrest Hospital and Endwell Hospital are merging. The new health information director for both hospitals needs to ensure that the two master patient indexes are accurately merged. Each hospital currently uses manual MPIs, and they will convert to one automated MPI. Which activity below
    should the director avoid?a. Establish a merger plan for the hospital MPIs.
    b. Perform manual alphabetic search to identify duplicate MPI files.
    c. Shred the manual MPI within four weeks after the conversion.
    d. Use soft ware to identify and correct errors in the automated MPI.
A

C

58
Q
  1. Hillcrest Hospital is conducting research on Alzheimer’s disease and wishes to obtain information from its states registry. Which information below
    would be unavailable from the registry?a. incidence of disease c patient names
    b. number of cases d. types of patients
A

C

59
Q
  1. The health information department is responsible for generating reports and statistics on the types of patients treated by the facility. This function is called
    a. case mix analysis c. quality management
    b. patient record abstracting d. utilization review
A

A

60
Q
  1. Civil law deals with the legal rights and responsibilities of private individuals and includes
    a. contracts c. contracts and torts
    b. criminal acts d. torts
A

C

61
Q
  1. The number of inpatients present at census taking refers to
    a. daily inpatient census c. average daily census
    b. discharged data statistics d. daily census count
A

D

62
Q
  1. Which of the following would not be considered a health information
    custodian?

a. Law office
b. Health care practitioners
c. Hospitals
d. Behavioural Facilities

A

A

63
Q
  1. Which of the following terms do not reflect the concept of data quality?
    a. data application c. data integrity
    b. data validity d. data reliability
A

A

64
Q
  1. Disease, procedure and physician indexes contain data abstracted (selected) from:
    a. computerized databases
    b. data sets
    c. patient records
    d. registers and registries
A

C

65
Q
  1. Mark Jones is receiving traction in the physical therapy department at Happy Hospital. The therapist sets the traction at a higher level than ordered and Mark is injured. The hospital is liable for the negligent act under the doctrine of
    a. res gestae c. res judicata
    b. res ipsa loquitur d. respondeat superior
A

D

66
Q
  1. Which, in the following list, is not an acceptable phone request option
    for release of medical information? (ROI)
       a. Patient calls ROI department and requests their recent MRI be faxed to  their family doctor.

   b. Legal office calls the ROI office to confirm that Margaret Smith  
   has records at the hospital, prior to sending their request.
    c. Physician‘s office calls ROI department to see if EMG result is on file
    yet.
       d. Patient’s family calls ROI to find out how to request their records.
A

B

67
Q
  1. The doctrine of respondeat superior would apply in which of the following situations:

• An ambulance company documents incorrect information on an ambulance report. The hospital is liable.

  b. An X-ray technician prepares the wrong patient for a CT scan. The             	supervisor is liable. c. A nurse administers the wrong medication to a patient. The hospital is liable.
 d. A release of Insurance specialist sends a patient’s information to the wrong 	facility. The director of health records is liable.
A

C

68
Q
  1. Public law deals with relationships between individuals and the government, and includes:
    a. criminal law and torts
    b. contracts and torts
    c. criminal law and regulations
    d. contracts and regulations
A

C

69
Q
  1. An authorization to disclose personal health information is NOT required when
    a. A patient’s new employer wishes to verify his past medical history.
    b. Dr. Jones releases’ records to DR Smith for continuity of patient care.
    c. Happy Hospital identifies a patient as a cancer survive in their newsletter.
    d. a police officer comes into the release of information department looking for information to support a case.
A

B

70
Q
  1. Anna, a release of information specialist releases information to ABC
    Legal firm with the consent of a patient. Within the chart was an item
    from another patient’s chart. This is considereda. subpoena duces tecum c. contempt of court
    b. Res gestae d. a breach of confidentiality
A

D

71
Q
  1. Jane Mo, a release of information specialist at Sunnyside Hospital receives a call from Princess Grace Hospital requesting information for a patient that is being seen in the emergency department of their hospital. Select what be done next.

• Obtain the patient information on the phone and fax the information with the fax number given.
• Request that they mail a consent directed to Sunnyside Hospital prior to releasing the information to Princess Grace Hospital.
• Do not respond to the request as they should not be requesting information via the phone.
d. Request the name of the person calling, the main number of the hospital and their extension. Call the number given, verify that it is a hospital and then ask for the patient name and date of birth. Also ask of them to send a request in writing on their letterhead so that this request may be filed in the patient chart for future reference.

A

D

72
Q
  1. Protected health information includes all of the following EXCEPT
    a. patients name c hospital address
    b. patients’ date of birth d. medical record numbers
A

C

73
Q
  1. Which is not an example of acceptable phone requests for medical information:

a) general info on privacy and release of information
b) may be asking that medical tests be sent to their family physician
c) Insurance firm asking confirmation if their client was a patient in the facility
d) may want reports sent automatically to physicians

A

C

74
Q
  1. Which of the following correctly describes a patient record?

• The patient has the right to extract information from the chart that they perceive as incorrect.

  b. All states have the same rules and laws requiring legality of patient records. c. Medical documentation is technically considered hearsay. d. Medical records are only admissible to court with a judge’s order
A

C

75
Q
  1. Susie Smith wants to obtain a copy of her medical report. She can obtain a copy of all reports EXCEPT for the
    a. admission history and physical c. incident report
    b. dental record d. Treatment plan
A

C

76
Q
  1. Summaries of a set of data using charts, graphs and tables are referred to as
  • aggregate data
  • comparative data
  • descriptive statistics
  • patient centric data
A

C

77
Q
  1. The organization that reviews and revises ICD is
    a. ADA
    b. AMA
    c. CMS
    d. WHO
A

D

78
Q
  1. Which is a standard classification of mental disorders published by the APA?
    a. CPT c. ICIDH
    b. DSM d NDC
A

B

79
Q
  1. Which is the following is typically not the way that requests flow into the Release of Information Department?
    a. walk -in c. email
    b. courier d. mail
A

C

80
Q
  1. The average number of inpatient’s treated during a given time period such as weekly, monthly, or annually is known as
    a. daily census count c. daily inpatient census
    b. daily mean d. average daily census
A

D

81
Q
  1. Barb is completing a report for the hospital governing board.. They want to review the types and categories of patients treated. Barb should use which data to prepare the report?
    a. case mix c. inpatient census
    b. coding d. severity of illness scores
A

A

82
Q

. Interdisciplinary guidelines developed by hospitals to facilitate the management and delivery of quality clinical care is called

a. Hospital pathways				c. MQ pathways
b. critical pathways					d. quality pathways
A

B

83
Q
  1. The process by which data elements are accumulated is known as data
    a. application c. warehousing
    * b. collection d. analysis
A

B

84
Q

Data _______ is the reliability of data regardless of the way in which
data was stored.

a. accessibility c. consistency
b. comprehensiveness d. precision

A

C

85
Q
  1. The _______ links a patient’s medical record with common identification data elements.
    a. smartcard c. face sheet
    b. master patient index d. consistency
A

B

86
Q
  1. Indexes, registers and registries are considered _______ sources of information.
    a. primary c. tertiary
    b. secondary d. standard
A

B

87
Q
  1. An admission/discharge/transfer system is used to input patient _______
    information, which creates an automated master index database.

a. registration c. abstract
b. records d. family

A

A

88
Q
  1. Failure to obey a subpoena constitutes _______:
    a. contempt of court c. fraud
    b. negligence d. a tort
A

A

89
Q
  1. The type of law based on judicial decisions and precedent rather than
    statutes is called ________.

a. case law/common law c. administrative law
b. tort d. statutory law

A

A

90
Q
  1. Patients have the right to _________ of protected information.
    a. maintenance c. access

b confidentiality d. breach

A

B

91
Q
  1. Facilities need to have in place a ______ in the event of an emergency that damages systems containing personal health information
    a. test model c. secondary procedure
    b. contingency plan d. second copy
A

B

92
Q
  1. Health information departments maintain a ___________ to document patient information released to authorized requesters.
    a. data base c. plan
    b. release of Information log d. procedure
A

B

Health Records Management (3 decks)

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