PQRI established financial incentive 4 eligible Pro who participate voluntary quality reporting

Tax Relief and Health Care Act of 2006

The doctrine of respondeat superior would apply in which of the following situations?

Nurse admits the wrong med to a PT; the hospital is liable.

Which of the following is an advantage of an automated system?

Eliminates paper record storage

Tom was injured on the job. According to HIPAA who can access his PHI regarding that job injury

Workers’ compensation carrier

Which characteristic of electronic data interchange (EDI) below is incorrect?

It determines claim status within 14 hours.

Progress notes should be written

as the patient’s condition warrants

Which of the following will occur in an HIM department that has an electronic record system?

Notes that are not authenticated

GINA is the abbreviation for ____________________

Genetic Information Nondiscrimination Act

Sally is completing analysis of a pt’s record, finds an original incident report in the record.

Send original incident report to the risk manager office.

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

Signature of requesting physician

The purpose of the HIPAA security rule is to

protect release of patient information & establish retention, adopt national standards for EHR information.

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Spring HIM108 Comprehensive Final

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Questions 92

Answers

1
Data becomes this after it is given meaning
Graphics
Images
Information
Analytics
2
PQRI established financial incentive 4 eligible Pro who participate voluntary quality reporting
Patient Safety and Quality Improvement Act
Deficit Reduction Act of 2005
HITECH Act
Tax Relief and Health Care Act of 2006
3
guidelines developed by hospitals to facilitate management & delivery of quality clinical care
clinical pathways
MQ pathways
quality pathways
critical pathways
4
The doctrine of respondeat superior would apply in which of the following situations?
Nurse admits the wrong med to a PT; the hospital is liable.
Attending DR operates on a PT wrong leg. Hospital is liable.
Xray tech prep the wrong PT for CT scan. Supervisors liable.
EMT company documents wrong info on report. Hospitals liable
5
Computer software must be purchased to manage a(n) ____________________ numbering system.
terminal
unit
serial
alpha-numeric
6
Standard classification of mental disorders published by American Psychiatric Association (APA)
NDC
DSM
CPT
ICIDH
7
Patients that undergo procedures that can be performed on an outpatient basis are categorized
clinic outpatients
ambulatory patients
observation patients
ambulatory surgery patients
8
Ms. Smith is admitted to Sunny Valley Hospital wearing a diamond ring. Documented on:
face sheet
financial record
patient property form
nursing assessment
9
Civil law deals with the legal rights and responsibilities of private individuals and includes
contracts
contracts and torts
torts
criminal acts
10
Medical staff membership category, Drs who deliver most of a hospital’s INPT medical services?
Associate
Active
Honorary
Consulting
11
Law passed by legislative body that can be amended, repealed, or expanded by legislative body
case law
common law
criminal law
statutory law
12
Ms. HIM files the following records: 223345, 223346, 223347, 223348, and 223349. Which system?
Numeric filing
Terminal digit filing
Straight numeric filing
Middle digit filing
13
Quaternary care is provided most commonly at ____________________ centers.
secondary
diagnostic care
primary care
tertiary care
14
Hospital reimbursement based on retrospective payment system issues payment based daily charges
fee-for-service.
RPS
per diem
an 80/20 plan
15
MVA victim, told his DR that if he stops breathing, heart stops, he doesn't want to be revived.
Health care proxy form
Do not resuscitate order
Living will
Standing order
16
An admissions clerk enters “right lower abdominal pain” as the admission diagnosis
administrative data
demographic data.
financial data
clinical data
17
The process of advising a patient about treatment options is known as
treatment consent.
applied consent.
patient consent.
informed consent.
18
The Medicaid Integrity Program, a fraud and abuse detection program, was established by the
American Recovery and Reinvestment Act
Genetic Information Nondiscrimination Act
Hill-Burton Act
Deficit Reduction Act
19
HCPCS Level II or _________________________ codes classify DME, drugs, & services not in CPT.
APC
national
DRG
ICD
20
The Joint Commission’s approach to accreditation is ______________ and data driven.
voluntarily centered
patient centered
staff centered
safety centered
21
With alphabetic filing, which name is filed first?
B. Kim
Brenda Polly Kim
Barbara Polly Kim
B. Polly Kim
22
The JC requires the HX and PX exam be documented in patient record within ____ of InPT admit.
24 hours
48 hours
7 hours
72 hours
23
Analyze PT record for deficiency & determine entry been authenticated w initials.
signature log
signature legend
authentication log
authentication legend
24
Which of the following is an advantage of an automated system?
Requires untrained staff
Low start-up costs
Eliminates paper record storage
User resistance is unlikely
25
The use of charts, graphs, and tables to summarize data is called _________________________.
descriptive statistics
quantitative statistics
developmental statistics
qualitative statistics
26
Security awareness & training programs include security reminders, log-in monitoring, and
Credit Editors
monitors
passwords
logins
27
The admission date and discharge date are considered
clinical information.
medical information.
financial information.
demographic information.
28
Nomenclature used for pathology laboratory, to gather information for staff pathologists.
SNOMED
SNOP
SNDO
SNO
29
Tom was injured on the job. According to HIPAA who can access his PHI regarding that job injury
Employer
Lawyer
Workers’ compensation carrier
Life insurance company
30
______ was used late 1990s to describe systems based imaging & merging data stand-alone systems
scantron system
electronic medical record
scanning systems
microfiche system
31
The abbreviation NPO means
not previously ordered
nothing abnormal found
no personal orders
nothing by mouth
32
Which characteristic of electronic data interchange (EDI) below is incorrect?
Payment of electronic claims is faster.
Lower administrative costs result
It determines claim status within 14 hours.
Online receipt is generated
33
Links a patient’s medical record number with common identification data elements.
Unit Index
Master Patient Index
Procedure Index
Disease Index
34
The JC requires that a discharge summary be completed within ____ days of discharge
15
30
25
20
35
Progress notes should be written
as the patient’s condition warrants
weekly
daily
on admission and discharge
36
The use of signature stamps should be specified in the
administrative policies
nursing policies
hospital bylaws
medical staff bylaws
37
Suzy job: coordinating PT care to ensure PT receive timely discharge or transfer. Her title is
risk manager
utilization manager
privacy officer
quality manager
38
Newborn death rate is calculated by dividing number of newborn deaths by _____ and * by 100.
number of pregnant women admitted
number of newborn patients
number of mothers discharged
number of fetal deaths
39
Document that informs health care providers of a patient’s wishes for life-sustaining treatment
health care proxy
do not resuscitate order
organ donation card
living will
40
Voluntary compliance with standards is known as ____________________.
non profit
licensed
accreditation
registered
41
Patients have the right to ____________________ of PHI.
Confidentiality
Electronic Health Records
Independent Assistance with records
Patient Portal
42
A health care enrollee is known as a(n) ____________________.
subscriber
provider
patient
physician
43
Which of the following would not be documented on a medication administration record?
Nurse who administered medication
Dosage given
Medication given
Provisional diagnosis
44
Which of the following will occur in an HIM department that has an electronic record system?
Misfiled patient information
Filing of patients’ progress notes
Notes that are not authenticated
Pulling records for physician access
45
A form of authentication by an individual in addition to the signature by the original author
fax signature
rubber stamp signature
countersignature
auto-authentication
46
GINA is the abbreviation for ____________________
Genetic Inflammation Nonsteriod Acids
Genetic Information Nondiscrimination Act
Generic Institutions Notification Actions
Generic Inflammation Nonsteroids Anti-Inflammatory
47
Sally is completing analysis of a pt’s record, finds an original incident report in the record.
Copy incident report pt record, send original to risk manage
Send original incident report to the risk manager office.
File the original incident report in the patient record
Make copy incident report 4 risk manage file original record
48
PT born at Mercy in 1967 assign PT 57690. She was admitted 1974 for tonsillectomy assign 57690.
unit numbering
numerical
serial numbering
serial-unit numbering
49
Which of the following is not documented as a part of a consultation report?
Diagnosis and findings
Consulting physician’s signature
Recommendations and opinions
Signature of requesting physician
50
The purpose of the HIPAA security rule is to
protect release of patient information & establish retention
outline specific security training require the privacy rule.
establish standards for business associate agreements
adopt national standards for EHR information.
51
Developes a draft strategic plan for Hospitals, presents plans to board of trustees meeting
chief operating officer
chief executive officer
chief information officer
chairperson of the board
52
The HIM department is responsible for generating reports & stats types of PTs treated facility.
patient record abstracting
utilization review
quality management
case mix analysis
53
The purpose of the HIPAA security rule is to
adopt national standards for electronic health information
outline security training requirements for privacy rule
protect the ROI information and establish retention periods
establish standards for the formation of BA agreements
54
Additional Dx that describe conditions that arise after beginning of hospital observation & Tx
morbidities
diagnosis
complications
treatments
55
Middle-digit filing uses the middle digit as the ____________________ number when filing.
terminal
quandary
secondary
primary
56
Dr. Smith documents in a Pts record that the patient may be released from the recovery room.
operative report
progress notes
postanesthesia note
postoperative note
57
The Latin term that means “the thing speaks for itself” is
res gestae
res ipsa loquitur
subpoena
stare decisis
58
A durable medical equipment company would classify medical equipment using
NDC codes.
CPT codes
HCPCS Level II codes.
CDT codes.
59
Hospitals use a ____________________ to record encounter data about ambulatory care
Electronic Health System
Chargemaster
Index
Computerized Health System
60
Indexes, registers, and registries are considered _____________ sources of patient information.
Honorary
By-passed
Primary
Secondary
61
In 1948, Happy Hospital was able to secure federal grant funds to update its surgical units.
FECA.
Medicare
Taft-Hartley Act.
Hill-Burton Act
62
Early medical record automation efforts focused on the
development of alerts, med records, Dr orders and notes.
networking between the systems of separate facilities
development of RHIOs.
scanning of documents into imaging systems
63
Pre- and postanesthesia evaluations would be found in a(n) ____ record.
behavioral health care
long-term care
surgical care
ambulatory care
64
Coding systems that a coding & reimbursement specialist will use include CPT, HCPCS, and
ICD8
ACMPC
ICD-10-CM/ICD-10-PCS
CCS
65
Dr. Blake is Susie’s attending physician. Who must sign the history and physical?
Dr. Blake only must sign.
Dr. Johns only must sign
Dr. Johns must sign report first; Dr. Blake must countersign
Dr. Blake must sign report first; Dr. Johns must countersign
66
Health Care Finance Administration, "____" was created to manage Medicare & Medicaid programs
Centers for Medicare and Medicaid Services
Health and Human Services
Public Health Administration
Women, Infant and Children Services
67
Which organization publishes CPT?
CMS
AMA
AAPC
AHIMA
68
The professional association that sponsors the Coding Specialist for Payors certification
American Health Information Management Association
American College of Medical Coding Specialists.
Professional Association of Health Care Office Managers
American College of Health Care Administrators.
69
Hillcrest Hospital wrote a retention policy for the HIM department. What index is permanent?
Procedure index
Disease index
Master patient index
Operative index
70
Generic term that refers to the various methods electronic document can authenticate _______
voice print
electronic signature
printing
signature
71
Home care record generated for Medicare Patient contains Home Care Certification & Plan of Care
CMS1500
CMS485
CMS210
CMS100
72
Critical access hospitals are located at a distance of of miles from each other?
35
20
50
30
73
Tom was admitted to drug rehabilitation facility. A friend calls the facility to speak with him
state that patients are not allowed to accept calls
state that the facility cannot confirm that Tom is a patient
provide only the patient’s room number
transfer the call to Tom’s room phone
74
Which of the following describes alphabetic filing systems?
Files expand at an even rate
Record security is high
Changed patient names are cross-referenced
A master patient index is required.
75
Which of the following is a disadvantage of automated systems?
There is no downtime
Technical staff is needed to maintain the system
Retrieval of customized information is difficult
Updates of information are not easy
76
The abbreviation q.h. means
every hour
every four hours
every day
every half hour.
77
To calculate the delinquent record rate, divide the total number of delinquent records by the
total # of admissions and then add the total # of discharges
length of stay for the period
total number of admissions in the period.
total number of discharges in the period
78
The name, address, and phone number of the third-party payer is considered
demographic data
financial data.
identification data.
supplemental data.
79
Which of the following record formats links all documentation to a specific problem?
Integrated
Problem-oriented
Paper-based
Source-oriented
80
Collection of cancer data from a variety of sources, reporting of cancer statistics, Credential
Certified Coding Associate
Certified Professional Coder
Registered Health Information Technologist
Cancer Registrar
81
Which of the following is a disadvantage of a manual record system?
difficult to abstract information
user resistance typically occurs
staff training is expensive
increased start-up costs
82
Which statement regarding the patient record is true?
Author each entry dont sign note supervising pro has sign it
All entries must be legible and complete.
An alias cannot be used in a patient record
Only front page of two-page document must contain patient ID
83
Which filing system should be used to distribute the records equally in the file area?
Numeric
Serial unit
Serial
Terminal digit
84
Medical staff members are granted clinical privileges by the
chief executive officer.
chief of medical services
medical staff
governing board
85
Funding for health care for the homeless was provided by the ____ Act.
Patient Self-Determination
Social Security
Migrant Health
McKinney
86
Which of the following is an advantage of a manual record system?
It improves access to patient information
Training of staff is simple
It is easy to abstract information
Retrieval of information is easily customized.
87
The exchange of data among multiple software products is known as _________________________
data exchange
computer interface
diagnostic interface
computer systems
88
Each year the business office, ancillary departments, and HIM update the charges codes for all
financial record.
encounter form
chargemaster.
superbill.
89
In a(n) ____________________ system, views of patient records can be customized by users.
systemic
paper-based
automated
diagnostic
90
Patient is transferred to a different level of care within the same hospital, a summary report:
level of care summary.
progress summary.
transfer summary.
discharge summary.
91
The admissions clerk is entering patient registration into a computerized system-logs in:
admission/discharge register (log book)
ADT system
manual master patient index system.
computer-interfaced master patient index.
92
PT record with different care, DR, and facilities linked to form view, over time,PT health care
Computerized
Unit
Paper-based
longitudinal

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