Final Exam

129 Questions  I  By Neelam1215
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Management Quizzes & Trivia
FINAL

  
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  • 1. 
    Which of the following is not an example of a long-term care?
    • A. 

      Skilled nursing

    • B. 

      Rehabilitation

    • C. 

      Subacute medical care

    • D. 

      Hospice


  • 2. 
    What is the only differentiation between a long-term acute-care hospital (LTCH) and a short-term acute-care hospital?
    • A. 

      Number of skilled nurses employed

    • B. 

      Surgical facility on-site

    • C. 

      Length of stay

    • D. 

      Number of affiliated physicians


  • 3. 
    What is the definitional length of stay for long-term acute-care hospitals?
    • A. 

      25 days or greater

    • B. 

      14 days or greater

    • C. 

      30 days or greater

    • D. 

      7 days or greater


  • 4. 
     The _______________________________ notifies physicians that Medicare payment to the facility is partly based on the patient’s principal and secondary diagnoses, as well as the major procedures performed, and that falsification of records can lead to fines, imprisonment, or civil penalty under federal laws
    • A. 

      Medicare reimbursement rule

    • B. 

      Physician acknowledgement statement

    • C. 

      Provider agreement

    • D. 

      Diagnosis and procedure validation statement


  • 5. 
    Long-term acute-care hospitals must have an agreement with a quality improvement organization (QIO) for periodic review. Which of the following is not among the items reviewed?
    • A. 

      The medical necessity, reasonableness, and appropriateness of hospital admissions and discharges

    • B. 

      Validity of the hospital’s diagnostic and procedural information

    • C. 

      Completeness, adequacy, and quality of the services furnished in the hospital

    • D. 

      Outcome of treatment


  • 6. 
    Long-term acute care is paid under which of the following Medicare Systems?
    • A. 

      Skilled Nursing Facility (SNF) Resource Utilization Groups (RUGS)

    • B. 

      Medicare Inpatient Rehabilitation Facilities (IRF)

    • C. 

      Medicare prospective payment system (PPS)

    • D. 

      Medicare Severity Diagnostic Related Groups (MS-DRGs)


  • 7. 
    What is the name of the form—usually the first page of a patient’s health record—that contains the demographic data and insurance information for the patient?
    • A. 

      Admission sheet

    • B. 

      Cover page

    • C. 

      Face sheet

    • D. 

      Patient data sheet


  • 8. 
    What is the name of the form used to help clarify principal and secondary diagnoses?
    • A. 

      Face sheet

    • B. 

      Physician query form

    • C. 

      Principal diagnosis form

    • D. 

      Admission data sheet


  • 9. 
    Within what period of time after admission to a LTCH must the history and physical be completed and placed in the health record?
    • A. 

      8 hours

    • B. 

      12 hours

    • C. 

      24 hours

    • D. 

      48 hours


  • 10. 
     Determination of __________________________ is considered to be one of the most difficult documentation issues facing the long-term care environment including the LTCH.
    • A. 

      Principal diagnosis or reason for admission

    • B. 

      Secondary diagnosis

    • C. 

      Appropriate reimbursement

    • D. 

      Procedures performed in the LTCH


  • 11. 
    A _________________ captures relevant past and current problems of each patient.
    • A. 

      Problem list

    • B. 

      Diagnosis form

    • C. 

      Patient data sheet

    • D. 

      Patient history form


  • 12. 
    The _______________ is a snapshot of a patient’s status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focused on a specific disease process or pathway.
    • A. 

      Face sheet

    • B. 

      Care plan

    • C. 

      Diagnosis plan

    • D. 

      Flow sheet


  • 13. 
    Which of the following organizations is not an accrediting body for long-term acute-care hospitals?
    • A. 

      Joint Commission

    • B. 

      American Osteopathic Association

    • C. 

      Commission on Accreditation of Rehabilitation Facilities

    • D. 

      Centers for Medicare and Medicaid


  • 14. 
    Which of the following describes a skilled-nursing facility?
    • A. 

      An institution primarily engaged in providing skilled-nursing care and related services for residents who require medical or nursing care

    • B. 

      An institution that provides rehabilitation services for the rehabilitation of injured, disabled, or sick persons

    • C. 

      An institution that is not primarily for the care and treatment of mental diseases

    • D. 

      All of the above


  • 15. 
    Which of the following is not a component of the Resident Assessment Instrument (RAI)?
    • A. 

      The resident's health record

    • B. 

      A standard Minimum Data Set (MDS)

    • C. 

      Resident Assessment Protocols (RAPs)

    • D. 

      Utilization guidelines


  • 16. 
    The ____________________ is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for long-term care (MDS 3.0).
    • A. 

      Resident Assessment Protocols (RAP)

    • B. 

      Resident Assessment Instrument (RAI)

    • C. 

      Utilization guidelines

    • D. 

      Minimum Data Set (MDS)


  • 17. 
    The ___________________________ is/are used to gather information about specific health status factors and include information about specific risk factors in the resident’s care.
    • A. 

      Resident Assessment Protocols (RAP)

    • B. 

      Resident Assessment Instrument (RAI)

    • C. 

      Utilization guidelines

    • D. 

      Minimum Data Set (MDS)


  • 18. 
    _______________________ are problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions).
    • A. 

      Resident Assessment Protocols (RAP)

    • B. 

      Resident Assessment Instrument (RAI)

    • C. 

      Utilization guidelines

    • D. 

      Minimum Data Set (MDS)


  • 19. 
    The Preadmission Screening Assessment and Annual Resident Review (PASARR) is a requirement mandated by ______________________ that provides a mechanism for screening mental illness and mental retardation (MI/MR).
    • A. 

      The federal government

    • B. 

      The state government

    • C. 

      The local government

    • D. 

      Both the federal and state government


  • 20. 
    A facility should strive to be restraint free, but in specific circumstances to ____________________________, a least-restrictive restraining device may be required.
    • A. 

      Maintain or improve the resident's medical condition

    • B. 

      Punish a resident

    • C. 

      Calm a resident

    • D. 

      Ease the staff's workload


  • 21. 
    A(n) ________________________ may be completed in the long-term care setting to help summarize the care given to the resident over time.
    • A. 

      Annual review

    • B. 

      Monthly summary

    • C. 

      Summary of care

    • D. 

      Patient history


  • 22. 
    What do health maintenance organizations (HMOs), also known as managed care plans, provide?
    • A. 

      Sliding scale payment systems

    • B. 

      Health coverage to voluntarily enrolled individuals in return for prepayment of a fixed fee, regardless of the services the individual enrollees use

    • C. 

      Medical services in a single specialty

    • D. 

      Primary healthcare, disease prevention services, and counseling for students


  • 23. 
    What percentage of all healthcare services are performed in an ambulatory-care setting?
    • A. 

      30 percent

    • B. 

      More than 75 percent

    • C. 

      More than 50 percent

    • D. 

      Less than 25 percent


  • 24. 
     ______________ play a major role in referral and tracking of the patient’s use of specialty providers.
    • A. 

      Primary-care physicians

    • B. 

      Insurance companies

    • C. 

      Health information management professionals

    • D. 

      Electronic health records


  • 25. 
    Coordination of care is dependent upon the quality of ________________ provided by each of the healthcare providers involved in the patient’s treatment.
    • A. 

      Treatment

    • B. 

      Documentation

    • C. 

      Communication

    • D. 

      Technology


  • 26. 
    How has advanced technology like endoscopes and lasers affected the postoperative recovery period?
    • A. 

      The recovery period is shorter

    • B. 

      The recovery period is longer

    • C. 

      Technology has eliminated the risk of complications

    • D. 

      Technology has had no effect


  • 27. 
    How are patients using ambulatory surgical centers for elective surgical procedures classified?
    • A. 

      Ambulatory

    • B. 

      Inpatient

    • C. 

      Temporary

    • D. 

      Outpatient


  • 28. 
    Patients undergoing elective procedures in ambulatory surgical centers are typically released from the surgery center _______________________.
    • A. 

      On the same day that the procedure is performed

    • B. 

      The day after the procedure is performed

    • C. 

      Eight hours after completion of the procedure

    • D. 

      Within an hour of completion of the procedure


  • 29. 
    According to Federated Ambulatory Surgery Association, what percentage of all surgeries in America are outpatient?
    • A. 

      50 percent

    • B. 

      30 percent

    • C. 

      70 percent

    • D. 

      90 percent


  • 30. 
    Which of the following specialties is not among the highest volumes for ambulatory surgical centers, in terms of annual Centers for Medicare and Medicaid Services (CMS) reimbursement dollars?
    • A. 

      Obstetrics and gynecology

    • B. 

      Gastroenterology

    • C. 

      Opthalmology

    • D. 

      Pain management


  • 31. 
    Birthing centers are usually staffed by what kind of healthcare provider?
    • A. 

      Obstetricians

    • B. 

      Obstetrical surgeons

    • C. 

      Nurses

    • D. 

      Nurse-midwives


  • 32. 
    What organization is responsible for setting standards for cancer treatments?
    • A. 

      The American Cancer Society

    • B. 

      The American College of Surgeons

    • C. 

      The Commission on Cancer

    • D. 

      The Joint Commission


  • 33. 
    Approximately what percent of all newly diagnosed cancer patients are treated in programs approved by the Commission on Cancer?
    • A. 

      60

    • B. 

      80

    • C. 

      75

    • D. 

      25


  • 34. 
    What kind of facility offers comprehensive, primary healthcare services to patients who otherwise would have limited access to healthcare?
    • A. 

      Community health centers

    • B. 

      Free health clinics

    • C. 

      Public health centers

    • D. 

      Sliding-scale centers


  • 35. 
    What kind of ambulatory-care facilities require neither informed consent nor payment?
    • A. 

      Community health centers

    • B. 

      Birthing centers

    • C. 

      Correctional facility health clinics

    • D. 

      Industrial health clinics


  • 36. 
    What is the fastest-growing physician service in the United States?
    • A. 

      Urology

    • B. 

      Gastroenterology

    • C. 

      Opthalmology

    • D. 

      Diagnostic Imaging


  • 37. 
    How are industrial health clinics usually financed?
    • A. 

      Through the employer's workers' compensation insurance plan

    • B. 

      By payments based on a sliding scale

    • C. 

      By public funding

    • D. 

      Through employee contributions to a general fund


  • 38. 
    What organizations offer a wide range of healthcare services and coverage in return for prepayment of a fixed fee, regardless of the services the individual enrollees use?
    • A. 

      Centers for Medicare and Medicaid

    • B. 

      Health maintenance organizations

    • C. 

      Industrial health clinics

    • D. 

      Community health centers


  • 39. 
    What kind of facilities evaluate and treat conditions that are not severe enough to require treatment in a hospital emergency department but still require treatment beyond normal physician office hours?
    • A. 

      Urgent-care centers

    • B. 

      Community health centers

    • C. 

      Industrial health clinics

    • D. 

      Outpatient-care centers


  • 40. 
    Which of the following is not one of the three predefined formats required for meaningful documentation in the ambulatory health record?
    • A. 

      Source-oriented

    • B. 

      Integrated system

    • C. 

      Patient-oriented

    • D. 

      Problem-oriented


  • 41. 
    Because it was developed to enhance comprehensive patient care, which record system format is especially appropriate for health maintenance organizations (HMOs) and neighborhood health centers, where a team of professionals offers total patient care?
    • A. 

      Problem-oriented record system

    • B. 

      Integrated record system

    • C. 

      Source-oriented record system

    • D. 

      Patient-oriented record system


  • 42. 
    The registration record documents the _______________________ collected before or during the initial patient visit and is maintained and updated on subsequent visits, as needed.
    • A. 

      Basic demographic data

    • B. 

      Administrative data

    • C. 

      Clinical data

    • D. 

      Physician data


  • 43. 
    Which of the following is not an element that should be included on a problem or summary list?
    • A. 

      Major medical and surgical problems that have long-term clinical significance for the patient

    • B. 

      Short-term illnesses that were resolved quickly

    • C. 

      The dates of onset and resolution for each problem

    • D. 

      Abnormal signs and symptoms that have the potential to become significant problems


  • 44. 
    Which of the following is not a key data element in the medication list?
    • A. 

      Names of medications

    • B. 

      Dosages and amounts dispensed

    • C. 

      Dispensing instructions (with signature)

    • D. 

      Dispensing pharmacy

    • E. 

      Prescription dates and discontinued dates


  • 45. 
    Once a patient has filled out an initial history questionnaire with a provider, approximately how often should the patient complete a new questionnaire?
    • A. 

      At every return visit

    • B. 

      Every year

    • C. 

      Every five years

    • D. 

      Every two years


  • 46. 
    Which of the following elements recommended for inclusion in a comprehensive medical history is not required when the patient presents for preventive care or health maintenance?
    • A. 

      Past medical history

    • B. 

      Social or personal history

    • C. 

      Present illness

    • D. 

      Family history


  • 47. 
    Which of the following is not required for physician’s orders?
    • A. 

      The order must be signed by the physician

    • B. 

      The orders must be dated

    • C. 

      The orders must be filled in the individual patient's health record

    • D. 

      The orders must be typed


  • 48. 
     Ideally, instructions to patients should be communicated both verbally and in writing. Which of the items below is not also recommended for patient instructions?
    • A. 

      A copy of the written instructions should be filed in the health record.

    • B. 

      The healthcare professional should sign the record to indicate that he or she issued the verbal instructions.

    • C. 

      The person receiving the instructions should sign the instructions to verify receipt and understanding

    • D. 

      Patient comments or questions should be documented, along with the clarifications the healthcare professional offered in response.


  • 49. 
    _________________ is defined as recognition by an external entity of achievement of predefined standards of excellence.         
    • A. 

      Accreditation

    • B. 

      Licensure

    • C. 

      Audit

    • D. 

      Certification


  • 50. 
     ___ __________________________ are the Joint Commission’s specific performance expectations and/or structures or processes that must be in place for an organization to pervade safe, high-quality care, treatment, and services.
    • A. 

      Performance Standards

    • B. 

      Expectations for Expectations

    • C. 

      Elements of Performance

    • D. 

      Standards of Performance


  • 51. 
    Leaving a sponge or foreign body such as a sponge in a patient after surgery is an example of a(n) ________________.
    • A. 

      Unexpected occurrence

    • B. 

      Provider error

    • C. 

      Sentinel error

    • D. 

      Reportable event


  • 52. 
    Which of the following is an accrediting body for ambulatory surgery facilities?
    • A. 

      AAAHC

    • B. 

      AAAASF

    • C. 

      ARC

    • D. 

      AHIMA


  • 53. 
    What is the recommended timeframe for a medical record to be left in a physician office after a regularly scheduled visit?
    • A. 

      48 hours

    • B. 

      14 days

    • C. 

      24 hours

    • D. 

      7 days


  • 54. 
    What kind of policy should detail the day and time of delivery for records of patients with regularly scheduled appointments?
    • A. 

      Shadow chart policy

    • B. 

      Missed/failed appointment policy

    • C. 

      Record maintenance policy

    • D. 

      Chart delivery policy


  • 55. 
    A comprehensive _____________________ is designed to minimize the facility’s potential risks and, when an incident occurs, its losses.
    • A. 

      Liability policy

    • B. 

      Risk management program

    • C. 

      Credentialing and licensure program

    • D. 

      Equipment maintenance policy


  • 56. 
    Collectively, home health agencies, home care, personal-care providers, and hospices are known as _________________________.
    • A. 

      Residential healthcare providers

    • B. 

      Home health facilities

    • C. 

      Home care organizations

    • D. 

      In-home service organizations


  • 57. 
    About how many individuals require services because of acute illness, long-term health conditions, permanent disability, or terminal illness?
    • A. 

      8,000,000

    • B. 

      2,000,000

    • C. 

      20,000

    • D. 

      800,000


  • 58. 
     The Centers for Medicare and Medicaid Services’ _____________________ developed a quality-monitoring system that makes highly specific data collection and information management demands on home care providers.
    • A. 

      Prospective payment system

    • B. 

      Conditions of Participation

    • C. 

      Home Health Initiative

    • D. 

      Home-Health Agency


  • 59. 
    The ________________ changed Medicare and Medicaid home care reimbursement from a cost-based system to a system of fixed-fee reimbursement based on a patient-need classification system.
    • A. 

      Prospective payment system

    • B. 

      Conditions of participation

    • C. 

      Home Health Initiative

    • D. 

      Home-Health Agency


  • 60. 
    ___ Home care organizations that choose to be accredited by the Joint Commission must meet its _________________ standards
    • A. 

      Management of the Environment of Care (EC)

    • B. 

      Management of Information (IM)

    • C. 

      Medication Management (MM)

    • D. 

      Ethics, Rights, and Responsiblities (RI)


  • 61. 
    The Joint Commission’s ORYX and Centers for Medicare and Medicaid Services’ OASIS are data sets that function as benchmarks of ___________________within and among organizations.
    • A. 

      Information management

    • B. 

      Quality assurance

    • C. 

      Data quality management

    • D. 

      Performance improvement


  • 62. 
    Data quality management (DQM) functions involve continuous improvement for data quality throughout an organization. Which of the following is not a key process for DQM?
    • A. 

      Collection

    • B. 

      Warehousing

    • C. 

      Analysis

    • D. 

      Presentation


  • 63. 
     In data quality management, _________________ is the purpose for which data are collected
    • A. 

      Warehousing

    • B. 

      Collection

    • C. 

      Application

    • D. 

      Analysis


  • 64. 
     In data quality management, _________________ is the processes by which data elements are accumulated.  
    • A. 

      Warehousing

    • B. 

      Collection

    • C. 

      Application

    • D. 

      Analysis


  • 65. 
    In data quality management, _________________ is the processes and systems used to archive data and data journals
    • A. 

      Collection

    • B. 

      Warehousing

    • C. 

      Application

    • D. 

      Analysis


  • 66. 
    In data quality management, _________________ is the process of translating data into information utilized for an application
    • A. 

      Analysis

    • B. 

      Warehousing

    • C. 

      Collection

    • D. 

      Application


  • 67. 
    Which of the following is not among the general categories that govern admission criteria?
    • A. 

      Medical stability (with the exclusion of hospice patients)

    • B. 

      Medical necessity

    • C. 

      Desire for home care (or hospice)

    • D. 

      Financial resources


  • 68. 
    Medicare Conditions of Participation 484.55 requires that each patient receive, and a home health agency provide a patient-specific ______________________________
    • A. 

      OASIS report

    • B. 

      Care plan

    • C. 

      Comprehensive assessment

    • D. 

      Drug regimen


  • 69. 
    For Medicare patients, how often must the home health agency’s assessment and care plan be updated?
    • A. 

      Every 60 days

    • B. 

      As often as the severity of the patient’s condition requires

    • C. 

      At least every 60 days or as often as the severity of the patient's condition requires

    • D. 

      Every 30 days


  • 70. 
    Which of the following may be included in an assessment of a hospice patient and his or her family? A. B. A spiritual assessment C. An assessment of needed bereavement support D. A pain assessment E. All of the above
    • A. 

      A psychosocial assessment including adaptive and coping abilities

    • B. 

      A spiritual assessment

    • C. 

      An assessment of needed bereavement support

    • D. 

      A pain assessment

    • E. 

      All of the above


  • 71. 
    When Medicare patients elect hospice care, Medicare reimbursement continues for treatment of their principal (terminal) diagnosis and related conditions outside of care provided by the designated hospice, by another hospice provided under arrangements made by the designated hospice, or by the individual’s attending physician when that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.
    • A. 

      True

    • B. 

      False


  • 72. 
    To be eligible for the Medicare hospice benefit, a patient must have __________.
    • A. 

      A terminal illness

    • B. 

      A life expectancy of six months or less

    • C. 

      A life expectancy of three months or less

    • D. 

      A physician-certified terminal illness


  • 73. 
    To prevent denials, coding personnel are advised to use the most specific diagnosis codes and to ensure that the ______________________ is always listed as the principal diagnosis.
    • A. 

      Primary disease or condition suffered

    • B. 

      Terminal diagnosis

    • C. 

      Complications of chronic condition

    • D. 

      Life expectancy


  • 74. 
    Medicare has defined four general hospice care levels and has assigned different reimbursement rates to each. Which of the following is not a Medicare-defined hospice care level?
    • A. 

      Inpatient respite care

    • B. 

      Continuous home care

    • C. 

      Continuous inpatient care

    • D. 

      Routine home care


  • 75. 
    According to Medicare hospice regulations, which of the following groups of employee roles represents the makeup of the interdisciplinary group, that plans and provides or supervises the care and services provided to patients and families?
    • A. 

      Doctor of medicine or osteopathy, registered nurse, social worker, pastoral or other counselor

    • B. 

      Doctor of medicine or osteopathy, registered nurse, health information manager, pastoral or other counselor

    • C. 

      Doctor of medicine or osteopathy, registered nurse, social worker, health information manager

    • D. 

      Doctor of medicine or osteopathy, registered nurse, social worker, member of the patient’s family


  • 76. 
    In hospices, Medicare requires that _________________ be used in administrative or direct patient care roles, such as providing services and support to the patient, family, or significant other.
    • A. 

      Registered nurses

    • B. 

      Health information professionals

    • C. 

      Social workers

    • D. 

      Volunteers


  • 77. 
    Bereavement counseling services are often provided to the family and caregivers after a patient’s death. Which of the following is not among the factors that determine what counseling services are provided?
    • A. 

      An assessment of the family's and caregiver's needs

    • B. 

      The length of the patient's hospice care

    • C. 

      The presence of any risk factors associated with the patient's death

    • D. 

      The ability of the family and caregivers to cope with grief


  • 78. 
    To be considered “continuous” by Medicare, home care must be provided for at least _________________, and care must be predominantly skilled-nursing care.  
    • A. 

      16 hours in one 36-hour period

    • B. 

      16 hours in one 24-hour period

    • C. 

      12 hours in one 24-hour period

    • D. 

      4 hours in one 12-hour period


  • 79. 
    Medicare reimburses all home health agencies (HHAs) under a ___________________________________ system.
    • A. 

      Prospective payment

    • B. 

      Pay for performance

    • C. 

      Interim payment

    • D. 

      Per-beneficiary visit


  • 80. 
     To be eligible for Medicare-reimbursed home healthcare, a Medicare beneficiary must meet which of the following conditions?
    • A. 

      The beneficiary is confined to home.

    • B. 

      The beneficiary is under the care of a physician, who establishes and approves the plan of care for the individual.

    • C. 

      The beneficiary needs intermittent, skilled-nursing care, physical therapy, speech therapy services, or continuing occupational therapy

    • D. 

      The beneficiary’s care is supervised by a registered nurse in conjunction with the patient’s care team, which establishes and approves the plan of care for the individual

    • E. 

      Both A and B

    • F. 

      Both A and D

    • G. 

      A, B, and C and above


  • 81. 
    To be considered "homebound" by the Centers for Medicare and Medicaid Services (CMS), the patient must be bedridden.
    • A. 

      True

    • B. 

      False


  • 82. 
    Using the ___________________________ to document data from home care record reviews and patient visits, Medicare home care surveyors use medical, nursing, and rehabilitative care indicators to determine the quality of a patient’s care and the scope of the home health agency services provided to the client.
    • A. 

      CMS Homecare Functional Survey

    • B. 

      CMS Home Health Functional Assessment

    • C. 

      CMS Home Health Assessment Survey

    • D. 

      CMS Quality Homecare Assessment Tool


  • 83. 
    Which of the following is not a function of the plan of care documentation?
    • A. 

      Give a clear picture of the patient's status before the onset of the acute illness

    • B. 

      Reflect an accurate diagnosis and list treatments and services to be provided

    • C. 

      Indicate the frequency and duration expected for each treatment modality

    • D. 

      Note that subsequent services have been provided within the bounds of the plan of care and any subsequent physician’s orders


  • 84. 
    How often must homecare agencies electronically report all OASIS data collected on all applicable patients in a format that meets Centers for Medicare and Medicaid Services (CMS) electronic data and editing specifications?
    • A. 

      Every day

    • B. 

      Every week

    • C. 

      Every two weeks

    • D. 

      Every month


  • 85. 
    Health records should be reviewed on admission, on discharge, and on a regular basis every _________________.  
    • A. 

      Two week

    • B. 

      Week

    • C. 

      30 to 60 days

    • D. 

      Six months


  • 86. 
    The fact that the Medicare Prospective Payment System (PPS) is reimbursed on the basis of the home health resource group means that the facility can skip the review of Medicare documentation.
    • A. 

      True

    • B. 

      False


  • 87. 
    Which of the following issues is not among the most important legal concerns in home care and hospice?
    • A. 

      Patient's rights

    • B. 

      Advance directives

    • C. 

      Do not resuscitate orders

    • D. 

      Family rights

    • E. 

      Issues related to the withholding of life-sustaining treatment


  • 88. 
    ________________________________________ requires organizations receiving Medicare and Medicaid funds to document that home care and hospice patients are informed of their rights and that they agree to their care plans.
    • A. 

      Centers for Medicare and Medicaid Services; Home Health Quality Initiatives

    • B. 

      The Omnibus Budget Reconciliation Act of 1987 (OBRA)

    • C. 

      Cruzan vs. Director of the Missouri Department of Health

    • D. 

      Federal privacy act; Final Rule


  • 89. 
    ____________________ are instruments patients can use to clarify treatment choices in the event that they are no longer capable of doing so.
    • A. 

      Living wills

    • B. 

      Advance directives

    • C. 

      Medical powers of attorney

    • D. 

      DNR orders


  • 90. 
    In hospice care cases, routine-care-only orders (or consent for care that indicates routine care only) do not substitute for a specific DNR order.
    • A. 

      True

    • B. 

      False


  • 91. 
    What technology creates images of handwritten and printed documents that are then stored in health record databases as electronic files?  
    • A. 

      Clinical data repository

    • B. 

      Data exchange standards

    • C. 

      Central processor

    • D. 

      Digital scanner


  • 92. 
    Which health record format is in use when documents are grouped together according to their point of origin?
    • A. 

      Electronic

    • B. 

      Source-oriented

    • C. 

      Problem oriented

    • D. 

      Integrated


  • 93. 
    What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user?
    • A. 

      Clinical data repository

    • B. 

      Data exchange standard

    • C. 

      Central processor

    • D. 

      Digital system


  • 94. 
    In health record documentation, the use of approved symbols, acronyms, and abbreviations is usually limited to those that:
    • A. 

      Have more than one meaning and are never used

    • B. 

      Are approved by the Joint Commission

    • C. 

      Are the most widely applicable and unambiguous

    • D. 

      Are approved by the Centers for Medicare and Medicaid Services (CMS)


  • 95. 
    In which Electronic Health Record (EHR) database model is all of the organization’s patient health information stored in one system?
    • A. 

      Distributed

    • B. 

      Centralized

    • C. 

      Hybrid

    • D. 

      Traditional


  • 96. 
    What is the key characteristic of the problem-oriented health record (POMR)?  
    • A. 

      Problem list

    • B. 

      Chief complaint

    • C. 

      Initial care plan

    • D. 

      Physical examination


  • 97. 
    What mechanism allows two or more databases to transfer data between them?
    • A. 

      Clinical data repository

    • B. 

      Data exchange standards

    • C. 

      Central processor

    • D. 

      Digital scanner


  • 98. 
    What process helps to ensure the quality and completeness of health record content in both paper-based and computer-based environments?
    • A. 

      Standardization of data-capture tools

    • B. 

      Data exchange standards

    • C. 

      Standardization of abbreviations

    • D. 

      Authentication of health record entries


  • 99. 
    Dr. Smith orders 500 mg of penicillin by mouth tid for Jane Doe in the hospital emergency department. The computer sends an alert to Dr. Smith to tell her that the patient, Jane Doe, is allergic to penicillin. What type of computer system is Dr. Smith using?
    • A. 

      Clinical data repository

    • B. 

      Data exchange standard

    • C. 

      Clinical decision support

    • D. 

      Health informatics standard


  • 100. 
    Which health record format is arranged in chronological order with documentation from various sources intermingled?
    • A. 

      Electronic

    • B. 

      Source-oriented

    • C. 

      Problem-oriented

    • D. 

      Integrated


  • 101. 
    Which of the following represents one of the biggest challenges in Electronic Health Record (EHR) development and implementation?
    • A. 

      Images of handwritten and printed documents

    • B. 

      Data exchange standards

    • C. 

      A workable data capture process

    • D. 

      A clinical data repository


  • 102. 
    What term is used to refer to an organized collection of data that have been stored electronically to facilitate easy access?
    • A. 

      Digital formatting

    • B. 

      Database

    • C. 

      Telemedicine

    • D. 

      Data capture


  • 103. 
     What is the term used in reference to the systematic review of sample health records to determine whether documentation standards are being met?
    • A. 

      Qualitative analysis

    • B. 

      Legal record review

    • C. 

      Quantitative analysis

    • D. 

      Ongoing record review


  • 104. 
    A(n)_________________________ is a unique personal identifier that is entered by the author of Electronic Health Record (EHR) documentation using computer technology.
    • A. 

      Electronic signature

    • B. 

      Digital signature

    • C. 

      Identification number

    • D. 

      Electronic authorization key


  • 105. 
    What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document?  
    • A. 

      Electronic validation

    • B. 

      Digital signature

    • C. 

      Electronic signature

    • D. 

      Electronic authorization key


  • 106. 
    _________ is the process of providing proof of the authorship of health record documentation?
    • A. 

      Identification

    • B. 

      Standardization of data capture

    • C. 

      Standardization of abbreviations

    • D. 

      Authentication


  • 107. 
    What type of health record analysis assesses the completeness and accuracy of patient health records?
    • A. 

      Qualitative analysis

    • B. 

      Legal record review

    • C. 

      Quantitative analysis

    • D. 

      Ongoing record review


  • 108. 
    Health Information Management (HIM) professionals sometimes monitor the records of current inpatients as well as closed records after the patients have been discharged or transferred. What is this process called?
    • A. 

      Qualitative record review

    • B. 

      Legal record review

    • C. 

      Quantitative record review

    • D. 

      Ongoing record review


  • 109. 
    A(n) ________________ is a descriptive list of names (also called representations or displays), definitions, and attributes of data elements to be collected in an information system or database.
    • A. 

      Data dictionary

    • B. 

      Standardization key

    • C. 

      Standardization system

    • D. 

      Enterprise-wide data standard


  • 110. 
    The purpose of the data dictionary is to _________________ definitions and ensure consistency of use.
    • A. 

      Identify

    • B. 

      Standardize

    • C. 

      Create

    • D. 

      Organize


  • 111. 
    What is the first step an organization should take when developing a data dictionary?
    • A. 

      Develop an approvals process

    • B. 

      Integrate common data elements

    • C. 

      Design a plan

    • D. 

      Ensure consistency


  • 112. 
     ________________ is/are the origin of recorded information that is attributed to a specific individual or entity.
    • A. 

      The health record

    • B. 

      Authorship

    • C. 

      Documentation

    • D. 

      Progress notes


  • 113. 
    Examples of _________________ include name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date element terminated from system, and system of origin.
    • A. 

      Auto-authentication fields

    • B. 

      Metadata

    • C. 

      Data

    • D. 

      Information fields


  • 114. 
    Which of the following is not a benefit of electronic authentication executed at the completion of documentation within an application?
    • A. 

      It saves time

    • B. 

      Entries are stamped with time and date

    • C. 

      It eliminates the possibility of documentation error

    • D. 

      Entries are legible


  • 115. 
    Each individual that has been authorized to document in the electronic health record uses a ___________ in the form of a code or password.
    • A. 

      Biometric identifier

    • B. 

      Digital signature

    • C. 

      Unique personal identifier

    • D. 

      Electronic signature


  • 116. 
    It is important for an organization to have ______________________ addressing how to deal with corrections made to erroneous entries in health records.
    • A. 

      Training sessions

    • B. 

      Written procedures

    • C. 

      Verbally communicated instructions

    • D. 

      A supervisory committee


  • 117. 
    ________________ is defined as an “intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity, or to some other party.”
    • A. 

      Documentation fraud

    • B. 

      Documentation abuse

    • C. 

      Healthcare fraud

    • D. 

      Healthcare abuse


  • 118. 
    Unintentional deception or misrepresentation of healthcare documentation by Electronic Health Record (EHR) users will be viewed gently by payers, evaluators, or litigators.
    • A. 

      True

    • B. 

      False


  • 119. 
    Borrowing record entries from another source and representing or displaying past as current documentation and are examples of a potential breach of ____________.  
    • A. 

      Patient identification and demographic accuracy

    • B. 

      Authorship integrity

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity


  • 120. 
    Copying and pasting documentation from one record to another or pulling information forward from a previous visit, someone else’s records, or other sources is a best practice in documentation because it saves time.  
    • A. 

      True

    • B. 

      False


  • 121. 
    Inadequate functions that make it impossible to detect when an entry was modified or borrowed from another source and misrepresented as an original entry by an authorized user is an example of a potential breach of ____________.
    • A. 

      Authorship integrity

    • B. 

      Documentation integrity

    • C. 

      auditing integrity

    • D. 

      Patient identification and demographic accuracy


  • 122. 
    An organization is served with a subpoena. An appropriate response to the reasonable anticipation of litigation would be to:
    • A. 

      Destroy all records associated with the anticipated litigation

    • B. 

      Distribute copies of records associated with the anticipated litigation to all parties involved

    • C. 

      Make a copy of the paper-based record associated with the anticipated litigation and give the original paper-based record to the organization’s legal counsel to be secured in a locked file

    • D. 

      Give all records associated with the anticipated litigation to the organization’s legal counsel to be secured in a locked file


  • 123. 
     Automated registration entries that generate erroneous patient identification—possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit—is an example of a potential breach of ____________.
    • A. 

      Authorship integrity

    • B. 

      Patient identification and demographic accuracy

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity


  • 124. 
    ___________________, defined as signing multiple documents at one time without opening the documents, falls short of federal and state authentication requirements and could place the organization at legal risk.
    • A. 

      Auto-authentication

    • B. 

      Manual authentication

    • C. 

      Automated insertion

    • D. 

      Proxy authentication


  • 125. 
    When should an e-discovery response team be formed?
    • A. 

      When an organization can reasonably anticipate litigation

    • B. 

      The team should be rebuilt yearly

    • C. 

      Well in advance of any litigation

    • D. 

      At least thirty days before the court date


  • 126. 
    Health Information Management (HIM) professionals assist in designing __________________ that address how information can be documented in the health record during down time or a disaster.
    • A. 

      Disaster recovery plans

    • B. 

      E-discovery response plans

    • C. 

      business continuity plans

    • D. 

      Emergency documentation plans


  • 127. 
    Which of the following was not demonstrated by the Hurricane Katrina experience?
    • A. 

      Good contingency plans should include backing up patient data to other media.

    • B. 

      Electronic health records make disaster planning unnecessary.

    • C. 

      It is important to make data accessible as soon as possible after a disaster.

    • D. 

      Thorough planning for health information access is essential in disaster preparedness and response.


  • 128. 
    Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of ____________.
    • A. 

      patient identification and demographic accuracy

    • B. 

      Authorship integrity

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity


  • 129. 
    A facility should strive to be restraint free, but in specific circumstances to ____________________________, a least-restrictive restraining device may be required.
    • A. 

      Maintain or improve the resident's medical condition

    • B. 

      Punish a resident

    • C. 

      Calm a resident

    • D. 

      Ease the staff's workload


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