Final Exam

129 Questions  I  By Neelam1215
FINAL 

  
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1.  Leaving a sponge or foreign body such as a sponge in a patient after surgery is an example of a(n) ________________.
A.
B.
C.
D.
2.   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.
B.
C.
D.
3.  What type of health record analysis assesses the completeness and accuracy of patient health records?
A.
B.
C.
D.
4.  What kind of facility offers comprehensive, primary healthcare services to patients who otherwise would have limited access to healthcare?
A.
B.
C.
D.
5.  ________________________________________ 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.
B.
C.
D.
6.  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.
B.
C.
D.
7.  Which of the following is not required for physician’s orders?
A.
B.
C.
D.
8.  What is the first step an organization should take when developing a data dictionary?
A.
B.
C.
D.
9.  What is the key characteristic of the problem-oriented health record (POMR)?  
A.
B.
C.
D.
10.  To be considered “continuous” by Medicare, home care must be provided for at least _________________, and care must be predominantly skilled-nursing care.  
A.
B.
C.
D.
11.  Which health record format is in use when documents are grouped together according to their point of origin?
A.
B.
C.
D.
12.  According to Federated Ambulatory Surgery Association, what percentage of all surgeries in America are outpatient?
A.
B.
C.
D.
13.  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.
B.
C.
D.
14.   What is the term used in reference to the systematic review of sample health records to determine whether documentation standards are being met?
A.
B.
C.
D.
15.  What is the fastest-growing physician service in the United States?
A.
B.
C.
D.
16.  What technology creates images of handwritten and printed documents that are then stored in health record databases as electronic files?  
A.
B.
C.
D.
17.  Which of the following was not demonstrated by the Hurricane Katrina experience?
A.
B.
C.
D.
18.  Health records should be reviewed on admission, on discharge, and on a regular basis every _________________.  
A.
B.
C.
D.
19.  Which of the following is not an element that should be included on a problem or summary list?
A.
B.
C.
D.
20.  The purpose of the data dictionary is to _________________ definitions and ensure consistency of use.
A.
B.
C.
D.
21.  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.
B.
C.
D.
22.  About how many individuals require services because of acute illness, long-term health conditions, permanent disability, or terminal illness?
A.
B.
C.
D.
23.  Which of the following is not a key data element in the medication list?
A.
B.
C.
D.
E.
24.  Which of the following issues is not among the most important legal concerns in home care and hospice?
A.
B.
C.
D.
E.
25.  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.
B.
C.
D.
26.  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.
B.
C.
D.
27.  In data quality management, _________________ is the process of translating data into information utilized for an application
A.
B.
C.
D.
28.  _________________ is defined as recognition by an external entity of achievement of predefined standards of excellence.         
A.
B.
C.
D.
29.  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.
B.
C.
D.
30.  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.
B.
C.
D.
31.  A comprehensive _____________________ is designed to minimize the facility’s potential risks and, when an incident occurs, its losses.
A.
B.
C.
D.
32.  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.
B.
C.
D.
33.  Coordination of care is dependent upon the quality of ________________ provided by each of the healthcare providers involved in the patient’s treatment.
A.
B.
C.
D.
34.  Which health record format is arranged in chronological order with documentation from various sources intermingled?
A.
B.
C.
D.
35.  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.
B.
C.
D.
36.  A(n) ________________________ may be completed in the long-term care setting to help summarize the care given to the resident over time.
A.
B.
C.
D.
37.   In data quality management, _________________ is the processes by which data elements are accumulated.  
A.
B.
C.
D.
38.  How are industrial health clinics usually financed?
A.
B.
C.
D.
39.  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.
B.
40.  Which of the following is not a component of the Resident Assessment Instrument (RAI)?
A.
B.
C.
D.
41.   Determination of __________________________ is considered to be one of the most difficult documentation issues facing the long-term care environment including the LTCH.
A.
B.
C.
D.
42.  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.
B.
C.
D.
E.
43.  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.
B.
C.
D.
44.  Which of the following is not a function of the plan of care documentation?
A.
B.
C.
D.
45.  Which of the following organizations is not an accrediting body for long-term acute-care hospitals?
A.
B.
C.
D.
46.  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.
B.
C.
D.
47.  How are patients using ambulatory surgical centers for elective surgical procedures classified?
A.
B.
C.
D.
48.  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.
B.
49.  An organization is served with a subpoena. An appropriate response to the reasonable anticipation of litigation would be to:
A.
B.
C.
D.
50.  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.
B.
C.
D.
51.   To be eligible for Medicare-reimbursed home healthcare, a Medicare beneficiary must meet which of the following conditions?
A.
B.
C.
D.
E.
F.
G.
52.  What mechanism allows two or more databases to transfer data between them?
A.
B.
C.
D.
53.  _________ is the process of providing proof of the authorship of health record documentation?
A.
B.
C.
D.
54.  In data quality management, _________________ is the processes and systems used to archive data and data journals
A.
B.
C.
D.
55.  A facility should strive to be restraint free, but in specific circumstances to ____________________________, a least-restrictive restraining device may be required.
A.
B.
C.
D.
56.  What is the only differentiation between a long-term acute-care hospital (LTCH) and a short-term acute-care hospital?
A.
B.
C.
D.
57.  Patients undergoing elective procedures in ambulatory surgical centers are typically released from the surgery center _______________________.
A.
B.
C.
D.
58.  How has advanced technology like endoscopes and lasers affected the postoperative recovery period?
A.
B.
C.
D.
59.  What kind of policy should detail the day and time of delivery for records of patients with regularly scheduled appointments?
A.
B.
C.
D.
60.  What is the definitional length of stay for long-term acute-care hospitals?
A.
B.
C.
D.
61.  What is the name of the form used to help clarify principal and secondary diagnoses?
A.
B.
C.
D.
62.  What kind of ambulatory-care facilities require neither informed consent nor payment?
A.
B.
C.
D.
63.  ___ Home care organizations that choose to be accredited by the Joint Commission must meet its _________________ standards
A.
B.
C.
D.
64.  Unintentional deception or misrepresentation of healthcare documentation by Electronic Health Record (EHR) users will be viewed gently by payers, evaluators, or litigators.
A.
B.
65.  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.
B.
C.
D.
66.  Long-term acute care is paid under which of the following Medicare Systems?
A.
B.
C.
D.
67.   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.
B.
C.
D.
68.  ________________ 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.
B.
C.
D.
69.  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.
B.
C.
D.
70.  Once a patient has filled out an initial history questionnaire with a provider, approximately how often should the patient complete a new questionnaire?
A.
B.
C.
D.
71.  What percentage of all healthcare services are performed in an ambulatory-care setting?
A.
B.
C.
D.
72.  Within what period of time after admission to a LTCH must the history and physical be completed and placed in the health record?
A.
B.
C.
D.
73.  ____________________ are instruments patients can use to clarify treatment choices in the event that they are no longer capable of doing so.
A.
B.
C.
D.
74.  The registration record documents the _______________________ collected before or during the initial patient visit and is maintained and updated on subsequent visits, as needed.
A.
B.
C.
D.
75.  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.
B.
76.  Which of the following represents one of the biggest challenges in Electronic Health Record (EHR) development and implementation?
A.
B.
C.
D.
77.  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.
B.
C.
D.
78.  Approximately what percent of all newly diagnosed cancer patients are treated in programs approved by the Commission on Cancer?
A.
B.
C.
D.
79.  Which of the following is not one of the three predefined formats required for meaningful documentation in the ambulatory health record?
A.
B.
C.
D.
80.  For Medicare patients, how often must the home health agency’s assessment and care plan be updated?
A.
B.
C.
D.
81.  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.
B.
C.
D.
82.  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.
B.
C.
D.
83.  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.
B.
C.
D.
84.  Each individual that has been authorized to document in the electronic health record uses a ___________ in the form of a code or password.
A.
B.
C.
D.
85.  In which Electronic Health Record (EHR) database model is all of the organization’s patient health information stored in one system?
A.
B.
C.
D.
86.  _______________________ are problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions).
A.
B.
C.
D.
87.  To be considered "homebound" by the Centers for Medicare and Medicaid Services (CMS), the patient must be bedridden.
A.
B.
88.  What process helps to ensure the quality and completeness of health record content in both paper-based and computer-based environments?
A.
B.
C.
D.
89.  It is important for an organization to have ______________________ addressing how to deal with corrections made to erroneous entries in health records.
A.
B.
C.
D.
90.  Birthing centers are usually staffed by what kind of healthcare provider?
A.
B.
C.
D.
91.  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.
B.
C.
D.
92.  Medicare reimburses all home health agencies (HHAs) under a ___________________________________ system.
A.
B.
C.
D.
93.  Borrowing record entries from another source and representing or displaying past as current documentation and are examples of a potential breach of ____________.  
A.
B.
C.
D.
94.  In health record documentation, the use of approved symbols, acronyms, and abbreviations is usually limited to those that:
A.
B.
C.
D.
95.  A(n)_________________________ is a unique personal identifier that is entered by the author of Electronic Health Record (EHR) documentation using computer technology.
A.
B.
C.
D.
96.   ___ __________________________ 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.
B.
C.
D.
97.  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.
B.
98.  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.
B.
C.
D.
99.  Which of the following is an accrediting body for ambulatory surgery facilities?
A.
B.
C.
D.
100.   ________________ is/are the origin of recorded information that is attributed to a specific individual or entity.
A.
B.
C.
D.
101.  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.
B.
C.
D.
102.  A facility should strive to be restraint free, but in specific circumstances to ____________________________, a least-restrictive restraining device may be required.
A.
B.
C.
D.
103.  Which of the following is not a benefit of electronic authentication executed at the completion of documentation within an application?
A.
B.
C.
D.
104.  When should an e-discovery response team be formed?
A.
B.
C.
D.
105.  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.
B.
C.
D.
106.  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.
B.
C.
D.
107.  Which of the following describes a skilled-nursing facility?
A.
B.
C.
D.
108.  Medicare Conditions of Participation 484.55 requires that each patient receive, and a home health agency provide a patient-specific ______________________________
A.
B.
C.
D.
109.  The ____________________ is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for long-term care (MDS 3.0).
A.
B.
C.
D.
110.  What do health maintenance organizations (HMOs), also known as managed care plans, provide?
A.
B.
C.
D.
111.  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.
B.
C.
D.
112.  Which of the following is not an example of a long-term care?
A.
B.
C.
D.
113.  A _________________ captures relevant past and current problems of each patient.
A.
B.
C.
D.
114.   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.
B.
C.
D.
115.  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.
B.
C.
D.
116.  Which of the following is not among the general categories that govern admission criteria?
A.
B.
C.
D.
117.  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.
B.
C.
D.
118.  What organization is responsible for setting standards for cancer treatments?
A.
B.
C.
D.
119.  What term is used to refer to an organized collection of data that have been stored electronically to facilitate easy access?
A.
B.
C.
D.
120.   ______________ play a major role in referral and tracking of the patient’s use of specialty providers.
A.
B.
C.
D.
121.  What is the recommended timeframe for a medical record to be left in a physician office after a regularly scheduled visit?
A.
B.
C.
D.
122.  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.
B.
C.
D.
123.  ___________________, 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.
B.
C.
D.
124.  To be eligible for the Medicare hospice benefit, a patient must have __________.
A.
B.
C.
D.
125.   In data quality management, _________________ is the purpose for which data are collected
A.
B.
C.
D.
126.  Collectively, home health agencies, home care, personal-care providers, and hospices are known as _________________________.
A.
B.
C.
D.
127.  What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user?
A.
B.
C.
D.
128.  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.
B.
C.
D.
129.   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.
B.
C.
D.
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