Hit Quiz 1 Practice

300 Questions  I  By Akay777
Questions to practice for HIT Quiz #1

  
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1. 
  • 1918: American College of Surgeons (ACS) started standardization movement to establish minimum quality standards for hospitals.
  • Hospitals realized records had to be complete, filed in orderly manner, with cross-index of operations, disease and doctors. Medical record clerk job subsequently established.
A.
B.
2.  A characteristic of data that includes every required data element is called                            .
3.  A characteristic of data where the data are useful is called                                .               
4.  A characteristic of data whose values are defined at the appropriate level of detail is                            .
5.  A definition of what constitutues a record, recording where each component is located, and noting dates of format changes are particularly important in:
A.
B.
C.
D.
6.  A final discharge note may be substituted for a discharge summary in the following cases:
  • Normal spontaneous delivery
  • Normal newborn
  • Stay of a minor nature that is less than 48 hours
A.
B.
7.  A growth and development record may be found in what type of record?
A.
B.
C.
D.
8.  A health record contains two types of data:
  • Clinical – documents a patient’s medical condition, diagnosis, treatment and medical services provided
  • Administrative – includes demographic, financial as well as consent and authorization forms
A.
B.
9.  A Joint Commission requirement is that a note relative to post-op anesthesia complications is required within 48 hours of surgery on inpatients.
A.
B.
10.  A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?
A.
B.
C.
D.
11.  A physical therapist documenting in the health record is an institutional health record user.
A.
B.
12.  A physician just received notification from an EHR system that a patient's lab test had a dangerously high value.  This is an example of what kind of clinical test?
A.
B.
C.
D.
13.  A physician should write an admission note, follow-up notes, and a discharge note
A.
B.
14.  A problem list is: 
  • Required for outpatients only
  • Must be started by the third visit
A.
B.
15.  A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records is is called                           .
16.  Abbreviations on the Joint Commission’s published prohibited abbreviation list should not be found in patient medical records
A.
B.
17.  Access – Paper records stored in locked area, accessed by authorized personnel, tracked to always know location. EHR has built in controls
A.
B.
18.  Accessibility: authorized users must be able to access information easily, 24 hours/day, 7 days/week. Systems must be in place that identify each patient and support access.
  • Paper records are protected by allowing only authorized staff access to records.
  • Electronic records are controlled through computer access techniques such as passwords, biometric devices, workstation restrictions.
A.
B.
19.  According to Joint Commission requirements, a copy of a hospital patient's history and physical exam done in a physician's office within 30 days can be used as long as any changes that may have occurred are recorded at the time of admission. 
A.
B.
20.  According to Joint Commission requirements, a hospital patient's history and physical exam must be completed within 24 hours and prior to surgery.
A.
B.
21.  According to the AHIMA data quality model, what is the term used to describe how data is translated into informaton?
A.
B.
C.
D.
22.  Accreditation Association for Ambulatory Healthcare (AAAHC)
  • Established standards for ambulatory documentation
  • Emphasize summaries for enhancing the continuity of care
A.
B.
23.  Accreditation Organizations
  • Accreditation is voluntary
  • Confers quality status and public recognition on a facility
  • Different types of healthcare facilities are accredited by different organizations
A.
B.
24.  Acknowledgment of Patient Rights – Medicare Conditions of Participation requires documentation that patients received information about patients’ rights while under care. Long term care facilities are required to provide residents with a patient’s bill of rights.
A.
B.
25.  Active members of AHIMMA include those who:
A.
B.
C.
D.
26. 
  • Active –“individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics. Active Members in good standing shall be entitled to all membership privileges including the right to vote.”
A.
B.
27.  Administrative Data includes Demographic and Financial Information.
A.
B.
28.  Advance Directives were introduced in 1991 due to the Patient Self Determination Act. This law requires facilities to document in the record the fact that a patient has an advance directive. It is required that a copy of the advance directive be placed in the medical record.
A.
B.
29.  Advance Directives – written document that names an individual to act on behalf of the patient in healthcare matters if and when the patient becomes unable to make their own decisions.
  • Living will
  • Durable power of attorney
  • Healthcare proxy
A.
B.
30.  AHIMA Foundation was formally known as:
  • FORE (Foundation of Research & Education in HIM) promotes education and research in HIM field - also, scholarships, student loans. It is a great resource for members seeking knowledge or information on a particular subject.
A.
B.
31.  AHIMA's Board of Directors (BOD) oversees which of the following: (select all that apply)
A.
B.
C.
D.
E.
F.
G.
32.  AHIMA's president appoints the members of the association's national committees, practice councils and workgroups.  
A.
B.
33.  All the primary purposes of the health record are associated directly with the provision of patient care.
A.
B.
34.  Ambulatory Surgical Care
  • Records maintained by free standing ambulatory surgi centers are very similar to those kept by hospital centers
  • Include any follow-up calls to patient
A.
B.
35.  American Osteopathic Association (AOA)
  • First started because it wanted to ensure the quality of its osteopathic residency programs
  • Accredits a wide range of healthcare organizations and facilities
A.
B.
36.  An accreditng organization is awarded deemed status by Medicare.  This means that the facilities receiving accreditation under its guidelines do not need to:
A.
B.
C.
D.
37.  An attending physician requests the advice of a 2nd physician who then reviews the health record and examines the patient.  The 2nd physician records impressions in what type of report?
A.
B.
C.
D.
38.  An auditor who is employed by medicare is reviewing a health record for a mortality study.  This auditor is an individual health record user.
A.
B.
39.  An individual's right to control access to his or her personal information is called                                .
40.  An operative note must be completed immediately after surgery.
A.
B.
41.  Anesthesia Report
  • required if more than local anesthesia given
  • preop meds recorded
  • anesthetic agents - amount, route, effect, duration
  • pts condition is noted including vital signs, blood loss, transfusions, IV’s
  • signed by person administering the anesthesia(nurse anesthetist or anesthesiologist)
A.
B.
42.  Antepartum record:
  • prenatal record done in MD office
  • includes history, physical exam
  • menstrual hx, reproductive hx, routine labs, rubella screen, syphilis screen
  • copy of prenatal record to birthing site at 36 weeks
  • ACOG & Hollister forms are popular
A.
B.
43.  As a lifelong record, the PHR could also include:
  • Information from providers
  • Genetic information
  • Personal, family, occupational, and environmental history
  • Health plans and goals
  • Health status of the individual
  • Documentation of choices related to organ donation, durable power of attorney, and advance directives
  • Charges paid for services and products
  • Health insurance information
  • Provider directory
A.
B.
44.  Authorization to disclose information allows the healthcare facility to verbally disclose or send health information to other organizations. Under HIPAA, covered providers are required to obtain a written authorization for the use or disclosure of protected health information if not for purposes of treatment, payment and/or healthcare operations (TPO)
A.
B.
45.  Autopsy Report
  • Also termed a necropsy report or post-mortem exam
  • Conducted on deceased patients when there is a question as to the cause of death or in a medico-legal situation
  • Can be ordered by a medical examiner or coroner in the case of a suspicious death
  • Autopsy report is signed by the pathologist and filed in the medical record
A.
B.
46.  Basic contents of the acute care health record:
  • Registration record Admin..& Clin.
  • Medical history and physical exam Clinical Data
  • Clinical observations (progress notes) Clinical Data
  • Physician’s orders Clinical Data
  • Reports of diagnostic and therapeutic procedures Clinical Data
  • Consultation reports Clinical Data
  • Discharge summary Clinical Data
  • Patient instructions Clinical Data
  • Consents, authorizations, and acknowledgements Administrative
A.
B.
47.  Basic principles of documentation:
  • Organizations should have policies that define the content and format of the record
  • Record should be organized systematically to ease data retrieval
  • Policy should delineate who can record in a medical record
  • Policy and/or medical staff rules and regs should specify who can receive and transcribe verbal and telephone orders
  • Documentation should be recorded at the time the service is rendered
  • Authors of all entries should be identified
  • Only approved abbreviations and symbols should be used
  • All entries should be permanent (no pencil or erasable ink)
  • Corrections must be made according to policy
  • Patient corrections should be added as an addendum
  • HIM dept should develop and utilize policies and procedures for quantitative and qualitative analysis
A.
B.
48.  Behavioral Health
  • Psychiatric care rendered in many different locales such as hospitals, opd clinics, community programs, etc.
  • Documentation is determined by type of facility and level of care/services provided
  • Both Federal govt and the Joint Commission set standards
  • Unique record components
    • Patient’s legal status
    • Multidisciplinary case conferences
    • Correspondence related to patient, including letters and dated notations of telephone conversations with others
    • Individualized aftercare plan
A.
B.
49.  Board of Directors (BOD)  is elected by vote of all members
A.
B.
50.  CAHIIM is the accrediting agency for HIT and HIA programs.
A.
B.
51.  Chronological/Integrated – record is organized in strict chronological order
A.
B.
52.  Clinical observations by medical professionals are termed progress notes  "notes" function to:
  • create chronological record of patient’s treatment & response to treatment
  • justify further acute care treatment
  • document the appropriateness and coordination of services
  • serve as a means of communication between caregivers
A.
B.
53.  CMS uses data to accredit hospitals.
A.
B.
54.  Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Accredits medical rehabilitation, assisted living, behavioral health, adult day care, employment and community services
A.
B.
55.  Common Data Elements of  the personal health record (PHR) includes:
  • Personal demographic information
  • General medical information
  • Allergies and drug sensitivities
  • Conditions
  • Hospitalizations
  • Surgeries
  • Medications
  • Immunizations
  • Clinical Tests
  • Pregnancy History
A.
B.
56.  Communities of Practice (CoP) - network of AHIMA members communicating via a web-based program. You must be an AHIMA member to access the CoP
A.
B.
57.  Confidentiality – expectation that the information shared with one’s provider will only be used for its intended purpose
A.
B.
58.  Connectivity: the capacity of health systems – especially electronic health records (EHR) to exchange information among different information systems.
A.
B.
59.  Cons of EHR implementation include:
  • adoption changes health information workflow
  • Sharing of records sometimes requires coordination
  • Development and implementation costs
  • Organizational and behavioral resistance
A.
B.
60.  Consent = permission for treatment, payment or healthcare operations
A.
B.
61.  Consent can be expressed or implied
  • Expressed – consent is either verbal or written
  • Implied – by virtue of the patient appearing at the hospital, they have implied consent to treat
A.
B.
62.  Consent to treat – often obtained in the admitting area before the patient is admitted and/or treated except in emergency situations.
A.
B.
63.  Consultation Reports
  • A report by another physician who specializes in a particular field of medicine. The consultant gives his/her opinion on the patient’s condition and often recommends a particular course of treatment.
  • The consult is requested by the patient’s attending physician
  • The report is based on the consultant’s physical exam of the patient as well as a review of the patient’s medical record
A.
B.
64.  Correctional facilities
  • Baseline information is collected on inmates at the time of their initial intake – includes H&P, chest x-ray, lab work, dental exam, psych testing
  • Additional information added when inmate is treated for illness, injury, medication, etc.
  • Inmates cannot maintain their own over the counter drugs so all must be dispensed to them
  • In addition to possible accreditation by the Joint Commission, can also be accredited by American Correctional Assn or National Commission on Correctional Health Care.
A.
B.
65.  Critique the following statement:  A user of health records includes only care providers who document in the health record or refer to it for patient care.
A.
B.
C.
D.
66.  Critique this statement:  The PHR and EHR are synonyms.
A.
B.
C.
D.
67.  Data Accessibility:  data are easily obtained. Factors that affect it: - Are records available when and where needed? - Is the dictation equipment accessible and working? - Is transcription accurate? - Are data-entry devices working properly and readily available?
A.
B.
68.  Data Accuracy:   Correctness of data Accuracy depends on: - The patient’s physical health and emotional state at the time the data were collected - The provider’s interviewing skills - The provider’s recording skills - Availability of clinical history - Dependability of automated equipment - Reliability of electronic communications media
A.
B.
69.  Data Comprehensiveness: the required elements are included in the record. Comprehensiveness means the record is complete, which is required for quality care, regulatory, legal and reimbursement requirements. It must include at least: - Patient ID - Consents for treatment - Problem list - Diagnoses - Clinical history - Diagnostic text results - Treatments and outcomes - Conclusions and follow-up plans at discharge
A.
B.
70.  Data Consistency: Is the data consistent no matter how many times it is collected, listed or processed? For example, does all documentation list the patient with a right above knee amputation?   
A.
B.
71.  Data Currency (& Timeliness): Information should be recorded at the time and place it occurs. Up-to-date information is essential to quality care.
A.
B.
72.  Data Definition: Each data element should be clearly defined and have a range of acceptable values.
A.
B.
73.  Data Granularity: Is the data at the correct level of detail? Example: patient temperature must be taken to one decimal level – a whole number will not do.
A.
B.
74.  Data means facts about people, measurements, processes, etc. Once collected and analyzed, they are converted to information, which is facts made into something meaningful.
A.
B.
75.  Data Precision: Are the expected data values delineated and have all appropriate values been included? For marital status, have you included single, married, divorced, separated, widowed and unknown?
A.
B.
76.  Data Relevancy: Are you collecting information because you need it? Be sure you know why you are collecting each data element.
A.
B.
77.  Data Timeliness: Is data entered in a timely manner? Is it available when needed by others in a timely fashion?
A.
B.
78.  Deemed status
  • states that a healthcare facility is in compliance with the Medicare Conditions of Participation, to qualify, facilities must maintain accreditation by the Joint Commission or AOA
A.
B.
79.  Deliveries & Newborns (Obstetric Data) includes which of the following: (select all that apply)
A.
B.
C.
D.
80.  Diagnostic & Therapeutic Orders
  • Orders must be written by the physician prior to any services or medications being given to the patient
  • There should always be an order from the physician to admit the patient to the hospital; in addition, there should be a discharge order as well (unless the pt. leaves against medical advice - AMA)
  • Orders must be written legibly and include the date and the physician’s signature
  • Standing orders – orders that are standardized and utilized frequently; generally specific to a physician or a procedure; usually preprinted or on a standard computer screen, but must be signed and dated by the ordering physician
  • Verbal/telephone orders – orders called in (telephone) or verbally dictated to a practitioner allowed to take such orders; medical staff rules & regs and state laws specify who can take such orders; this is generally limited to RN’s and pharmacists
  • Authentication of verbal/telephone orders - medical staff rules and regs will specify how and when such orders must be signed
A.
B.
81.  Diagnostic Reports include which of the following: (select all that apply)
A.
B.
C.
D.
E.
82.  Discharge summary also includes instructions to the patient at the time of discharge. These instructions should include information on diet, medications, activity level and follow-up care.
A.
B.
83.  Discharge summary does not have to signed by the physician.
A.
B.
84.  Discharge summary is a concise recapitulation of the patient’s illness that includes reason for admission, course of treatment, response to treatment, condition at time of discharge and instructions to the patient.
A.
B.
85.  Discharge summary is used for the following purposes:
  • Continuity of care – used by other providers
  • Review of care provided to the patient
  • Concise summary of patient’s stay that can be used to answer information requests
A.
B.
86.  Efficiency: storage efficiency of paper records is limited due to their size and need to be physically transported from place to place. In a computerized system, the structure of the data must be considered. If data has been scanned into the EHR, it cannot be analyzed efficiently because of its structure. If data is entered using vocabularies and code sets, it can be manipulated, utilized, and analyzed to a much greater level.
A.
B.
87.  EHR
  • Collect data at the point of care
  • Readily exchange date to facilitate continuity of care
  • Measure clinical process improvement and outcomes
  • Report health data to public health, regulatory and accreditation bodies
  • Support management reporting
A.
B.
88.  Electronic health record
  • An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized by clinicians and staff across more than one health organization. (NAHIT 2008)
A.
B.
89.  Electronic Health Records
  • Addresses many of the deficiencies of a paper record
    • Can be easily updated
    • Multiple users can view simultaneously
    • Back up copies are readily made thus preventing against loss or destruction
A.
B.
90.  Electronic Medical Record:
  • An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health organization.
A.
B.
91.  Emergency Care
  • Focus is on diagnosing and stabilizing the patient
A.
B.
92.  Enabling technologies that support a CPR
  • Database systems
  • Data Input – many alternatives such as transcription, optical character readers (ocr), voice recognition, automated templates, bar code readers, etc.
  • Image processing and storage systems – allows multimedia record
  • Text processing and Data retrieval – allows search for specific text/data, allows for indexing of data; most effective approaches consider the end user's needs.
  • System Communications and networks – options include wireless, internet, extranet, broadband, client server, fiber optics, application service providers
A.
B.
93.  End-Stage Renal Disease (ESRD) Services
  • Medicare Conditions for Coverage have standards for record content and keeping for ESRD pts.
A.
B.
94.  Errors in paper-based records include:
  • drawing a single line through the incorrect entry
  • printing the word "error" at the top of the entry with signature or initials, date, time, reason for change, and title and discipline of person making the correction
  • correct entry added to the record
  • original entry should remain legible
  • corrections entered in chronological order
  • late entries identified as such
A.
B.
95.  Examples of national committees include which of the following: (select all that apply)
A.
B.
C.
D.
E.
96.  Examples of patient care delivery usage of the medical record include which of the following uses?
A.
B.
C.
D.
97.  Final autopsy report must be completed within 60 days
A.
B.
98.  Final privacy rule effective Oct. 2002 permits all covered entities to use and disclose patients’ protected health information for their own treatment, payment, or healthcare operations (TPO).
A.
B.
99.  Financial and other administrative processes: determines payment provider will receive.
A.
B.
100.  Flexibility - Paper records have limited flexibility as information is generally displayed in only one format. EHR’s, on the other hand, give more flexibility to the user as display formats can be changed depending on the user’s need.
A.
B.
101.  For which patients must a discharge summary be made:
A.
B.
C.
D.
102.  Health Insurance Portability and Accountability Act of 1996 (HIPAA) – federal legislation to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information.
A.
B.
103.  Health Level Seven (HL7) has developed guidelines that address which aspect of the electronic record?
A.
B.
C.
D.
104.  HIM has been recognized as an allied health profession since:
A.
B.
C.
D.
105.  Home Health Care
  • Regulated by Federal ( Medicare pts) and state gov’ts
  • Accredited by the Joint Commission
  • Above groups have documentation requirements that include:
    • Periodic assessments
    • Home health certification/plan of care
    • Physician must review and approve plan every 60 days
    • OASIS – outcome and assessment information set
      • Medicare mandated standardized patient assessment tool
      • Completed at start of care, when significant change occurs and upon transfer or discharge
      • It is the basis for reimbursement under Medicare
    • Medical record may be kept in patient’s home during treatment period
A.
B.
106.  Hospice
  • Provides palliative care to patients in their homes
  • Regulated by federal gov’t as well as accreditation agencies
  • Provides palliative care to terminally ill patients
    • Focuses on symptom and pain relief rather than cure
  • Plan of care is established by an interdisciplinary team
    • Care plan review must be documented every 30 days
A.
B.
107.  House of Delegates:
  • Legislative body of AHIMA
  • Meets annually
  • Each state association elects representatives to the House of Delegates who has power to approve standards like coding Ethics, Initial Certification of HIA and HIT Programs, etc.
A.
B.
108.  Hybrid Health Records
  • Include both paper and electronic documents
  • Use both manual and electronic processes
  • Many formats
  • Both manual and computer processes must be supported
A.
B.
109.  I am a patient.  My medical history including information from myself and my physicians is stored on the Internet.  This is an example of which of the following:
A.
B.
C.
D.
110.  I just told my physician something embarrassing about myself.  I told him because I expect him to use the information for my care only.  This concept is called. 
A.
B.
C.
D.
111.  I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease.  I must work for what type of organization?
A.
B.
C.
D.