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Hit Quiz 1 Practice

300 Questions  I  By Akay777
HIT Quiz 1 Practice
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.
112.  I work for CMS: how would I use the health record?
A.
B.
C.
D.
113.  If a consent is not obtained prior to a surgical procedure, the patient could potentially sue for battery (unlawful touching)
A.
B.
114.  If a patient is readmitted [to the hospital] within 30 days with the same diagnosis, an interval note may be used in lieu of a full history and physical exam. The interval note should document any changes in the patient's condition since their previous hospitalization.
A.
B.
115.  If there is a delay between dictation and transcription, the surgeon must write a progress note summarizing surgery.
A.
B.
116.  In 1970 the American Association of Medical Record Librarians (AAMRL) dropped the term "librarian" and became the American Medical Record Association (AMRA).
A.
B.
117.  In 1991, the American Medical Record Association (AMRA) became the American Health Information Management Association (AHIMA).
A.
B.
118.  In 1999, AHIMA House of Delegates approved a credential name change.  Registered record administrator (RRA) became registered health information administrator (RHIA) and accredited record technician (ART) became registered health information technician (RHIT).
A.
B.
119.  In 2001, the National Committee on Vital and Health Statistics (NCVHS) issued a report and recommendations detailing how to build a national health information infrastructure. President George W. Bush has outlined a plan to achieve EHR’s for most Americans by 2014. The Office of the National Coordinator for Health Information Technology (ONC) is driving this effort.
A.
B.
120.  In 2004 The Institute of Medicine (IOM) began a process to identify 8 core functionalities of the EHR.
  • health information and data
  • results management
  • order entry and management
  • decision support
  • electronic communication and connectivity
  • patient support
  • administrative processes
  • reporting and population health management
A.
B.
121.  In 2006 the National Alliance for Health Information Technology (NAHIT) published a report that defined a electronic medical record (EMR) vs. an electronic health record (EHR.)
A.
B.
122.  In 2009 President Barack Obama signed into law the American Recovery and Reinvestment Act, and economic stimulus package that provides, among other things, reimbursement incentives to providers and hospitals that are meaningful users of certified HER technology. The reimbursement incentives should serve to accelerate EHR adoption in the US.
A.
B.
123.  In 2010, health information management (HIM) professionals were working in 40 different settings under 125 different job titles.
A.
B.
124.  In a problem-oriented health record, problems are organized by:
A.
B.
C.
D.
125.  In addition to storing health information, EHRs will do which of the following: (select all that apply)
A.
B.
C.
126.  In an integrated health record, documentation by heath professionals is organized:
A.
B.
C.
D.
127.  In Behavioral Health: 
  • It is important to note that although HIPAA has some special handling rules for psychotherapy notes, this type of behavioral health documentation is a very unique special type of document which is by definition not part of the health record. A psychotherapy note is different than a routine progress note written by a behavioral health professional.
A.
B.
128.  In case of a death, the physician should either complete a discharge summary or add a final progress note detailing the circumstances surrounding the death.
A.
B.
129.  In Emergency Care:
  • Documentation is generally limited to the presenting problem and diagnostic and therapeutic services rendered related to the problem.
A.
B.
130.  In Emergency Care:
  • Documentation of instructions given to the patient at discharge are considered very important
A.
B.
131.  In general, a medical record: 
  • Must be completed within a timeframe defined by the medical staff rules & regulations
  • In no case can this timeframe exceed 30 days
A.
B.
132.  In order to participate in the Medicare program, facilities must abide by the Medicare Conditions of Participation or Conditions for Coverage.
  • Conditions of Participation address documentation requirements as well as other issues
  • Conditions for Coverage required of suppliers of ESRD (End Stage Renal Disease) services
A.
B.
133.  In Rehab Services, unique record components include:
  • Dx of disability
  • Rehab problems, goals, prognosis
  • Reports from assessments, referrals, outside consultants, etc.
  • Designation of manager for patient’s program
  • Evidence of patient/family participation in decision making
  • Report of staff conferences
  • Patient’s total program plan
  • Plans from each service involved in care
A.
B.
134.  In Rehab Services:
  • Prospective payment system currently being implemented
  • PAI (patient assessment instrument ) will follow and will be used to determine a payment level for an inpt rehab stay
A.
B.
135.  In the New Model, the physical (paper-based) health record is being replaced by the electronic health record.
A.
B.
136.  Individual Users of health records include: (select all that apply)
A.
B.
C.
D.
E.
137.  Institutional Users of health records include: (mark all that apply)
A.
B.
C.
D.
E.
F.
G.
138.  Integrated Records:
  • Arranged by episode of care or patient visit
  • Entire record is typically in reverse chronological order with most recent on top
  • This arrangement used most often in physician offices
  • Within each visit/occasion of service, arrangement of record can vary depending on the needs of the user
A.
B.
139.  Interdisciplinary care plans are an important part of what type of health record?
A.
B.
C.
D.
140.  Issues with paper records
  • Only one user can view at a time
  • Difficult to update due to its transient character
  • Susceptible to damage from fire, water, wear/tear
  • Can be easily lost or misplaced
A.
B.
141.  It was suggested that we enter the patient's age manually in all of our information systems.  What quality characteristic would be the justification for not doing this but rather sharing informaton between systems.
A.
B.
C.
D.
142.  Items found in ER records not always found in acute care records:
  • Time and means of arrival
  • Emergency care given prior to arrival (copy of ambulance run sheets, paramedic records)
  • Documentation when the patient leaves the facility against medical advice (AMA)
A.
B.
143.  Labor & Delivery Record
  • delivery to postpartum period
  • updated history, membrane status, bleeding, last food intake, meds, allergies, anesthesia, bottle or breast
  • delivery details recorded, as is neonate
  • Apgar scores at 1 & 5 minutes (Apgar score is an objective measure of the infant’s condition)
  • Fetal monitoring strips identified, part of record
A.
B.
144.  Long Term Care
  • Includes SNF, NF, ICF, assisted living, TCU
  • Highly regulated by state and federal government
  • Most of these facilities do not obtain voluntary accreditation status with the Joint Commission, etc.
A.
B.
145.  Long Term Care:
  • Interdisciplinary care team develops a care plan for each resident
  • Care plan format is the RAI (resident assessment instrument)
  • RAI includes the MDS (minimum data set), triggers and RAP’s (resident assessment protocols).
  • Residents are assessed upon admission and then quarterly and annually thereafter unless a significant change occurs before.
  • MDS submitted electronically to each state which then forwards it to CMS
  • MD visits to resident occur much less frequently than acute care
A.
B.
146.  Medicaid is a joint funded program between federal and state governments but is administered by the states so requirements vary by state
A.
B.
147.  Medical History
  • Gives the medical history of the patient as well as details about their current illness
  • Typically given by the patient (relative may do so but record should document if so)
Contains:
  • CC – chief complaint; in patient’s own words his/her current problem.
  • PI – present illness; a brief chronological description of the current illness. Physician describes in chronological order the patient’s symptoms since the current illness has started.
  • PH – past history (includes prior illnesses, surgeries, allergies, medications)
  • SH – social history (education, occupation, alcohol, smoking, marital status)
  • FH – family history (significant family illnesses)
  • ROS – review of systems; physician systematically reviews all body systems with patient to uncover any current or past subjective symptoms that patient may have forgotten to mention
A.
B.
148.  Medical record documentation is
  • The primary communication between caregivers
  • Used for continuing patient care
  • Used for evidence that treatment took place
  • Used for performance improvement and risk management
  • Used in medical education programs
  • Reviewed by external agencies to measure quality of services
  • Used by third party payers to prove services were provided
  • Used by the legal system as evidence
A.
B.
149.  Medical staff rules & regs or a medical staff policy will spell out the types of procedures/surgery that requires consent, timeframes in obtaining consent, who can obtain consent, etc.
A.
B.
150.  National Committee for Quality Assurance (NCQA)
  • Accredits managed care organizations and more recently, preferred provider organizations
  • Standards reflect common documentation principles with the most important elements labeled as critical
A.
B.
151.  Neonatal (newborn) data
  • A copy of the Mom’s labor and delivery record is generally included in the newborn’s record
  • Identification: banded while in delivery room; Mom and babe both have bands with mom’s number and babe’s sex and time of birth
  • Physical Exam: done generally by pediatrician; full physical exam usually done at the time of birth and the time of discharge
  • Progress Notes: notes by docs and nurses; may also contain note if circumcision was done; the Joint Commission requires if oxygen given, must be noted concentration of oxygen as per policies/procedures
A.
B.
152.  New Graduate – for student AHIMA members who graduate. Entitled to 1 year of reduced membership dues.
A.
B.
153.  New roles for HIM managers include: (select all that apply)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
154.  Nursing Forms often utilized
  • Nursing assessment: upon admission often followed by care plan (summary o the pt’s problems from nurse/professional’s perspective and detailed plan for intervention.
  • Nursing notes: may write own or may be integrated; describe pt’s condition in objective, behavioral terms, generally written each shift
  • Graphic Sheet: records vital signs; pulse, temp, resp, bp; may include weight; frequency depends on pt’s status; vital signs generally done each shift
  • Medication Sheet: records meds, date, time, dose, route
  • Special Care Units: have their own sheets with much more data recorded
A.
B.
155.  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
A.
B.
156.  Often times progress notes are kept in an integrated format, meaning that all providers write within the progress notes in chronological order. Each provider identifies their particular area of expertise such as anesthesia note, physical therapy note, nursing note, etc.
A.
B.
157.  Operative Forms include which of the following: (select all that apply):
A.
B.
C.
D.
E.
F.
G.
158.  Operative Report:
  • required for surgical patients
  • dictated by surgeon
  • top portion includes:
  • preop dx
  • postop dx
  • procedure performed
  • assistants
A.
B.
159.  Operative reports must be dictated immediately following surgery as required by the joint commission. If there is a transcription delay the surgeon must document a brief operative note in the progress notes.
A.
B.
160.  Order Entry/Order Management – Computerized provider order entry (CPOE) – with EHR decision support is built in, elimination of lost orders, illegible handwriting, duplicate orders, etc.
A.
B.
161.  Organization of Record Librarians was formed after a meeting in Boston in 1928 and the ARLNA was formed. This was the predecessor of AHIMA.
A.
B.
162.  Other Administrative Information –
  • Property lists/valuables
  • Birth/death certificates
A.
B.
163.  Paper recordes may require thinning in which two settings?
A.
B.
C.
D.
164.  Pathology Report
  • gross and microscopic examination of tissue
  • report written and signed by pathologist
  • original included in medical record
A.
B.
165.  Patient care delivery: helps doctors, nurses, etc. to make informed decisions about diagnoses and treatments. It is a communication tool among caregivers, thus ensuring continuity of care. It also represents legal evidence of services received by patient.
A.
B.
166.  Patient care management: refers to activities related to managing services provided to patients; ie, developing practice guidelines and evaluating quality of care.
A.
B.
167.  Patient care support processes: relates to handling of resources, analysis of trends, communication among departments.
A.
B.
168.  Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record?
A.
B.
C.
D.
169.  Patient self-management: individuals are more actively involved in their healthcare and are becoming the primary user.
A.
B.
170.  Patients do not have the right to add missing information to the health record.
A.
B.
171.  Pediatric care should include items such as:
  • Birth history
  • Growth and development record
  • Documentation of well-child visits and immunizations
A.
B.
172.  Per the Joint Commission, discharge summary must be completed within 30 days of discharge unless medical staff rules and regulations specify sooner.
A.
B.
173.  Personal Health Records
  • Maintained and controlled by individual. As more people keep their health information, policies need to be in place to determine what information becomes part of a facility’s record.
A.
B.
174.  Physical Exam
  • Physician examines the patient and documents his findings
  • Includes all major body systems as well as patient’s vital signs at the time of the exam
  • Generally concludes with the physician’s provisional diagnosis, also referred to as impression
  • Medical history and physical exam are often combined into one document called the History & Physical exam
  • The Joint Commission requires the H&P to be completed within 24 hrs of admission and prior to surgery
A.
B.
175.  Physician is responsible for obtaining the patient’s consent prior to a surgical procedure.
A.
B.
176.  Physician’s Office (Ambulatory Care)
  • Problem lists – facilitates ongoing patient care management
    • Includes diagnoses, procedures, medications, allergies
  • Medication lists
  • Copies of previous hospitalizations
  • Patient history questionnaires
  • Misc. flow sheets (growth and immunization charts)
A.
B.
177.  Portions of a treatent record may be maintained in a patient's home in which two types of settings?
A.
B.
C.
D.
178.  Postpartum Record
  • Assess mom after delivery
  • breasts, fundus, perineum, teaching
  • documented by nurses
A.
B.
179.  Practice Councils such as those in Clinical Classification and Terminology, Health Information Exchange, and Privacy and Security Practice advise AHIMA and provide expertise related to best practices in specific areas.
A.
B.
180.  Practitioners permitted to record in the progress notes will be delineated in the medical staff rules & regs.
A.
B.
181.  Pre-anesthesia and post-anesthesia assessment included in Anesthesia Report:
  • pre- located on back of form or in progress notes; includes procedure, choice of anesthesia, explanation of same, past anesthesia history and ASA Class (I - IV)
  • post - completed within 24 hrs of surgery; can be found in progress notes, anesthesia form, recovery room form; states if any post anesthesia complications  
A.
B.
182.  Primary Purposes of records include which of the following: (select all that apply)
A.
B.
C.
D.
E.
183.  Privacy – right of an individual patient to control access to their own information
A.
B.
184.  Problem oriented records:
  • Problem list – each problem has a unique number, date of onset, date of resolution
  • Database – very similar to the history & physical exam
  • Initial care plan – lays out initial plans for treatment of patient
  • Progress notes - written in what is called the SOAP format
A.
B.
185.  Problem oriented – contains four distinct components: database, problem list, initial plan and progress notes
A.
B.
186.  Progress note can be integrated (meaning that all professions write in one set of progress notes) or are sometimes separated by profession/department (for example, PT would have their own progress notes, dietary would have their own and so on.
A.
B.
187.  Provisional autopsy report must be completed within 72 hours (3 days)
A.
B.
188.  Quality: All individuals in an organization depend on quality information, which depends on the design of the organization’s systems and processes for collecting the information. There are 10 characteristics of data quality.
A.
B.
189.  Records in early 20th century did not contain graphic records or labs. Incomplete records were filed as received at time of discharge.
A.
B.
190.  Recovery Room Record (PACU – post anesthesia care unit) is usually signed by the surgeon.
A.
B.
191.  Recovery Room Record (PACU – post anesthesia care unit) includes:
  • patient’s level of consciousness upon arrival and departure from recovery room (RR)
  • vital signs
  • status of IV’s, dressings, tubes, catheters, drains
A.
B.
192.  Recovery Room Record (PACU – post anesthesia care unit)
  • Documents care from time pt leaves Operating Room until patient returns to their assigned hospital bed
A.
B.
193.  Referral form is required when pt. is moved from acute care to another hc organization. Also called a transfer record.
A.
B.
194.  Registration Record
  • Also called a face sheet or admission record
  • Often the first page of each encounter
  • Contains demographic and financial data about the patient as well as clinical such as admitting diagnosis (dx) and discharge diagnoses/processes added at the time of discharge
A.
B.
195.  Rehab Services
  • Range of facilities varies widely from comprehensive inpt to outpt
  • Documentation reflects the level of care/services provided
  • CARF (Commission on Accreditation of Rehabilitation Facilities) accredits rehab facilities and maintains documentation standards
A.
B.
196.  Research organizations develop and test experimental patient care protocols.
A.
B.
197.  Results Management – with the EHR, providers have access to results over a period of time to improve efficiency and effectiveness of treatment.
A.
B.
198.  Results management, order entry and order management were added to the EHR functional mode in 2003 by the IOM.
A.
B.
199.  Secondary Purposes: Related to environment in which care is provided: Education, Research, Regulation, Policy making and support, Public health and Homeland Security, and Industry.  
A.
B.
200.  Security: access to information must be weighed against patient’s right to privacy
A.
B.
201.  Security – protection of health information from unauthorized access as well as fire, flood and other damage
A.
B.
202.  Senior AHIMA members can not vote.
A.
B.
203.  Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in what records?
A.
B.
C.
D.
204.  SOAP Format:
  • S = subjective - in patients words
  • O = objective - factual information - i.e. lab results or a factual observation
  • A = assessment (their assessment of the above information)
  • P = plan (their plan for future or ongoing treatment)
A.
B.
205.  Someone suggested that we collect a patient's eye color.  This was not implemented.  Waht quality characteristic would be the justification for not collecting this information:
A.
B.
C.
D.
206.  Source oriented records (i.e. by department) are the most common form of records in hospitals today.  
      • End users may find this format difficult to use because they must look through various sections to get an overview of the patient’s condition at any point in time
A.
B.
207.  Source oriented – record is organized by the department that initiates the information; e.g. – lab, EKG, physician orders; most common paper-based format
A.
B.
208.  Specialized Health Record Content  varies due to:
  • The setting in which the care takes place (hospital, opd, LTC)
  • Accreditation standards
  • State and local laws
  • Medicare status
  • Medical services required (ob vs. pediatric)
  • Duration of services
  • Traits of individual patients (age, functional status)
  • Complexity of patient’s condition
A.
B.
209.  State and Local Chapters:
  • Called component state associations (CSA)
  • Some CSA’s are further broken down into regional and/or local associations
  • Provide membership with education, networking and representation
  • When you become a member of AHIMA, you can designate one CSA that you wish to belong to.
A.
B.
210.  State Regulations
  • States mandate regulations pertaining to healthcare organizations in their state
  • Facilities must comply with state regulations in order to be licensed
  • Many state regulations include documentation requirements
A.
B.
211.  Student members of AHIMA have voiting rights.
A.
B.
212.  Student members of AHIMA  can serve on committees with voice but no vote (reduced membership dues while a student enrolled in a CAHIIM accredited program).
A.
B.
213.  Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.
A.
B.
214.  The AHIMA Fellowship Program is a program of earned recognition for members who have made significant and sustained contributions to the HIM profession.
A.
B.
215.  The ambulatory surgery record contains information most similar to?
A.
B.
C.
D.
216.  The body of the Operative Report contains:
  • findings
  • technical description of procedure
  • organs explored
  • numbers of packs, drains, sponges, sutures
  • condition of pt at conclusion
  • signed by dictating surgeon
A.
B.
217.  The documentation that indicates current and past medical conditions is:
A.
B.
C.
D.
218.  The EHR Best Practices workgroup focuses on guidelines for e-HIM practice.
A.
B.
219.  The Emergency Department record must be authenticated by the treating physician.
A.
B.
220.  The face sheet is filled with demographic & financial information including:
  • Patient’s name
  • Patient ID # or M.R.#
  • Address
  • DOB
  • Place of birth
  • Gender
  • Race
  • Marital status
  • S.S. number
  • Name and address of next of kin
  • Date and time of admission
  • Type of admission (inpt/opd)
  • Name, address, tel. # of hospital
A.
B.
221.  The Fellowship Recognition is a lifetime award, subject to continuing AHIMA membership and compliance with the AHIMA code of ethics.
A.
B.
222.  The health care record is the principal repository for data and information about the healthcare services provided to individual patients.
A.
B.
223.  The health record is the principal repository for data and information about services. It documents the who, what, when, where, why and how of patient care.
A.
B.
224.  The hospital standardization movement was inaugurated by the:
A.
B.
C.
D.
225.  The Institute of Medicine (IOM) defines users of records as: “individuals who enter, verify, correct, analyze or obtain information from the record, directly or indirectly through an intermediary”. Some users are direct care givers who access an individual patient’s record in order to do their job while other users may not directly access an individual record but may review aggregate data that has been gathered from many patient records.
A.
B.
226.  The joint Commission requires a pre-op anesthesia assessment.
A.
B.
227.  The Joint Commission requires one (l) postoperative anesthesia note to note presence or absence of anesthesia complications; takes place after pt. discharged from recovery room
A.
B.
228.  The Joint Commission requires the Provisional autopsy report to be completed within 72 hours of the autopsy and the final report to be filed in the medical record within 60 days of the autopsy.
A.
B.
229.  The Joint Commission- sometimes called the JC (formerly: The Joint Commission on Accreditation of Healthcare Organizations - JCAHO)
  • Accredits a wide variety of healthcare facilities
  • Applies a core set of documentation standards consistently across the health care continuum and then adds supplemental standards for specific types of care
  • Focuses on continuous improvement and continuous standards, monitoring sentinel events, and tracer methodology
A.
B.
230.  The lab test "hemoglobin: 14.6 gm/110ml" is considered information.
A.
B.
231.  The most important attributes of record storage include which of the following: (select all that apply)
A.
B.
C.
D.
E.
F.
232.  The new model of HIM practice is:
A.
B.
C.
D.
233.  The only financial information maintained in the record is that which is collected at the time of admission such as:
  • Payer
  • Policy holder
  • Patient’s relationship to policy holder
  • Employer of policy holder
  • Insurance numbers
A.
B.
234.  The organization that accredits HIM programs is:
A.
B.
C.
D.
235.  The original copy of the consent is filed in the medical record.
A.
B.
236.  The patient indicates that her pain is worse.  In which part of a SOAP note would this information be recorded?
A.
B.
C.
D.
237.  The personal health record (PHR) as defined by NAHIT as:
  • An electronic record of health related information on an individual that conforms to nationally recognized interoperability standards, and that can be drawn from multiple sources while being managed, shared, and controlled by the individual (NAHIT 2005)
A.
B.
238.  The powers of the House of Delegates (HOD) include which functions: (select all that apply)
A.
B.
C.
D.
E.
F.
G.
H.
239.  The primary focus of AHIMMA is to:
A.
B.
C.
D.
240.  The primary function of the health record is to store patient care documentation.
A.
B.
241.  The traditional HIM was department based and Vision 2006 is information based.
A.
B.
242.  The Traditional Model is based on creating, tracking, and storing physical records.
A.
B.
243.  The traditional model of HIM practice was: 
A.
B.
C.
D.
244.  The virtual network used by AHIMA members is:
A.
B.
C.
D.
245.  Throughout the years, HIM roles have:
A.
B.
C.
D.
246.  Today, the role of the Board of Registration is played by AHIMA's Commission on Certification for Health Informatics and Information Management (CCHIIM).
A.
B.
247.  Traditional Model: Department based, HIM activities performed in department. New Model: Tasks are information based. HIM's activities are performed outside Dept. (QI, decision support, Data Security, etc.)
A.
B.
248.  Traditional: Confidentiality and release of information New Model: computer data security programs, privacy programs
A.
B.
249.  Traditional: Paper forms design New Model: User interface
A.
B.
250.  Typically recording in progress notes are doctors, nurses, social workers, therapists (PT, OT, Speech), dieticians, etc.
A.
B.
251.  Up until 1918, attending doctors were solely responsible for creation and management of medical records.
A.
B.
252.  Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.
A.
B.
253.  USERS OF RECORDS: Includes care givers; however, others use records including managed care organizations, integrated delivery systems, regulatory and accreditation organizations, licensing bodies, educational organizations, 3rd party payers, and research facilities all use info originally collected to document care.
A.
B.
254.  Vision 2010 – defined HIM as “the body of knowledge and practice that ensures the availability of health information to facilitate real-time healthcare delivery and critical health related decision-making for multiple purposes across diverse organizations, settings and disciplines”.  
A.
B.
255. 
  • Vision 2016 – Blueprint for HIM Education – “The transition of the healthcare industry to become more patient-centric and evidence-based has given rapid momentum to improvements in adoption of electronic health records (EHR) and health information exchanges (HIE).
A.
B.
256.  Volunteer
  • BOD (Board of Directors)  – manages the property, affairs and operations of AHIMA
  • CCHIIM – oversees certification process and sets policies and procedures
  • CAHIIM – oversees AHIMA’s accreditation of college programs in HIT and HIA   
A.
B.
257.  We had 324 Medicare patients last month.  This statement represents which of the following:
A.
B.
C.
D.
258.  What are common types of format used in paper-based record systems: (select all that apply)
A.
B.
C.
D.
E.
259.  What are the three key prioritiesof the Blueprint of Vision 2016?
A.
B.
C.
D.
260.  What components of Vision 2006 are different from the Aggregation and display of data from the traditional HIM? (select all that apply)
A.
B.
C.
D.
261.  What components of Vision 2006 are different from the Confidentiality and release of information in the traditional HIM? 
A.
B.
C.
262.  What components of Vision 2006 are different from the Forms and records design of the traditional HIM?
A.
B.
C.
D.
263.  What components of Vision 2006 are different from the physical records of the traditional HIM? (select all that apply)
A.
B.
C.
D.
E.
264.  What evolving role assesses quality in health record banking?
A.
B.
C.
D.
265.  What evolving role oversees the process that begins at the time of documentation through billing?
A.
B.
C.
D.
266.  What organization was the predecessor of AHIMA?
A.
B.
C.
D.
267.  What type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?
A.
B.
C.
D.
268.  What was NOT a role of the Board of Registration?
A.
B.
C.
D.
269.  What year was the Commission on Certificaton for Health Informatics and Information established?
A.
B.
C.
D.
270.  When a discharge summary is not required, a final progress note must be documented.  
A.
B.
271.  When an emergency room patient is admitted to the hospital, the original copy of their emergency report is placed in the inpatient record
A.
B.
272.  When was formal curriculum for the education of medical records workers adopted?
A.
B.
C.
D.
273.  When were the first schools for medical record librarians surveyed and approved by ARLNA?
A.
B.
C.
D.
274.  Which group focuses on accreditation of managed care and preferred provider organizations?
A.
B.
C.
D.
275.  Which of the following administrative documents names the patient's choice of legal representative for healthcare purposes?
A.
B.
C.
D.
276.  Which of the following are characteristics of data quality (select all that apply)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
277.  Which of the following are requirements to earn fellowship (FAHIMA): (select all that apply)
A.
B.
C.
D.
E.
278.  Which of the following are tasks performed by a health information manager? (select all that apply)
A.
B.
C.
D.
279.  Which of the following electronic record technological capabilites would allow an x-ray to be sent to a physician in another state?
A.
B.
C.
D.
280.  Which of the following functions as the legislative body of AHIMA?
A.
B.
C.
D.
281.  Which of the following groups has instituted a health record-prohibited abbreviation list?
A.
B.
C.
D.
282.  Which of the following is a disadvantage of an EHR over a paper-based record?
A.
B.
C.
D.
283.  Which of the following is an accrediting organizaton?
A.
B.
C.
D.
284.  Which of the following is an example of a primary purpose of the medical record?
A.
B.
C.
D.
285.  Which of the following is not considered patient demographic informaton?
A.
B.
C.
D.
286.  Which of the following is true of paper-based records?
A.
B.
C.
D.
287.  Which of the following promotes education and research?
A.
B.
C.
D.
288.  Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patient's record?
A.
B.
C.
D.
289.  Which of the following terms refers to state or county regulations that healthcare facilities must meet to provide care?
A.
B.
C.
D.
290.  Which of the following users of the health record is an example of an institutional user?
A.
B.
C.
D.
291.  Which of the following users would utilize aggregate data?
A.
B.
C.
D.
292.  Which of the following would not be found in a medical history?
A.
B.
C.
D.
293.  Which report provides info on tissue removed during a procedure?
A.
B.
C.
D.
294.  Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
A.
B.
C.
D.
295.  Which standardized tool is used to assess medicare-certified rehabilitation facilities?
A.
B.
C.
D.
296.  Which two types of data are contained in the health record?
A.
B.
C.
D.
297.  Which type of data input mechanism is commonly used in both paper and electronic environments?
A.
B.
C.
D.
298.  Which type of health record includes both paper and computerized components?
A.
B.
C.
D.
299.  While a totally problem oriented record format is not frequently used due to the time it takes to document in this fashion, progress notes are often recorded in the SOAP format.
A.
B.
300.  Written or spoken consent to proceed with care is classified as:
A.
B.
C.
D.
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