Hit Review Quiz 1

136 Questions  I  By Mathewes48
HIT Review Quiz 1
HIT Review Quiz 1

  
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1.  A complete autopsy protocol or report is made part of the health record within
A.
B.
C.
D.
2.  A home health care aide bathes a patient in her home on March 15. A nurse sees the patient on that day to administer an insulin injection. On March 16, the aide returns to bathe the patient; the nurse returns to administer another insulin injection. How many visits will the agency be allowed to bill Medicare?
A.
B.
C.
D.
3.  Which health maintenance organization model requires employed physicains to treat patients in the organization's facilities?
A.
B.
C.
D.
4.  The JCAHO requires creation of a new record for emergency patients
A.
B.
C.
D.
5.  The inpatient's record generally begins in the
A.
B.
C.
D.
6.  Hospice patients spend the majority of their hospice stay at home. As a result,
A.
B.
C.
D.
7.  Which is documented in the physical examination report?
A.
B.
C.
D.
8.  The terminal digit number filed first in the following series is
A.
B.
C.
D.
9.  With alphabetical filing, which of the following names would be filed first?
A.
B.
C.
D.
10.  An 85-year old female home health patient requires assistance with daily bathing, weekly housecleaning, and daily preparation of one meal. She is recovering from recent hip replacement surgery on the right. She has completely recovered from the left hip replacement surgery she underwent 3 months ago. The home health agency reviewed her request and assigned a caregiver. Unfortunately, a home health aide was unavailable for this assignment; the agency sent a nurse to perform the above tasks. This is an example of
A.
B.
C.
D.
11.  A departmentalized medical staff is organized according to service. What is the title of the individual who is responsible for directing the functions of each service?
A.
B.
C.
D.
12.  The reanalysis of health records refers to
A.
B.
C.
D.
13.  A disease index organized patient data according to the
A.
B.
C.
D.
14.  Which gives legal approval for a facility to offer services?
A.
B.
C.
D.
15.  Utilization review of hospice services uses objective criteria to monitor concerns. Review each statement below and select the one that would be considered utilization review monitoring.
A.
B.
C.
D.
16.  How long should annual statistical reports based on monthly analyses of hospital services be kept?
A.
B.
C.
D.
17.  A cancer registry program must acheive which follow-up rate to receive approval by the American College of Surgeons?
A.
B.
C.
D.
18.  Unitized microforms include all of the following EXCPET:
A.
B.
C.
D.
19.  Mary Jones sustained a laceration to her hand while on the job and was seen in the facotry's clinic where the hand was evaluated by the nurse. Ms. Jones was sent to the hospital's emergency department for suturing. This visit to the factory's clinic is a form of
A.
B.
C.
D.
20.  Reports that summarize administration of therapeutic radiation are documented
A.
B.
C.
D.
21.  The major advantage of straight numeric filing is
A.
B.
C.
D.
22.  Rehabilitative care requires coordination of health disciplines to facilitate a successful patient outcome. A critical factor in the coordination of the rehabilitation process is
A.
B.
C.
D.
23.  Pathology (tissue) reports must be completed on
A.
B.
C.
D.
24.  An accident report was generated on Joe Poole when he was found on the floor next to his nursing facility bed. Mr. Poole was evaluated and found to be unharmed by the presumed fall. The staff responsible for caring for Mr. Poole completed an accident report and
A.
B.
C.
D.
25.  Which modification of the unit numbering system includes pseudonumbers
A.
B.
C.
D.
26.  The diagnosis recorded at the conclusion of the history and physical is the
A.
B.
C.
D.
27.  Dr. Dawson performs an operation on a patient and realizes that there is a backlog in transcription turnaround time of operative reports. According to the JCAHO standards, he should
A.
B.
C.
D.
28.  A department maintains records in hard copy form instead of microfilming; it also has limited space for record storage. Which would the department benefit most from?
A.
B.
C.
D.
29.  Which statement bwlow representsa current trend in the provision of ambulatory care?
A.
B.
C.
D.
30.  File guides are more permanent with which filing system?
A.
B.
C.
D.
31.  Which best describes the organization of the source-oriented record on the nursing unit?
A.
B.
C.
D.
32.  A physician who is anactive member in one hospital and applies to admit an occasional patient to another is applying for what kind of medical staff membership at the second facility?
A.
B.
C.
D.
33.  For records of medium thickness, a fule guide should be provided for every
A.
B.
C.
D.
34.  Patients admitted to the hospital on September 18th were issued the following patient nubmers: 9010, 2053, 9011, 9012, 3155, 0381. Which numbering system is being used?
A.
B.
C.
D.
35.  Home health care agencies have established a protion of the record that can be maintained in the home. Information contained in this record would include all EXCEPT:
A.
B.
C.
D.
36.  Color coding of health record folders helps prevent
A.
B.
C.
D.
37.  Which statement is characteristic of a group practice?
A.
B.
C.
D.
38.  How would the last name, St. John, be filed in an alphabetical file?
A.
B.
C.
D.
39.  Programs designed to bring health care to the economically disadvantaged are called
A.
B.
C.
D.
40.  Part of the accreditation survey process is listed below in responses A to E. Identify the first step that is out of order
A.
B.
C.
D.
E.
41.  The more information abstracted into a disease and operation index, the
A.
B.
C.
D.
42.  Which would be considered an ancillary department?
A.
B.
C.
D.
43.  A health care facility receives notification from the Joint Commission of Accreditation of Healthcare Organizations that it has received an accreditation with commendation.This means that:
A.
B.
C.
D.
44.  If a record cannot be completed because of the death of a physician, the health information practitioner should
A.
B.
C.
D.
45.  Quantitative analysis of the health record would include review for
A.
B.
C.
D.
46.  All of the following are types of cancer registries EXCEPT:
A.
B.
C.
D.
47.  A minimum data set is mandated for use in certified long-term care facilities. The federal requirements that address this document are found under
A.
B.
C.
D.
48.  A final note serves as a discharge summary in minor cases requiring less than
A.
B.
C.
D.
49.  Which is a distinctive feature of health maintenance organizations (HMO's)?
A.
B.
C.
D.
50.  A postanesthesia evaluation is documented in the patient's record by the practitioner administering the anesthetic
A.
B.
C.
D.
51.  The first step in developing a problem-oriented record is
A.
B.
C.
D.
52.  The health information manager who investigates the establishment of a policy for mental health record retention should first
A.
B.
C.
D.
53.  A satellite ambulatory care unit
A.
B.
C.
D.
54.  Veterans Health Admininstration facilities consistently use which of the following as a basis for their numbering system?
A.
B.
C.
D.
55.  Which type of microfilm has the greatest storage density?
A.
B.
C.
D.
56.  The major advantages of the problem-oriented health record include all of the following EXCEPT:
A.
B.
C.
D.
57.  Sally Sims is seen in the hospital and undergoes a bilateral mammogram because this type of radiographic equipment is not available in her physician's office.
A.
B.
C.
D.
58.  The integrated health record format is identified by its
A.
B.
C.
D.
59.  The increase in home health care services being offered has resulted in a (n)
A.
B.
C.
D.
60.  The best application for bar coding in the health information department is
A.
B.
C.
D.
61.  A rubber stamp of Dr. Day's signature is acceptable for use if
A.
B.
C.
D.
62.  A nongovernment-owned hospital can be sponsered by any of the following EXCEPT:
A.
B.
C.
D.
63.  A final progress note may be substituted for a discharge summary when a (an)
A.
B.
C.
D.
64.  Which of the following demonstrates the personal use of the health record?
A.
B.
C.
D.
65.  Which has ultimate authority and responsiblility for providing proper care to hospital patients?
A.
B.
C.
D.
66.  The four major sections of a problem-oriented health record are:
A.
B.
C.
D.
67.  Peer Review Organizations obtain government contracts to evaluate the necessity and quality of health services rendered to Medicare patients. Reviews are conducted and judgments are based primarily on the
A.
B.
C.
D.
68.  Which is the name of the data set developed by the DHHS and approved by the National Committee on Vital and Health Statistics?
A.
B.
C.
D.
69.  The chief complaint included in a history and physical examination report is a statement made by the
A.
B.
C.
D.
70.  Medicare would categorize a county health department home health agency as
A.
B.
C.
D.
71.  Sally Smith underwent emergency surgery in the hospital's day surgery unit and stayed a total of 18 hours. The care rendered during this time was
A.
B.
C.
D.
72.  Which filing system organizes records in strict chronological order?
A.
B.
C.
D.
73.  According to JCAHO requirements, a Type 1 recommendation may be given if the total number os health records delinquent exceeds what percentage of the average monthly discharges?
A.
B.
C.
D.
74.  Standing orders
A.
B.
C.
D.
75.  An ambulatory care encounter is defined as
A.
B.
C.
D.
76.  With which filing system is quality control most difficult?
A.
B.
C.
D.
77.  An infant's record is
A.
B.
C.
D.
78.   Which was the first major U.S. impetus for improvig hostipal health records?
A.
B.
C.
D.
79.  The term nursing facility is being applied to facilities participating in the Medicaid program and replaces the term
A.
B.
C.
D.
80.  Upon review of discharged health records, the analysis clerk notices that one physician in consistent in his lack of timely discharge summary documentation. He has previously been notified of this problem. Next, the analysis clerk should
A.
B.
C.
D.
81.  A factory guaranteed that all employees would seek care at the local hispital and was able to negotiate a special reduced rate for care rendered. This is a(an)
A.
B.
C.
D.
82.  Which allows family members who normally provide care to a person to take a break from providing that care?
A.
B.
C.
D.
83.  A local hospital expanded its services offered to the community and operates an urgent care center across town in addition to the hospital.This would now be considered a
A.
B.
C.
D.
84.  Which problem-oriented record portion incorporates the history and physical?
A.
B.
C.
D.
85.  On January 15, the patient underwent an intravenous pyelogram performed by the x-ray technician and interpreted by the radiologist, who also met with the patient briefly; urinalysis performed by the lab technician and interpreted by the pathologist; and one hour of gait training was conducted by the physical therapist in the Physical Theropy Department. How many occasions of service were provided?
A.
B.
C.
D.
E.
86.  Because the clinical record is a confidential document, release of information must be handled in such a way that no unauthorized person has access to the record. Another consideration is the situation in which a patient is transferred from one facility to another. The transferring facility fowards copies of records to the receiving facility; this information from the transferring facility is placed in the receiving facility's health record. Upon discharge of the patient from the second facility, the insurance campany responsible for paying for the stay requests copies of any and all records on this particular patient. How should the receiving facility handle the rerelease of copies of the transferring facility's health record?
A.
B.
C.
D.
87.  Which represents records filed within a primary section in terminal digit order?
A.
B.
C.
D.
88.  The P in the SOAP note of the problem-oriented record refers to the
A.
B.
C.
D.
89.  Progress notes
A.
B.
C.
D.
90.  Many long-term care facilities perform chart thinning. This means that
A.
B.
C.
D.
91.  A facility that has a medical staff consisting of MD's and DO's desires American Osteopathic Association accreditation status. It is also currently accredited by the Joint Commission on Accreditation of Healthcare Organizations. The facility
A.
B.
C.
D.
92.  A question on the documentation practices of a particular physician arises through health information department analysis. The health information practitioner should first notify the
A.
B.
C.
D.
93.  Which organizations' directives establish minimum contents of a health record?
A.
B.
C.
D.
94.  Revisions of report forms created for use in the record must be approved by the
A.
B.
C.
D.
95.  Susan is a nurse who brings to your attention an error in the health record. She is uncertain how to make the correction. What would Susan's first step be in amending an error in a health record?
A.
B.
C.
D.
96.  A physician who has newly relocated to the area applied and was accepted as an active staff member at the local hospital. The physician will
A.
B.
C.
D.
97.  Mrs. Hughston is transported to the hospital after complaining of sever right lower quadrant pain. She is evaluated and undergoes laboratory tests, which prove to be negative. She is discharged to be seen by her primary care physician in his office.
A.
B.
C.
D.
98.  Inpatient discharges total 1,763 in one month; 521 of these discharged health records are complete at discharge. Calculate the month's incomplete health record rate.
A.
B.
C.
D.
99.  Regulations about physician completion of health records are developed by the
A.
B.
C.
D.
100.  The terminal digit file area requires 2000 file guides.  What is the pattern of file guides?
A.
B.
C.
D.
101.  Which would be the chief criterion for determining record inactivity?
A.
B.
C.
D.
102.  Birth and death certificates should be maintained by the facility
A.
B.
C.
D.
103.  The release of health records that contain information about a drug addiction for which the patient sought treatment is controlled by
A.
B.
C.
D.
104.  Compliance by a long-term care facility with which of the following would be considered voluntary?
A.
B.
C.
D.
105.  Which is the most important consideration in designing a form?
A.
B.
C.
D.
106.  CARF accredits
A.
B.
C.
D.
107.  All of the following are physicians EXCEPT:
A.
B.
C.
D.
108.  Which number was most recently assigned to a new patient by the admitting department of a facility that uses unit numbering to assign numbers and terminal digit filing to file records?
A.
B.
C.
D.
109.  A multidisciplinary team approach in mental health care allows for participation in monitoring and socumenting the patient's  progress during and response to treatment. Which documentation system would best allow for the above process?
A.
B.
C.
D.
110.  As HIM Director, you have been asked to report the incomplete record rate for the month of October at the medical staff meeting. There were 2,250 discharges and 200 incomplete records in the month of October. What would the incomplete record rate be?
A.
B.
C.
D.
111.  Divorce complicates which type of numbering system?
A.
B.
C.
D.
112.  Henry Franklin undergoes a right inguinal herniorraphy at 7:00 A.M. and is discharged at noon to return home in order to recuperate.
A.
B.
C.
D.
113.  A terminal digit file guide is labeled: 40/30.The 40 is considered
A.
B.
C.
D.
114.  Who has primary responsibility for the home health care client's plan of care?
A.
B.
C.
D.
115.  The master patient index should be kept
A.
B.
C.
D.
116.  If a patient falls while in the hospital, an incident form is generated and
A.
B.
C.
D.
117.  Which would be considered a major component of the record control function?
A.
B.
C.
D.
118.  Which is the most important use of a number index?
A.
B.
C.
D.
119.  All of the following are cinsedered long-term care facilities EXCEPT:
A.
B.
C.
D.
120.  Which system makes it easiest to purge records for microfilming?
A.
B.
C.
D.
121.  Which of the following would be found in a history report?
A.
B.
C.
D.
122.  Anytown Medical Center uses a decentralized system for record keeping. The next number in the serial system for inpatient hospital admissions is 16888. The next number to be assigned in the outpatient clinic is unit number 17845. Mary Jones's last number on outpatient admissions was 10921 and on hospital admission was 15824. What patient number will be assigned to Mary Jones if she returns to the hospital as an outpatient?
A.
B.
C.
D.
123.  The JCAHO requires mental health care facilities to conduct several types of quality assurance reviews. Review the list below and select the type of review that would be more characteristic of that conducted in a mental health care facility than a hospital.
A.
B.
C.
D.
124.  Which would provide a chronological listing of all patient admissions?
A.
B.
C.
D.
125.  Which is responsible for coordinating all hospital clinical activities?
A.
B.
C.
D.
126.  Which statement would be documented in the physical examination report?
A.
B.
C.
D.
127.  When documenting SOAP notes, reference is made to the problem list by
A.
B.
C.
D.
128.  A family numbering system is most useful in
A.
B.
C.
D.
129.  Mary Forbes is registered for her weekly physical therapy and undergoes treatment consisting of whirlpool baths and diathermy.
A.
B.
C.
D.
130.  A hospital administrator requests the health information management department to provide a report detailing the number of incompleted discharged health records during the past 6 months.  Such a report would be the result of a(an)
A.
B.
C.
D.
131.  All would be contained in thephysical examination report EXCEPT:
A.
B.
C.
D.
132.  The middle digit number filed last in the following series is
A.
B.
C.
D.
133.  The chronological listing of all patients in a cancer/tumor registry is called the
A.
B.
C.
D.
134.  Which form would provide the basic facts about a long-term care resident who has been transferred from a hospital?
A.
B.
C.
D.
135.  Which of the following demonstrates the personal use of the health record?
A.
B.
C.
D.
136.  Which is an example of a medical staff rule and regulation?
A.
B.
C.
D.
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