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42 Questions
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FINAL

Questions and Answers
  • 1. 
    Which of the following organizations is not an accrediting body for long-term acute-care hospitals?
    • A. 

      Joint Commission

    • B. 

      American Osteopathic Association

    • C. 

      Commission on Accreditation of Rehabilitation Facilities

    • D. 

      Centers for Medicare and Medicaid

  • 2. 
    The _______________ is a snapshot of a patient’s status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focused on a specific disease process or pathway.
    • A. 

      Face sheet

    • B. 

      Care plan

    • C. 

      Diagnosis plan

    • D. 

      Flow sheet

  • 3. 
    Coordination of care is dependent upon the quality of ________________ provided by each of the healthcare providers involved in the patient’s treatment.
    • A. 

      Treatment

    • B. 

      Documentation

    • C. 

      Communication

    • D. 

      Technology

  • 4. 
    Which of the following is not a component of the Resident Assessment Instrument (RAI)?
    • A. 

      The resident's health record

    • B. 

      A standard Minimum Data Set (MDS)

    • C. 

      Resident Assessment Protocols (RAPs)

    • D. 

      Utilization guidelines

  • 5. 
    What percentage of all healthcare services are performed in an ambulatory-care setting?
    • A. 

      30 percent

    • B. 

      More than 75 percent

    • C. 

      More than 50 percent

    • D. 

      Less than 25 percent

  • 6. 
     ______________ play a major role in referral and tracking of the patient’s use of specialty providers.
    • A. 

      Primary-care physicians

    • B. 

      Insurance companies

    • C. 

      Health information management professionals

    • D. 

      Electronic health records

  • 7. 
    The Joint Commission’s ORYX and Centers for Medicare and Medicaid Services’ OASIS are data sets that function as benchmarks of ___________________within and among organizations.
    • A. 

      Information management

    • B. 

      Quality assurance

    • C. 

      Data quality management

    • D. 

      Performance improvement

  • 8. 
     Determination of __________________________ is considered to be one of the most difficult documentation issues facing the long-term care environment including the LTCH.
    • A. 

      Principal diagnosis or reason for admission

    • B. 

      Secondary diagnosis

    • C. 

      Appropriate reimbursement

    • D. 

      Procedures performed in the LTCH

  • 9. 
    A comprehensive _____________________ is designed to minimize the facility’s potential risks and, when an incident occurs, its losses.
    • A. 

      Liability policy

    • B. 

      Risk management program

    • C. 

      Credentialing and licensure program

    • D. 

      Equipment maintenance policy

  • 10. 
    What organizations offer a wide range of healthcare services and coverage in return for prepayment of a fixed fee, regardless of the services the individual enrollees use?
    • A. 

      Centers for Medicare and Medicaid

    • B. 

      Health maintenance organizations

    • C. 

      Industrial health clinics

    • D. 

      Community health centers

  • 11. 
    Which of the following is not one of the three predefined formats required for meaningful documentation in the ambulatory health record?
    • A. 

      Source-oriented

    • B. 

      Integrated system

    • C. 

      Patient-oriented

    • D. 

      Problem-oriented

  • 12. 
    How are patients using ambulatory surgical centers for elective surgical procedures classified?
    • A. 

      Ambulatory

    • B. 

      Inpatient

    • C. 

      Temporary

    • D. 

      Outpatient

  • 13. 
    Because it was developed to enhance comprehensive patient care, which record system format is especially appropriate for health maintenance organizations (HMOs) and neighborhood health centers, where a team of professionals offers total patient care?
    • A. 

      Problem-oriented record system

    • B. 

      Integrated record system

    • C. 

      Source-oriented record system

    • D. 

      Patient-oriented record system

  • 14. 
    Which of the following is not an element that should be included on a problem or summary list?
    • A. 

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

    • B. 

      Short-term illnesses that were resolved quickly

    • C. 

      The dates of onset and resolution for each problem

    • D. 

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

  • 15. 
    Medicare Conditions of Participation 484.55 requires that each patient receive, and a home health agency provide a patient-specific ______________________________
    • A. 

      OASIS report

    • B. 

      Care plan

    • C. 

      Comprehensive assessment

    • D. 

      Drug regimen

  • 16. 
    Which of the following is not a function of the plan of care documentation?
    • A. 

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

    • B. 

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

    • C. 

      Indicate the frequency and duration expected for each treatment modality

    • D. 

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

  • 17. 
     In data quality management, _________________ is the purpose for which data are collected
    • A. 

      Warehousing

    • B. 

      Collection

    • C. 

      Application

    • D. 

      Analysis

  • 18. 
     In data quality management, _________________ is the processes by which data elements are accumulated.  
    • A. 

      Warehousing

    • B. 

      Collection

    • C. 

      Application

    • D. 

      Analysis

  • 19. 
    Which of the following represents one of the biggest challenges in Electronic Health Record (EHR) development and implementation?
    • A. 

      Images of handwritten and printed documents

    • B. 

      Data exchange standards

    • C. 

      A workable data capture process

    • D. 

      A clinical data repository

  • 20. 
    In data quality management, _________________ is the processes and systems used to archive data and data journals
    • A. 

      Collection

    • B. 

      Warehousing

    • C. 

      Application

    • D. 

      Analysis

  • 21. 
    Medicare has defined four general hospice care levels and has assigned different reimbursement rates to each. Which of the following is not a Medicare-defined hospice care level?
    • A. 

      Inpatient respite care

    • B. 

      Continuous home care

    • C. 

      Continuous inpatient care

    • D. 

      Routine home care

  • 22. 
    In data quality management, _________________ is the process of translating data into information utilized for an application
    • A. 

      Analysis

    • B. 

      Warehousing

    • C. 

      Collection

    • D. 

      Application

  • 23. 
    Which of the following is not among the general categories that govern admission criteria?
    • A. 

      Medical stability (with the exclusion of hospice patients)

    • B. 

      Medical necessity

    • C. 

      Desire for home care (or hospice)

    • D. 

      Financial resources

  • 24. 
    According to Federated Ambulatory Surgery Association, what percentage of all surgeries in America are outpatient?
    • A. 

      50 percent

    • B. 

      30 percent

    • C. 

      70 percent

    • D. 

      90 percent

  • 25. 
    To prevent denials, coding personnel are advised to use the most specific diagnosis codes and to ensure that the ______________________ is always listed as the principal diagnosis.
    • A. 

      Primary disease or condition suffered

    • B. 

      Terminal diagnosis

    • C. 

      Complications of chronic condition

    • D. 

      Life expectancy

  • 26. 
    How often must homecare agencies electronically report all OASIS data collected on all applicable patients in a format that meets Centers for Medicare and Medicaid Services (CMS) electronic data and editing specifications?
    • A. 

      Every day

    • B. 

      Every week

    • C. 

      Every two weeks

    • D. 

      Every month

  • 27. 
    What is the key characteristic of the problem-oriented health record (POMR)?  
    • A. 

      Problem list

    • B. 

      Chief complaint

    • C. 

      Initial care plan

    • D. 

      Physical examination

  • 28. 
    _________ is the process of providing proof of the authorship of health record documentation?
    • A. 

      Identification

    • B. 

      Standardization of data capture

    • C. 

      Standardization of abbreviations

    • D. 

      Authentication

  • 29. 
    What mechanism allows two or more databases to transfer data between them?
    • A. 

      Clinical data repository

    • B. 

      Data exchange standards

    • C. 

      Central processor

    • D. 

      Digital scanner

  • 30. 
    Dr. Smith orders 500 mg of penicillin by mouth tid for Jane Doe in the hospital emergency department. The computer sends an alert to Dr. Smith to tell her that the patient, Jane Doe, is allergic to penicillin. What type of computer system is Dr. Smith using?
    • A. 

      Clinical data repository

    • B. 

      Data exchange standard

    • C. 

      Clinical decision support

    • D. 

      Health informatics standard

  • 31. 
     What is the term used in reference to the systematic review of sample health records to determine whether documentation standards are being met?
    • A. 

      Qualitative analysis

    • B. 

      Legal record review

    • C. 

      Quantitative analysis

    • D. 

      Ongoing record review

  • 32. 
    Health Information Management (HIM) professionals sometimes monitor the records of current inpatients as well as closed records after the patients have been discharged or transferred. What is this process called?
    • A. 

      Qualitative record review

    • B. 

      Legal record review

    • C. 

      Quantitative record review

    • D. 

      Ongoing record review

  • 33. 
    A(n)_________________________ is a unique personal identifier that is entered by the author of Electronic Health Record (EHR) documentation using computer technology.
    • A. 

      Electronic signature

    • B. 

      Digital signature

    • C. 

      Identification number

    • D. 

      Electronic authorization key

  • 34. 
    What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document?  
    • A. 

      Electronic validation

    • B. 

      Digital signature

    • C. 

      Electronic signature

    • D. 

      Electronic authorization key

  • 35. 
    What process helps to ensure the quality and completeness of health record content in both paper-based and computer-based environments?
    • A. 

      Standardization of data-capture tools

    • B. 

      Data exchange standards

    • C. 

      Standardization of abbreviations

    • D. 

      Authentication of health record entries

  • 36. 
    Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of ____________.
    • A. 

      patient identification and demographic accuracy

    • B. 

      Authorship integrity

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity

  • 37. 
    What type of health record analysis assesses the completeness and accuracy of patient health records?
    • A. 

      Qualitative analysis

    • B. 

      Legal record review

    • C. 

      Quantitative analysis

    • D. 

      Ongoing record review

  • 38. 
     ________________ is/are the origin of recorded information that is attributed to a specific individual or entity.
    • A. 

      The health record

    • B. 

      Authorship

    • C. 

      Documentation

    • D. 

      Progress notes

  • 39. 
    Each individual that has been authorized to document in the electronic health record uses a ___________ in the form of a code or password.
    • A. 

      Biometric identifier

    • B. 

      Digital signature

    • C. 

      Unique personal identifier

    • D. 

      Electronic signature

  • 40. 
    Borrowing record entries from another source and representing or displaying past as current documentation and are examples of a potential breach of ____________.  
    • A. 

      Patient identification and demographic accuracy

    • B. 

      Authorship integrity

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity

  • 41. 
    Inadequate functions that make it impossible to detect when an entry was modified or borrowed from another source and misrepresented as an original entry by an authorized user is an example of a potential breach of ____________.
    • A. 

      Authorship integrity

    • B. 

      Documentation integrity

    • C. 

      auditing integrity

    • D. 

      Patient identification and demographic accuracy

  • 42. 
     Automated registration entries that generate erroneous patient identification—possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit—is an example of a potential breach of ____________.
    • A. 

      Authorship integrity

    • B. 

      Patient identification and demographic accuracy

    • C. 

      Documentation integrity

    • D. 

      Auditing integrity