RHIT - Health Data Content And Standards (Part 1)

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In preparation for EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document managment system. THe unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you most likely to give to this form is
A. recovery room record
B. pathology report
C. operative report
D. discharge summary

B. pathology report

(C and D) although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be

A. personal identification
B. cognitive patterns
C. procedures and dates
D. principal diagnosis

B. cognitive patterns

Answers A, C, And D represent items collected on Medicare inpatients according to UHDDS requirements. Only B represents a data item collected more typically in long-term care settings and required in the MDS.

In the past, Joint Commission standards have focused on promoting the use of facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the

A. prohibited use of any abbreviations
B. flagrant use of specialty-specific abbreviations
C. use of prohibited or "dangerous" abbreviations
D. use of abbreviations in the final diagnosis

C. use of prohibited or "dangerous" abbreviations
The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4". Spelling out the unit is preferred.

In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent?

A. the number of primary cancers reported for the patient
B. the year the case was entered into the database of the registry
C. the sequence number of the case
D. the stage of the tumor based upon the TNM system of staging

B. the year the case was entered into the database of the registry

Every case entered into the registry is assigned a unique accession number preceeded by the accession year, or the year the case is entered into the database.

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the

A. doctor's progress notes
B. integrated progress notes
C. incident reports
D. nurses' notes

C. incident reports

Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record.

For continuity of care, abulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

A. interdisciplinary patient care plan
B. dishcarge summary
C. transfer record
D. problem list

D. problem list

(A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients.

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

A. it is too easy to delegate use of computer passwords
B. evidence cannot be provided that the physician acutally reviewed and approved each report
C. electronic signatures are not acceptable in every state
D. tampering too often occures with this method of authentication

B. evidence cannot be provided that the physician actually reviewed and approved each report

Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.

As part of a quality improvement study, you have been asked to provide information on the menstral history, number of pregnancies, and number of living children on each OB patient from a stack of old obstectrical records. The best place in the record to locate this information is the

A. prenatal record
B. labor and delivery record
C. postpartum record
D. discharge summary

A. prenatal record

The antepartum record should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history.

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical (H&P) for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman

A. a new H&P is required for every inpatient admission
B. that you apologize for not noticing the H&P provided
C. the H&P copy is acceptable as long as she documents any interval changes
D. Joint Commission standards do not allow copies of any kind in the original record

C. the H&P copy is acceptable as long as she documents any interval changes

Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the orginial H&P is readily available.

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's

A. disease index
B. number control index
C. physician's index
D. patient index

A. disease index

The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. B. The number index identifies new health record numbers and the patients to whom they were assigned. C. The physician's index identifies all patients treated by each doctor. D. The patient index links each patient treated in a facility with the health number under which the clinical information can be located.

Joint Commission requires the attending physician to countersign health record documentation that is entered by

A. interns or medical students
B. business associates
C. consulting physicians
D. physician partners

A. interns and medical students

Those who make entries in the medical record are given that privilege by the medical staff. Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.

The minimum length of time for retaining original medical records is primarily governed by

A, Joint Commission
B. medical staff
C. state law
D. readmission rates

C. state law

The statute of limitations for each state is information that is crucial in determining record retention schedules.

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of

A. fingerprint signatures
B. voice recognition systems
C. expert systems
D. electronic signatures

D. electronic signatures

Authentication by signature stamps requires a written agreement with the facility not to delegate the use of the stamps. Similarly, in a computer-based system, it is important to ensure that personal identification codes used to authenticate entries are used only by the persons to whom they are assigned. A. Fingerprint signatures are individualized automatically.
Discharge summary documentation must include
A. a detailed history of the patientB. a note from social services or discharge planningC. significant findings during hospitalizationD. correct codes for significant procedures
C. significant findings during hospitalization
Some reference to the patient's history may be found in the discharge summary but not a detailed history. B. The attending physician records the discharge summary. D. Codes are usually recorded on a different form in the record.
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
A. quality of care through the use of pre-established criteriaB. adverse effects and contraindications of drugs utilized during hospitalizationC. potentially compensable eventsD. the overall quality of documentation
D. the overall quality of documentation
Ultimate responsibility for the quality and completion of entries in patient health records belongs
A. chief of staffB. attending physicianC. HIM directorD. risk manager
B. attending physician
The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new case area assessment, utilization guidelines, and the
The foundation for communicating all patient goals in long-term care settings is the
A. legal assessmentB. medical historyC. interdisciplinar plan of careD. Uniform Hospital Discharge Data Set
C. interdisciplinary plan of care
As the Directory of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in the program, you will need to regularly access the Web site of this governmental agency
As part of Joint Commission's National Patient Safety Goal Initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for
A. including the primary caregiver in surgery consultsB including the surgeon in the preanestthesia assessmentC. marking the surgical siteD. apprising the patient of all complications that might occur
C. marking the surgical site
In preparing your facility for initial accreditation by the Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended changes is to
A. have more frequent committee meetingsB. have the committee report to the Executive Committee C. have a physician perform all the reviewsD. provide for record reviews to be performed by a interdisciplinary team of care providers
D. provide for record reviews to be performed by an interdisciplinary team of care providers.

According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations wold most likely be prohibited
A. 0.4 mg LasixB. 4 mg LasixC. 40 mg LasixD. .4 mg Lasix
D. .4 MG Lasix
Among those abbreviations considered confusing or likely to be misinterpreted are those containing a leading decimal point.
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates
A. noncompliance with Joint Commission standardsB. compliance with Joint Commission standardsC. compliance with Medicare regulationsD. compliance with Joint Commission standards for nonsurgical patients
A. noncompliance with Joint Commission standards
Joint Commission specifies that H&Ps must be completed within 24 hours.
Using the SOAP method of recording progress notes, which entry would most would most likely include a differential diagnosis?
A. assessmentB. planC. subjectiveD. objective
A. assessment
The assessment statement combines the objective and subjective into a diagnostic conclusion, sometimes in the form of a differential diagnosis
You have been asked by peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?
A. disease indexB. physician indexC. master patient indexD. operation index
D. operation index

The best example of point-of-care service and documentation is
A. using an automated tracking system to locate a recordB. using occurrence screens to identify adverse eventsC. doctors using voice recognition systems to dictate radiology reportsD. nurses using bedside terminals to record vital signs
D. nurses using bedside terminals to record vital signs
Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to
A. placement of hospital logoB. signature line for authenticationC. use of box designD. bar code placement
D. bar code placement

Which of the following is a form or view that is typically seen in the health record of long-term care patient but is rarely seen in records of acute care patients?
A. pharmacy consultationB. medical consultationC. physical examD. emergency record

A. pharmacy consultation

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?
A. data comprehensivenessB. data granularityC. data precisionD. data accuracy
D. data accuracy

The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is
A. 12-0000/00B. 12-0000/01C. 12-0001/00D. 12-0001/01
C. 12-0001/00
Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data
A. reliability B. timelinessC. precisionD. validity
C. Precision
In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the
A. CARF manualB. hospital bylawsC. Joint Commission accreditation manualD. Federal Register
D. Federal Register