Registered Health Information Technician! Practice Test Trivia Quiz

Documentation of instructions given to the patient at discharge is considered very important in emergency care because it ensures that the patient understands the necessary steps for their recovery and follow-up care. This documentation serves as a reference for both the patient and the healthcare providers, helping to prevent misunderstandings and potential complications. It also provides legal protection for the healthcare facility by demonstrating that proper instructions were given. Overall, accurate and thorough documentation plays a crucial role in ensuring the continuity of care and the well-being of the patient.

Long term care facilities typically have an interdisciplinary care team that develops a care plan for each resident. The care plan format used is the RAI (resident assessment instrument), which 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 there is a significant change in their condition. The MDS is submitted electronically to each state, which then forwards it to CMS (Centers for Medicare and Medicaid Services). Compared to acute care, medical doctor visits to residents in long term care occur much less frequently. Therefore, the statement "Interdisciplinary care team develops a care plan for each resident" is true.

The explanation for the given correct answer is that home health care is regulated by both the federal government (specifically for Medicare patients) and state governments. It is also accredited by the Joint Commission. These regulatory bodies have documentation requirements that include periodic assessments, a home health certification/plan of care, and the physician must review and approve the plan every 60 days. Additionally, the OASIS (Outcome and Assessment Information Set) is a Medicare-mandated standardized patient assessment tool that is completed at the start of care, when a significant change occurs, and upon transfer or discharge. This tool is the basis for reimbursement under Medicare. Lastly, the medical record may be kept in the patient's home during the treatment period.

Psychotherapy notes are indeed a unique type of document in behavioral health that have special handling rules under HIPAA. They are distinct from routine progress notes and are not considered part of the health record. Therefore, the statement "True" is correct.

Rehab Services requires unique record components such as the diagnosis of disability, rehabilitation problems, goals, and prognosis, reports from assessments and referrals, designation of the manager for the patient's program, evidence of patient and family participation in decision making, reports of staff conferences, and the patient's total program plan. Plans from each service involved in care are also included. Therefore, the statement "In Rehab Services, unique record components include" is true.

The given answer is true because it accurately describes the correct procedure for handling errors in paper-based records. When an error is made, a single line should be drawn through the incorrect entry. The word "error" should be printed at the top of the entry along with the signature or initials, date, time, reason for change, and the title and discipline of the person making the correction. The correct entry should then be added to the record, while the original entry remains legible. Corrections should be entered in chronological order, and any late entries should be identified as such.

Accreditation is a voluntary process that healthcare facilities can choose to undergo. It is a way for facilities to demonstrate their commitment to quality and safety standards. Accreditation confers a quality status and public recognition on a facility, indicating that it has met certain criteria and standards set by accrediting organizations. Different types of healthcare facilities, such as hospitals, clinics, and nursing homes, may be accredited by different organizations that specialize in accrediting specific types of facilities. Therefore, the statement that different types of healthcare facilities are accredited by different organizations is true.

The National Committee for Quality Assurance (NCQA) accredits managed care organizations and preferred provider organizations. Their standards reflect common documentation principles, with the most important elements labeled as critical. This suggests that the statement is true.

The given answer is true. The SOAP format is a widely used method in medical documentation. It stands for Subjective, Objective, Assessment, and Plan. The subjective part includes the patient's symptoms and concerns in their own words. The objective part includes factual information such as lab results or observations made by the healthcare provider. The assessment part is the healthcare provider's analysis and interpretation of the subjective and objective information. The plan part outlines the proposed treatment or management plan for the patient. Overall, the SOAP format helps organize and structure medical notes to ensure comprehensive and effective patient care.

Paper records have several issues compared to digital records. One user can view a paper record at a time, making it less accessible than digital records that can be accessed simultaneously by multiple users. Paper records are also difficult to update due to their transient nature, as any changes or updates require physically altering the document. Additionally, paper records are susceptible to damage from fire, water, and wear and tear, which can result in the loss of important information. Lastly, paper records can be easily lost or misplaced, leading to difficulties in retrieving and organizing the information they contain. Therefore, the statement that issues exist with paper records is true.

The Institute of Medicine (IOM) identified 8 core functionalities of the EHR in 2004. These functionalities include health information and data management, results management, order entry and management, decision support, electronic communication and connectivity, patient support, administrative processes, and reporting and population health management. Therefore, the statement "In 2004 The Institute of Medicine (IOM) began a process to identify 8 core functionalities of the EHR" is true.

The statement is true because in 1970, the American Association of Medical Record Librarians (AAMRL) changed its name to the American Medical Record Association (AMRA). This change indicates that the organization decided to drop the term "librarian" from its name, suggesting a shift in focus or a desire to broaden its scope beyond traditional library services.

The given answer is true because the traditional approach to designing forms involves using paper, where the forms are physically printed and filled out by hand. On the other hand, the new model involves designing forms using a user interface, which could be a digital platform or software that allows users to create and fill out forms electronically. This shift from paper forms to a digital user interface offers numerous advantages such as easier editing, faster data entry, and improved data accuracy.

Data refers to raw facts and figures that are collected and analyzed. Once this data is processed and interpreted, it becomes meaningful information that can be used for decision-making and understanding. Therefore, the statement that data is converted into information is true.

The given statement is true. In 2001, the National Committee on Vital and Health Statistics (NCVHS) issued a report and recommendations on building a national health information infrastructure. President George W. Bush also outlined a plan to achieve electronic health records (EHRs) for most Americans by 2014. The Office of the National Coordinator for Health Information Technology (ONC) is leading the efforts to achieve this goal.

The operative report is a document that is required for surgical patients. It is dictated by the surgeon and includes important information such as the preoperative diagnosis, postoperative diagnosis, procedure performed, and any assistants involved. This report is crucial for maintaining accurate and detailed records of the surgical procedure and is used for documentation and communication purposes. Therefore, the statement "The operative report is required for surgical patients" is true.

The given answer is true because the labor and delivery record includes important information such as the delivery details, the condition of the neonate, Apgar scores at 1 and 5 minutes, and the identification of fetal monitoring strips. These components are all crucial for documenting and assessing the mother and baby's health during and after delivery.

The statement is true because in order to participate in the Medicare program, facilities must abide by the Medicare Conditions of Participation or Conditions for Coverage. The Conditions of Participation address documentation requirements as well as other issues, while the Conditions for Coverage are specifically required for suppliers of ESRD (End Stage Renal Disease) services.

The given statement is true. An electronic health record is a digital version of a patient's paper chart. It contains information about the patient's medical history, diagnoses, medications, allergies, and laboratory test results. It is designed to be easily accessible and shareable among different healthcare providers, allowing for more coordinated and efficient care. The statement accurately describes the key features of an electronic health record, including its adherence to interoperability standards and its accessibility to authorized clinicians and staff across multiple health organizations.

The Institute of Medicine (IOM) defines users of records as individuals who perform various tasks related to the record, such as entering, verifying, correcting, analyzing, or obtaining information from it. These users can access the record directly or indirectly through an intermediary. This means that some users, like direct care givers, access individual patient records to perform their job duties, while others may review aggregate data collected from multiple patient records. Therefore, the statement "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" is true.

The statement is true because privacy refers to the right of an individual patient to have control over who can access their personal information. This means that patients have the authority to decide who can view and use their medical records, ensuring that their sensitive information remains confidential and protected. This right is crucial in maintaining patient trust and confidentiality in healthcare settings.

The given statement is true because it states that paper records are stored in a locked area and can only be accessed by authorized personnel. Additionally, the records are tracked to always know their location. This ensures the security and confidentiality of the paper records. Furthermore, the statement mentions that EHR (Electronic Health Records) have built-in controls, which implies that electronic records also have security measures in place. Therefore, the given answer is true.

The statement is true because a problem-oriented approach to healthcare includes four distinct components: a database, a problem list, an initial plan, and progress notes. These components help organize and track the patient's medical information, identify and prioritize their health issues, develop a treatment plan, and document their progress over time. This approach allows healthcare professionals to have a comprehensive view of the patient's health and make informed decisions about their care.

The given answer is true because the basic contents of the acute care health record include registration records, medical history and physical exam, clinical observations (progress notes), physician's orders, reports of diagnostic and therapeutic procedures, consultation reports, discharge summary, patient instructions, and consents, authorizations, and acknowledgements. These components are essential for documenting and managing the patient's care during their stay in the acute care setting.

The given statement is true. Recording in progress notes is typically done by various healthcare professionals such as doctors, nurses, social workers, therapists (PT, OT, Speech), and dieticians. Progress notes are an important part of a patient's medical record and are used to document the patient's condition, treatment, and progress over time. These notes serve as a communication tool among healthcare providers and help ensure continuity of care.

The Joint Commission, a regulatory body, mandates that one postoperative anesthesia note should document the presence or absence of anesthesia complications. This note is typically made after the patient has been discharged from the recovery room. Therefore, the statement is true.

The statement is true because the recovery room record, also known as the PACU or post anesthesia care unit, documents the care provided to a patient from the time they leave the operating room until they return to their assigned hospital bed. This record is important for tracking the patient's progress, monitoring vital signs, documenting any complications or adverse reactions, and ensuring a smooth transition from the operating room to the recovery room.

The given statement is true. After delivery, it is important to assess the mother's condition. This includes checking the condition of her breasts, fundus (the upper part of the uterus), perineum (the area between the vagina and anus), and providing necessary teaching and education. These assessments and actions are typically documented by nurses to ensure proper postpartum care for the mother.

A referral form is necessary when a patient is transferred from an acute care facility to another healthcare organization. This form, also known as a transfer record, provides important information about the patient's condition, medical history, and treatment plan to ensure continuity of care. It allows the receiving healthcare organization to have all the relevant details to provide appropriate and effective care for the patient. Therefore, the statement "Referral form is required when pt. is moved from acute care to another hc organization. Also called a transfer record" is true.

An autopsy report is conducted on deceased patients when there is a question as to the cause of death or in a medico-legal situation. It can be ordered by a medical examiner or coroner in the case of a suspicious death. The report is signed by the pathologist and filed in the medical record. Therefore, the statement "True" is correct.

Consent can be expressed or implied. Expressed consent refers to consent that is given verbally or in writing. Implied consent, on the other hand, is when consent is assumed based on the patient's actions or behavior. In this case, if a patient appears at the hospital seeking treatment, it is implied that they have given consent to be treated. Therefore, the given statement that consent can be expressed or implied is true.

Under HIPAA, healthcare facilities are required to obtain written authorization for the use or disclosure of protected health information if it is not for purposes of treatment, payment, and/or healthcare operations. This means that healthcare facilities need authorization to verbally disclose or send health information to other organizations. Therefore, the statement "Authorization to disclose information allows the healthcare facility to verbally disclose or send health information to other organizations" is true.

In a physician's office, problem lists are used to facilitate ongoing patient care management. These lists include diagnoses, procedures, medications, and allergies, which are crucial for providing appropriate treatment and monitoring the patient's health. Additionally, medication lists, copies of previous hospitalizations, patient history questionnaires, and miscellaneous flow sheets such as growth and immunization charts are also commonly found in a physician's office to support comprehensive patient care. Therefore, the statement is true.

Behavioral health refers to psychiatric care provided in various settings such as hospitals, outpatient clinics, and community programs. The documentation required for behavioral health services depends on the type of facility and the level of care provided. Both the federal government and the Joint Commission establish standards for behavioral health documentation. Unique components of behavioral health records include information about the patient's legal status, multidisciplinary case conferences, correspondence related to the patient, and an individualized aftercare plan. The given answer, "True," is correct because the statement accurately reflects the information provided.

Pediatric care should include items such as birth history, growth and development records, and documentation of well-child visits and immunizations. These items are important for monitoring the health and development of children. By keeping track of a child's birth history, growth and development, and ensuring they receive necessary vaccinations, healthcare providers can ensure that children are growing and developing properly and are protected against preventable diseases. Therefore, the statement is true.

The given statement is true because it provides information about the collection of baseline information on inmates during their initial intake, the addition of additional information when they are treated for various reasons, the dispensing of over the counter drugs to inmates, and the possible accreditation of correctional facilities by various organizations.

The explanation for the correct answer is that Medicare Conditions for Coverage have specific standards for record content and keeping for patients with End-Stage Renal Disease (ESRD). This means that healthcare providers who treat ESRD patients must adhere to these standards in order to meet Medicare's requirements for coverage. Therefore, the statement "Medicare Conditions for Coverage have standards for record content and keeping for ESRD pts" is true.

Personal Health Records (PHRs) are indeed maintained and controlled by individuals. This means that individuals have the authority to decide what health information they want to include in their PHR. As more people start keeping their health information in PHRs, it becomes necessary to establish policies to determine which information should be included in a healthcare facility's record. Therefore, the statement is true.

State regulations are indeed mandated for healthcare organizations in their respective states. These regulations are necessary for facilities to obtain and maintain their licenses. Additionally, many state regulations include specific requirements for documentation that healthcare organizations must comply with. Therefore, the statement "States mandate regulations pertaining to healthcare organizations in their state" is true.

The health care record serves as the main storage for all data and information regarding the healthcare services given to individual patients. It contains a comprehensive record of medical history, diagnoses, treatments, medications, and any other relevant information. This record is crucial for healthcare providers to make informed decisions, provide appropriate care, and ensure continuity of care for patients. Therefore, it is true that the health care record is the principal repository for such data and information.

The explanation for the given correct answer is that deemed status refers to the compliance of a healthcare facility with the Medicare Conditions of Participation. In order to qualify for deemed status, facilities must maintain accreditation by either the Joint Commission or AOA. Therefore, the statement is true.

The given answer is true because integrated records are indeed arranged by episode of care or patient visit. This means that all the information related to a particular episode or visit is grouped together in the record. Additionally, the entire record is typically in reverse chronological order with the most recent information on top. This arrangement is commonly used in physician offices. Within each visit or occasion of service, the arrangement of the record can vary depending on the needs of the user.

EHRs (Electronic Health Records) are digital versions of a patient's paper chart. They collect data at the point of care, allowing healthcare providers to input and access patient information in real-time. EHRs also facilitate the exchange of data between different healthcare providers, ensuring continuity of care. Additionally, EHRs can be used to measure clinical process improvement and outcomes, as well as report health data to public health, regulatory, and accreditation bodies. They also support management reporting by providing data for decision-making and analysis. Therefore, the statement "True" is a correct answer.

The given statement is true. In 2006, the National Alliance for Health Information Technology (NAHIT) indeed published a report that differentiated between electronic medical records (EMR) and electronic health records (EHR). The report provided definitions and distinctions between the two terms, highlighting the varying functionalities and scope of each.

The statement "Hybrid Health Records include both paper and electronic documents" is true. This means that in a hybrid health record system, healthcare organizations use a combination of paper documents and electronic documents to store and manage patient health information. This allows for flexibility and accommodates different formats and processes, as both manual and computer processes must be supported.

If a patient is readmitted to the hospital within 30 days with the same diagnosis, an interval note may be used instead of a full history and physical exam. This means that instead of repeating the entire examination process, a shorter note can be used to document any changes in the patient's condition since their previous hospitalization. This allows for more efficient and streamlined care for the patient. Therefore, the statement is true.

If there is a delay between dictation and transcription, it means that the surgeon's dictated notes are not being transcribed immediately. In such cases, it is important for the surgeon to write a progress note summarizing the surgery to ensure that the details are documented and not lost during the delay. This is necessary to maintain accurate and up-to-date patient records.

The given statement is true because it states that the final autopsy report must be completed within 60 days. This implies that there is a specific time limit within which the report needs to be finished.

A medical record must be completed within a timeframe defined by the medical staff rules and regulations. In no case can this timeframe exceed 30 days. This means that there are specific guidelines and regulations in place that dictate when a medical record must be completed. These rules ensure that medical records are completed in a timely manner, allowing for accurate and up-to-date documentation of a patient's medical history and treatment. Failing to complete a medical record within the specified timeframe can lead to delays in patient care and potential legal and regulatory consequences. Therefore, the statement is true.

In 1991, the American Medical Record Association (AMRA) changed its name to the American Health Information Management Association (AHIMA). This suggests that the statement "in 1991, the American Medical Record Association (AMRA) became the American Health Information Management Association (AHIMA)" is true.

The statement is true. In 1999, AHIMA House of Delegates approved a credential name change. The credential previously known as Registered Record Administrator (RRA) was changed to Registered Health Information Administrator (RHIA), and the credential previously known as Accredited Record Technician (ART) was changed to Registered Health Information Technician (RHIT).

The given answer is true because the traditional approach to confidentiality and release of information has evolved into computer data security programs and privacy programs. This suggests that there has been a shift in how information is protected and shared, with a greater emphasis on safeguarding data in the digital age.

The given statement is true. Vision 2010 defines HIM as the body of knowledge and practice that ensures the availability of health information for real-time healthcare delivery and decision-making across various organizations, settings, and disciplines.

The statement is true because the EHR Best Practices workgroup specifically focuses on providing guidelines for e-HIM (electronic health information management) practice. This implies that the workgroup is dedicated to establishing and promoting best practices in managing electronic health records, which is an essential aspect of e-HIM.

The House of Delegates is the legislative body of AHIMA, the American Health Information Management Association. It meets annually and is composed of representatives elected by each state association. These representatives have the power to approve standards such as coding ethics and the initial certification of HIA and HIT programs. Therefore, the statement "True" is correct.

The explanation for the given correct answer is that the Fellowship Recognition is indeed a lifetime award. However, in order to maintain this award, individuals must continue their AHIMA membership and adhere to the AHIMA code of ethics. This means that recipients of the Fellowship Recognition must remain active members of AHIMA and uphold the professional standards set by the organization.

The given statement is true because a health record is indeed the main storage place for all data and information related to patient care. It contains details about the patient, the services provided, the timing of the care, the location, the reasons behind the care, and the methods used. This comprehensive documentation helps in maintaining a complete and accurate record of the patient's medical history and aids in providing quality healthcare.

Patient care management refers to activities related to managing services provided to patients. This includes developing practice guidelines and evaluating the quality of care. Therefore, the statement is true.

The statement is true because patient care support processes involve various activities such as handling resources, analyzing trends, and facilitating communication among different departments. These processes are crucial for ensuring efficient and effective patient care.

The statement is true because computerized provider order entry (CPOE) with EHR decision support can help eliminate issues such as lost orders, illegible handwriting, and duplicate orders. With CPOE, healthcare providers can enter orders electronically, reducing the risk of orders getting lost or misinterpreted due to illegible handwriting. Additionally, the system can provide decision support, alerting providers to potential errors or conflicts in the orders, further reducing the likelihood of mistakes. Therefore, the use of CPOE with EHR decision support can improve order entry and management processes.

The explanation for the given correct answer is that the medical history provides important information about the patient's past illnesses, surgeries, allergies, medications, social history, family history, and review of systems. It also includes the chief complaint and present illness, which describe the patient's current problem and symptoms. This information is typically provided by the patient, although a relative may do so in some cases. Therefore, the statement is true.

The given answer is true because the passage mentions two types of administrative information: property lists/valuables and birth/death certificates. This implies that there is indeed other administrative information besides these two mentioned in the passage.

The given answer is true because the items mentioned in the options (time and means of arrival, emergency care given prior to arrival, documentation when the patient leaves against medical advice) are specific to the emergency department and may not be included in the records of acute care.

Long-term care includes various types of facilities such as skilled nursing facilities (SNF), nursing homes (NF), intermediate care facilities (ICF), assisted living facilities, and transitional care units (TCU). These facilities are highly regulated by both state and federal governments to ensure the safety and well-being of the residents. While some long-term care facilities may voluntarily seek accreditation from organizations like the Joint Commission, it is not a requirement for most facilities. Therefore, the statement "Most of these facilities do not obtain voluntary accreditation status with the Joint Commission, etc." is true.

Medical record documentation is used for a variety of purposes. It serves as the primary communication between caregivers, ensuring that important information about a patient's condition and treatment is shared accurately. It is also used for continuing patient care, as it provides a comprehensive history of the patient's medical issues and treatment plans. Additionally, medical record documentation is used as evidence that treatment took place, which can be important for legal and insurance purposes. It is also used for performance improvement and risk management, as well as reviewed by external agencies to measure the quality of services provided. Finally, medical record documentation is used by third party payers to verify that services were provided and by the legal system as evidence.

The statement "Confidentiality - expectation that the information shared with one's provider will only be used for its intended purpose" is true. Confidentiality refers to the assurance that any information shared with a provider will be kept private and used only for the purpose for which it was disclosed. This is an important aspect of trust and privacy in professional relationships, particularly in fields such as healthcare or legal services. It ensures that sensitive information remains secure and is not misused or disclosed without consent.

The statement is true because security is indeed about protecting health information from unauthorized access and also from physical damage like fire or flood. It involves implementing measures such as access controls, encryption, firewalls, and disaster recovery plans to ensure the confidentiality, integrity, and availability of the information. By having strong security measures in place, organizations can safeguard sensitive health information and prevent unauthorized individuals from gaining access to it.

The anesthesia report is required if more than local anesthesia is given. The report includes important information such as preop meds, anesthetic agents used, their amount, route, effect, and duration. It also notes the patient's condition including vital signs, blood loss, transfusions, and IVs. Finally, the report must be signed by the person administering the anesthesia, either a nurse anesthetist or an anesthesiologist. Therefore, the statement "True" is correct as all the mentioned requirements are necessary for an anesthesia report.

The specialized health record content varies due to multiple factors such as 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), and the complexity of the patient's condition. These factors influence the specific information that needs to be documented in a health record for each patient.

The statement is true because records maintained by free standing ambulatory surgical centers are indeed very similar to those kept by hospital centers. This includes the inclusion of any follow-up calls made to the patient.

Student members of AHIMA can serve on committees with voice but no vote because they have reduced membership dues while they are enrolled in a CAHIIM accredited program. This allows students to gain valuable experience and contribute to the organization while still in school. Although they do not have voting rights, their input and perspective are still valued and considered in committee discussions and decisions.

The AHIMA Fellowship Program is indeed a program that recognizes members who have made significant and sustained contributions to the HIM (Health Information Management) profession. This program serves as a way to acknowledge and honor individuals who have demonstrated exceptional dedication and expertise in their field. It is a prestigious recognition that highlights the achievements and contributions of these professionals within the HIM community.

The statement is true because financial and administrative processes play a crucial role in determining which payment provider will receive the payment. These processes involve various tasks such as invoicing, budgeting, tracking expenses, and ensuring compliance with financial regulations. By managing these processes effectively, organizations can choose the most suitable payment provider based on factors like cost, reliability, and security. Therefore, financial and administrative processes do have an impact on the selection of a payment provider.

The explanation for the given correct answer is that progress notes are commonly kept in an integrated format where all providers write in chronological order. This allows for a comprehensive view of the patient's progress and ensures that each provider can identify their specific area of expertise within the notes.

In 2003, the IOM (Institute of Medicine) added results management, order entry, and order management to the functional mode of Electronic Health Records (EHR). This means that these features were incorporated into the EHR system to enhance its capabilities. Therefore, the given statement is true.

The given statement is true. With the Electronic Health Record (EHR), healthcare providers can access and review patients' results over a period of time. This allows them to track changes, monitor progress, and make informed decisions about treatment. By having access to historical data, providers can improve the efficiency and effectiveness of treatment by identifying patterns, trends, and potential areas for improvement. This also helps in reducing errors and ensuring continuity of care.

The explanation for the given correct answer is that recording information at the time and place it occurs ensures that it is accurate and reflects the current situation. Up-to-date information is crucial in providing quality care as it allows healthcare professionals to make informed decisions and provide appropriate treatment based on the most recent data available.

The given answer is true because it states that the expected data values for marital status have been delineated and all appropriate values, including single, married, divorced, separated, widowed, and unknown, have been included. This indicates that the data precision has been taken into consideration and the necessary values have been accounted for.

The explanation for the given correct answer is that it is important to collect information only if it is needed. Collecting unnecessary data can lead to increased storage and processing costs, as well as potential privacy and security risks. Therefore, it is crucial to evaluate the relevance of each data element before collecting it.

The statement is true because the progress notes are an important part of a patient's medical record, and it is crucial to accurately document the patient's progress and any treatments or interventions provided. Therefore, only authorized practitioners who are familiar with the medical staff rules and regulations should be allowed to record in the progress notes to ensure the accuracy and integrity of the information.

The given statement is true. The antepartum record is a prenatal record that is typically done in a medical doctor's office. It includes a comprehensive history and physical examination of the pregnant individual. It also includes important information such as menstrual history, reproductive history, routine laboratory tests, rubella screening, and syphilis screening. Additionally, it is common practice to send a copy of the prenatal record to the birthing site at around 36 weeks of pregnancy. ACOG (American College of Obstetricians and Gynecologists) and Hollister forms are popular formats for documenting the antepartum record.

The statement is true because it is the responsibility of the physician to obtain the patient's consent before performing a surgical procedure. This is an important ethical and legal requirement to ensure that the patient is fully informed about the risks, benefits, and alternatives of the procedure, and that they have given their voluntary and informed consent to undergo the surgery. Without obtaining the patient's consent, the physician would be violating the patient's rights and potentially facing legal consequences.

The final privacy rule effective October 2002 allows covered entities to use and disclose patients' protected health information for their own treatment, payment, or healthcare operations. This means that healthcare providers can access and share patient information for the purpose of providing treatment, receiving payment, or conducting necessary healthcare operations.

In the context of a hospital's emergency department, it is crucial for the treating physician to authenticate the records. This means that the physician needs to verify and confirm the accuracy and validity of the information in the records. Authentication is important for legal and medical purposes, ensuring that the records are reliable and can be trusted by other healthcare professionals involved in the patient's care. Therefore, the statement "The Emergency Department record must be authenticated by the treating physician" is true.

Hospice is a type of care that provides palliative care to terminally ill patients. It focuses on symptom and pain relief rather than cure. The care is provided in the patient's home. Hospice is regulated by the federal government as well as accreditation agencies. The plan of care is established by an interdisciplinary team, and it is required to be reviewed and documented every 30 days. Therefore, the statement "Hospice provides palliative care to patients in their homes" is true.

The statement is true because in Rehab Services, a prospective payment system is currently being implemented. This means that the payment for an inpatient rehab stay will be determined based on the patient assessment instrument (PAI). The PAI will be used to assess the patient and assign a payment level for their stay.

The American Osteopathic Association (AOA) started with the goal of ensuring the quality of its osteopathic residency programs. It has since expanded its role to accredit a wide range of healthcare organizations and facilities. This means that the statement is true, as the AOA does indeed accredit a variety of healthcare organizations and facilities in addition to its original purpose of overseeing residency programs.

CARF is an organization that accredits various types of healthcare and community services, including medical rehabilitation, assisted living, behavioral health, adult day care, employment, and community services. This means that these services have met the standards set by CARF for quality and effectiveness. Therefore, the statement that CARF accredits these services is true.

Research organizations are known for their role in developing and testing new experimental patient care protocols. They conduct studies and trials to evaluate the effectiveness and safety of these protocols before implementing them in clinical practice. This process helps in improving patient care by identifying innovative approaches and treatments. Therefore, the statement "Research organizations develop and test experimental patient care protocols" is true.

The given statement is true. An electronic medical record is indeed 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. This digital system allows for easy access, storage, and sharing of patient information, leading to improved efficiency and coordination of care within the healthcare organization.

The statement is true because the common data elements of a personal health record (PHR) typically include personal demographic information, general medical information, allergies and drug sensitivities, conditions, hospitalizations, surgeries, medications, immunizations, clinical tests, and pregnancy history. These elements are important for maintaining a comprehensive and accurate record of an individual's health information.

The Personal Health Record (PHR) is a lifelong record that includes various types of information. It can include information from healthcare 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, and provider directory. Therefore, the statement "As a lifelong record, the PHR could also include" is true.

The Joint Commission is an independent organization that sets standards for healthcare organizations in the United States. One of their requirements is that a pre-operative anesthesia assessment must be conducted before a surgery. This assessment helps ensure that the patient is in good health and able to tolerate anesthesia. It also allows the anesthesiologist to gather important information about the patient's medical history, medications, and allergies, which can help in determining the appropriate anesthesia plan for the surgery. Therefore, the statement "The Joint Commission requires a pre-op anesthesia assessment" is true.

The given statement suggests that records in the early 20th century did not include graphic records or labs. It also states that incomplete records were filed as received at the time of discharge. Based on this information, it can be inferred that the statement is true.

The statement is true because it states that the Organization of Record Librarians was formed after a meeting in Boston in 1928 and the ARLNA was formed. This indicates that the Organization of Record Librarians existed before AHIMA, making the statement true.

The explanation for the given correct answer is that the Traditional Model indeed relies on the creation, tracking, and storage of physical records. In this model, information is typically recorded on physical documents, such as paper files or printed forms, and these records are manually organized, tracked, and stored in physical filing systems. This approach has been widely used in various industries for many years before the advent of digital technologies.

The given statement is true because the New Model is replacing the physical health record with an electronic health record. This means that instead of using paper-based records, all health information will be stored digitally. This transition allows for easier access to patient information, more efficient record-keeping, and the ability to easily share information between healthcare providers.

The explanation for the correct answer "True" is that active members of AHIMA are individuals who are interested in the purpose of AHIMA and are willing to abide by the Code of Ethics. These active members are in good standing and are entitled to all membership privileges, including the right to vote. Therefore, the statement is true.

State and Local Chapters, also known as component state associations (CSA), provide AHIMA members with education, networking, and representation. Some CSA's are further divided into regional and/or local associations. When you become a member of AHIMA, you have the option to choose one CSA that you want to belong to. Therefore, the statement "State and Local Chapters provide membership with education, networking, and representation" is true.

The statement is true because the American Recovery and Reinvestment Act of 2009 did indeed include reimbursement incentives for providers and hospitals that use certified Electronic Health Record (EHR) technology. These incentives were designed to encourage the adoption of EHRs and promote their meaningful use in healthcare settings.

The explanation for the given correct answer is that data granularity refers to the level of detail at which data is collected and recorded. In this case, the question is asking if the data is at the correct level of detail, specifically mentioning that patient temperature must be taken to one decimal level. Therefore, the answer "True" indicates that the data is indeed at the correct level of detail, meeting the requirement of recording patient temperature to one decimal level.

In 2010, health information management professionals were indeed working in 40 different settings under 125 different job titles. This implies that there was a wide range of roles and responsibilities within the field, indicating the diverse nature of the profession at that time.

The primary function of a health record is to store patient care documentation. This is because health records serve as a comprehensive and centralized repository of all relevant information related to a patient's medical history, including their diagnoses, treatments, medications, and test results. These records are essential for healthcare providers to track and monitor a patient's progress, make informed decisions about their care, and ensure continuity of care across different healthcare settings. Additionally, health records also play a crucial role in legal and financial matters, as they provide evidence of the care provided and serve as a reference for billing and reimbursement purposes.

The statement is true because both paper records and electronic records have measures in place to ensure authorized access. Paper records are protected by only allowing authorized staff access to them, while electronic records are controlled through computer access techniques such as passwords, biometric devices, and workstation restrictions. This ensures that only authorized users can access the information and supports accessibility 24 hours a day, 7 days a week.

A physician should write an admission note, follow-up notes, and a discharge note because these notes are essential for effective communication and continuity of care between healthcare providers. The admission note provides important information about the patient's initial condition and treatment plan. Follow-up notes document the patient's progress, any changes in treatment, and any new concerns or findings. The discharge note summarizes the patient's overall condition, treatment received, and any post-discharge instructions. These notes help ensure that all healthcare providers involved in the patient's care have access to relevant information and can make informed decisions about the patient's treatment.

According to the Joint Commission, it is required to complete the discharge summary within 30 days of discharge, unless there are specific rules and regulations set by the medical staff that specify an earlier timeframe. Therefore, the statement is true.

If a patient does not give their consent before a surgical procedure, it can be considered as unlawful touching or battery. This means that the patient has the right to sue the medical professional or institution for performing the procedure without their permission. Consent is a crucial aspect of medical ethics and is necessary to ensure that patients have autonomy over their own bodies and decisions regarding their healthcare. Therefore, the statement is true.

The statement is true. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal legislation that aims to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information. HIPAA sets standards for the electronic exchange, privacy, and security of health information. It also gives individuals certain rights regarding their health information, such as the right to access and amend their records. Overall, HIPAA plays a crucial role in protecting the privacy and security of individuals' health information.

When an emergency room patient is admitted to the hospital, their original emergency report is placed in the inpatient record. This is done to ensure that all relevant information from the emergency visit is included in the patient's overall medical record. By placing the report in the inpatient record, it can be easily accessed by healthcare providers who may be involved in the patient's care during their hospital stay. This helps to provide continuity of care and ensure that all necessary information is available to guide treatment decisions.

The given answer is true because implementing an electronic health record (EHR) system can have several drawbacks. One of the cons is that it brings about changes in the workflow of health information. This means that healthcare providers may need to adapt to new processes and systems, which can be challenging and time-consuming. Additionally, sharing patient records electronically may require coordination between different healthcare organizations, which can be complex and may lead to delays or errors. Another disadvantage is the high costs associated with the development and implementation of an EHR system. Lastly, there can be resistance from both the organization and individuals towards adopting and using the new system, which can hinder its successful implementation.

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. This means that if a patient has recently had a history and physical exam done in a physician's office, the hospital can use that information as long as any changes that may have occurred are documented at the time of admission. This allows for continuity of care and ensures that the hospital has the most up-to-date information about the patient's health status.

The statement suggests that patients are taking a more active role in managing their own healthcare and are becoming the primary users. This implies that individuals are becoming more responsible for their own health and are actively participating in making decisions about their care. This shift towards patient self-management can lead to better health outcomes and increased patient satisfaction.

The explanation for the given correct answer is that data comprehensiveness refers to the inclusion of all the required elements in a record. In this case, the required elements include the patient ID, consents for treatment, problem list, diagnoses, clinical history, diagnostic text results, treatments and outcomes, and conclusions and follow-up plans at discharge. Therefore, if all these elements are included in the record, it can be considered comprehensive.

The given statement is true because it states that orders must be written by the physician before any services or medications are given to the patient. This is a standard practice in healthcare to ensure that the physician has provided clear instructions and authorization for the care being provided.

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. This means that it is true that operative reports must be dictated immediately after surgery. If there is any delay in transcription, the surgeon should provide a brief operative note in the progress notes to ensure that the necessary information is documented.

In certain cases, a final discharge note can be used instead of a discharge summary. These cases include normal spontaneous delivery, normal newborns, and stays of minor nature that are less than 48 hours. In such situations, a final discharge note can provide sufficient information about the patient's condition and treatment, eliminating the need for a detailed discharge summary. Therefore, the statement "True" is correct.

Long-term care facilities are required to provide residents with a patient's bill of rights as part of the Medicare Conditions of Participation. This bill of rights ensures that patients are aware of their rights while under care. Therefore, the statement that acknowledgment of patient rights is required is true.

The correct answer is true because in emergency care, the main focus is on quickly diagnosing the patient's condition and stabilizing them. This is done in order to prevent further harm or deterioration of their health. Emergency care providers prioritize immediate interventions and treatments to address life-threatening conditions or injuries. Once the patient is stabilized, they may be transferred to a different department or facility for further treatment or care.

Medicaid is indeed a joint funded program between the federal and state governments. However, it is administered by the states, which means that the requirements and regulations for eligibility and benefits can vary from state to state. Therefore, the statement that "requirements vary by state" is accurate.

The statement is true because the Joint Commission requires healthcare facilities to document any complications related to post-operative anesthesia within 48 hours of surgery for inpatients. This requirement ensures that any issues or adverse events are promptly addressed and appropriate measures are taken to ensure patient safety and quality of care.

The statement suggests that the traditional HIM (Health Information Management) was organized based on departments, while Vision 2006 is organized based on information. This implies that the traditional HIM system focused on managing health information within specific departments, whereas Vision 2006 focuses on managing health information across departments and integrating it into a centralized information system. Therefore, the statement is true.

The president of AHIMA is responsible for appointing the members of the association's national committees, practice councils, and workgroups. This means that the president has the authority to select individuals who will serve in these important roles within the organization.

Medical staff rules and regulations or a medical staff policy typically outline the specific procedures or surgeries that require patient consent, specify the timeframes within which consent must be obtained, and identify the individuals who are authorized to obtain consent. These policies are put in place to ensure that patients are fully informed about their medical treatment and have the opportunity to make informed decisions about their healthcare. Therefore, the given answer "True" is correct.

The statement is true because in 1918, the American College of Surgeons (ACS) initiated a movement to standardize hospitals and establish minimum quality standards. As part of this movement, hospitals recognized the need for complete and orderly medical records, which led to the establishment of the medical record clerk job. These clerks were responsible for ensuring that records were filed properly and included a cross-index of operations, diseases, and doctors.

The statement is explaining the concept of connectivity in health systems, particularly the ability of electronic health records (EHR) to exchange information with other information systems. This implies that health systems should have the capability to share data and communicate effectively between different systems. Therefore, the correct answer is true.

The statement is true because consent refers to the permission given by an individual for their treatment, payment, or healthcare operations. It implies that a person has willingly agreed to undergo medical procedures, pay for healthcare services, or allow their health information to be used for administrative purposes. Consent is an essential ethical and legal principle in healthcare that ensures respect for patient autonomy and privacy.

The statement is true because it aligns with the basic principles of documentation mentioned in the given list. These principles include having policies for the content and format of the record, systematic organization for easy retrieval, identification of authors, use of approved abbreviations, permanent entries, making corrections according to policy, adding patient corrections as an addendum, and the development of policies and procedures for analysis by the HIM department.

The Accreditation Association for Ambulatory Healthcare (AAAHC) has established standards for ambulatory documentation. These standards emphasize the importance of summaries in enhancing the continuity of care. Therefore, the statement is true.

The correct answer is "Newborn." In the context of the question, the mentioned records such as sleeping patterns, measurements, feeding and elimination status, weight, and Apgar scores are typically recorded for newborn babies. These records are important for monitoring the health and development of newborns and providing necessary care and interventions.

The explanation for the given answer is that a provisional autopsy report must be completed within 72 hours or 3 days. This means that the initial report summarizing the findings and observations from the autopsy should be finished within this timeframe. It is important to complete the report promptly to ensure timely communication of the autopsy results and to facilitate any necessary further investigations or legal proceedings.

New graduates who are student members of AHIMA are entitled to 1 year of reduced membership dues. This means that they can continue their membership with AHIMA at a lower cost for the first year after graduating. Therefore, the statement "New Graduate - for student AHIMA members who graduate. Entitled to 1 year of reduced membership dues" is true.

The explanation for the given answer is that Communities of Practice (CoP) is a network of AHIMA members who communicate through a web-based program. In order to access the CoP, one must be an AHIMA member. Therefore, the statement "You must be an AHIMA member to access the CoP" is true.

The given statement is true because in a chronological or integrated record, the information is organized in a strict chronological order. This means that events or data are arranged according to their time of occurrence. This type of organization allows for easy tracking and retrieval of information based on timelines.