Registered Health Information Technician! Practice Test Trivia Quiz

A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records is is called                           .

An individual's right to control access to his or her personal information is called                                .

A characteristic of data that includes every required data element is called                            .

When a discharge summary is not required, a final progress note must be documented.  

• True

• False

Up until 1918, attending doctors were solely responsible for creation and management of medical records.

• True

• False

Today, the role of the Board of Registration is played by AHIMA's Commission on Certification for Health Informatics and Information Management (CCHIIM).

• True

• False

Traditional Model: Department based, HIM activities performed in department. New Model: Tasks are information based. HIM's activities are performed outside Dept. (QI, decision support, Data Security, etc.)

• True

• False

• Vision 2016 – Blueprint for HIM Education – “The transition of the healthcare industry to become more patient-centric and evidence-based has given rapid momentum to improvements in adoption of electronic health records (EHR) and health information exchanges (HIE).

• True

• False

Volunteer

• BOD (Board of Directors)  – manages the property, affairs and operations of AHIMA
• CCHIIM – oversees certification process and sets policies and procedures
• CAHIIM – oversees AHIMA’s accreditation of college programs in HIT and HIA   

• True

• False

Practice Councils such as those in Clinical Classification and Terminology, Health Information Exchange, and Privacy and Security Practice advise AHIMA and provide expertise related to best practices in specific areas.

• True

• False

USERS OF RECORDS: Includes care givers; however, others use records including managed care organizations, integrated delivery systems, regulatory and accreditation organizations, licensing bodies, educational organizations, 3^rd party payers, and research facilities all use info originally collected to document care.

• True

• False

Quality: All individuals in an organization depend on quality information, which depends on the design of the organization’s systems and processes for collecting the information. There are 10 characteristics of data quality.

• True

• False

Efficiency: storage efficiency of paper records is limited due to their size and need to be physically transported from place to place. In a computerized system, the structure of the data must be considered. If data has been scanned into the EHR, it cannot be analyzed efficiently because of its structure. If data is entered using vocabularies and code sets, it can be manipulated, utilized, and analyzed to a much greater level.

• True

• False

Registration Record

• Also called a face sheet or admission record
• Often the first page of each encounter
• Contains demographic and financial data about the patient as well as clinical such as admitting diagnosis (dx) and discharge diagnoses/processes added at the time of discharge

• True

• False

Physical Exam

• Physician examines the patient and documents his findings
• Includes all major body systems as well as patient’s vital signs at the time of the exam
• Generally concludes with the physician’s provisional diagnosis, also referred to as impression
• Medical history and physical exam are often combined into one document called the History & Physical exam
• The Joint Commission requires the H&P to be completed within 24 hrs of admission and prior to surgery

• True

• False

Progress note can be integrated (meaning that all professions write in one set of progress notes) or are sometimes separated by profession/department (for example, PT would have their own progress notes, dietary would have their own and so on.

• True

• False

Pre-anesthesia and post-anesthesia assessment included in Anesthesia Report:

• pre- located on back of form or in progress notes; includes procedure, choice of anesthesia, explanation of same, past anesthesia history and ASA Class (I - IV)
• post - completed within 24 hrs of surgery; can be found in progress notes, anesthesia form, recovery room form; states if any post anesthesia complications  

• True

• False

The body of the Operative Report contains:

• findings
• technical description of procedure
• organs explored
• numbers of packs, drains, sponges, sutures
• condition of pt at conclusion
• signed by dictating surgeon

• True

• False

Pathology Report

• gross and microscopic examination of tissue
• report written and signed by pathologist
• original included in medical record

• True

• False

Neonatal (newborn) data

• A copy of the Mom’s labor and delivery record is generally included in the newborn’s record
• Identification: banded while in delivery room; Mom and babe both have bands with mom’s number and babe’s sex and time of birth
• Physical Exam: done generally by pediatrician; full physical exam usually done at the time of birth and the time of discharge
• Progress Notes: notes by docs and nurses; may also contain note if circumcision was done; the Joint Commission requires if oxygen given, must be noted concentration of oxygen as per policies/procedures

• True

• False

Discharge summary is used for the following purposes:

• Continuity of care – used by other providers
• Review of care provided to the patient
• Concise summary of patient’s stay that can be used to answer information requests

• True

• False

Discharge summary also includes instructions to the patient at the time of discharge. These instructions should include information on diet, medications, activity level and follow-up care.

• True

• False

The Joint Commission requires the Provisional autopsy report to be completed within 72 hours of the autopsy and the final report to be filed in the medical record within 60 days of the autopsy.

• True

• False

The face sheet is filled with demographic & financial information including:

• Patient’s name
• Patient ID # or M.R.#
• Address
• DOB
• Place of birth
• Gender
• Race
• Marital status
• S.S. number
• Name and address of next of kin
• Date and time of admission
• Type of admission (inpt/opd)
• Name, address, tel. # of hospital

• True

• False

The only financial information maintained in the record is that which is collected at the time of admission such as:

• Payer
• Policy holder
• Patient’s relationship to policy holder
• Employer of policy holder
• Insurance numbers

• True

• False

The original copy of the consent is filed in the medical record.

• True

• False

OASIS – outcome and assessment information set

• Medicare mandated standardized patient assessment tool
• Completed at start of care, when significant change occurs and upon transfer or discharge
• It is the basis for reimbursement under Medicare

• True

• False

Rehab Services

• Range of facilities varies widely from comprehensive inpt to outpt
• Documentation reflects the level of care/services provided
• CARF (Commission on Accreditation of Rehabilitation Facilities) accredits rehab facilities and maintains documentation standards

• True

• False

The Joint Commission- sometimes called the JC (formerly: The Joint Commission on Accreditation of Healthcare Organizations - JCAHO)

• Accredits a wide variety of healthcare facilities
• Applies a core set of documentation standards consistently across the health care continuum and then adds supplemental standards for specific types of care
• Focuses on continuous improvement and continuous standards, monitoring sentinel events, and tracer methodology

• True

• False

Source oriented records (i.e. by department) are the most common form of records in hospitals today.  

• • • End users may find this format difficult to use because they must look through various sections to get an overview of the patient’s condition at any point in time

• True

• False

Problem oriented records:

• Problem list – each problem has a unique number, date of onset, date of resolution
• Database – very similar to the history & physical exam
• Initial care plan – lays out initial plans for treatment of patient
• Progress notes - written in what is called the SOAP format

• True

• False

While a totally problem oriented record format is not frequently used due to the time it takes to document in this fashion, progress notes are often recorded in the SOAP format.

• True

• False

Electronic Health Records

• Addresses many of the deficiencies of a paper record
  • Can be easily updated
  • Multiple users can view simultaneously
  • Back up copies are readily made thus preventing against loss or destruction

• True

• False

Enabling technologies that support a CPR

• Database systems
• Data Input – many alternatives such as transcription, optical character readers (ocr), voice recognition, automated templates, bar code readers, etc.
• Image processing and storage systems – allows multimedia record
• Text processing and Data retrieval – allows search for specific text/data, allows for indexing of data; most effective approaches consider the end user's needs.
• System Communications and networks – options include wireless, internet, extranet, broadband, client server, fiber optics, application service providers

• True

• False

The personal health record (pHR) as defined by NAHIT as:

• An electronic record of health related information on an individual that conforms to nationally recognized interoperability standards, and that can be drawn from multiple sources while being managed, shared, and controlled by the individual (NAHIT 2005)

• True

• False

In 1970 the American Association of Medical Record Librarians (AAMRL) dropped the term "librarian" and became the American Medical Record Association (AMRA).

• True

• False

Data means facts about people, measurements, processes, etc. Once collected and analyzed, they are converted to information, which is facts made into something meaningful.

• True

• False

Patient care delivery: helps doctors, nurses, etc. to make informed decisions about diagnoses and treatments. It is a communication tool among caregivers, thus ensuring continuity of care. It also represents legal evidence of services received by patient.

• True

• False

Secondary Purposes: Related to environment in which care is provided: Education, Research, Regulation, Policy making and support, Public health and Homeland Security, and Industry.  

• True

• False

Flexibility - Paper records have limited flexibility as information is generally displayed in only one format. EHR’s, on the other hand, give more flexibility to the user as display formats can be changed depending on the user’s need.

• True

• False

Data Accuracy:   Correctness of data Accuracy depends on: - The patient’s physical health and emotional state at the time the data were collected - The provider’s interviewing skills - The provider’s recording skills - Availability of clinical history - Dependability of automated equipment - Reliability of electronic communications media

• True

• False

Data Accessibility:  data are easily obtained. Factors that affect it: - Are records available when and where needed? - Is the dictation equipment accessible and working? - Is transcription accurate? - Are data-entry devices working properly and readily available?

• True

• False

Data Consistency: Is the data consistent no matter how many times it is collected, listed or processed? For example, does all documentation list the patient with a right above knee amputation?   

• True

• False

Data Definition: Each data element should be clearly defined and have a range of acceptable values.

• True

• False

Data Timeliness: Is data entered in a timely manner? Is it available when needed by others in a timely fashion?

• True

• False

Clinical observations by medical professionals are termed progress notes  "notes" function to:

• create chronological record of patient’s treatment & response to treatment
• justify further acute care treatment
• document the appropriateness and coordination of services
• serve as a means of communication between caregivers

• True

• False

Recovery Room Record (PACU – post anesthesia care unit) includes:

• patient’s level of consciousness upon arrival and departure from recovery room (RR)
• vital signs
• status of IV’s, dressings, tubes, catheters, drains

• True

• False

Consultation Reports

• A report by another physician who specializes in a particular field of medicine. The consultant gives his/her opinion on the patient’s condition and often recommends a particular course of treatment.
• The consult is requested by the patient’s attending physician
• The report is based on the consultant’s physical exam of the patient as well as a review of the patient’s medical record

• True

• False