Registered Health Information Technician! Practice Test Trivia Quiz
Are you studying to become a registered health information technician and are looking for a practice test trivia quiz to help you get your certification? A person is this position is expected to properly record patient health information and keep an up to date record. This quiz is perfect for you, how about you check it out and see how much more practice you might need.
Questions and Answers
- 1.
HIM has been recognized as an allied health profession since:
- A.
1910
- B.
1918
- C.
1928
- D.
2006
Correct Answer
C. 1928Explanation
HIM, which stands for Health Information Management, has been recognized as an allied health profession since 1928. This means that in that year, HIM was acknowledged and classified as a profession within the allied health field. It is important to note that allied health professions encompass a wide range of healthcare roles and disciplines that support and complement the work of physicians and nurses. The recognition of HIM as an allied health profession in 1928 signifies its establishment and acceptance within the healthcare industry.Rate this question:
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- 2.
The hospital standardization movement was inaugurated by the:
- A.
American Health Information Management Association
- B.
American College of Surgeons
- C.
Record Librarians of North America
- D.
American College of Physicians
Correct Answer
B. American College of SurgeonsExplanation
The American College of Surgeons initiated the hospital standardization movement. This means that they were the ones who started the movement to establish and promote standardized practices and procedures in hospitals. They likely recognized the need for consistency and quality in surgical care and took the lead in advocating for standardized guidelines and protocols across hospitals.Rate this question:
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- 3.
Throughout the years, HIM roles have:
- A.
Remained the same
- B.
Broadened in scope
- C.
Become more focused
- D.
Diminished
Correct Answer
B. Broadened in scopeExplanation
Over the years, HIM roles have expanded and become more diverse in their responsibilities and areas of focus. This means that individuals working in HIM roles are now required to possess a broader skill set and knowledge base to effectively manage and analyze health information. This expansion in scope reflects the evolving healthcare landscape and the increasing importance of health information management in ensuring quality care delivery and patient safety.Rate this question:
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- 4.
The traditional model of HIM practice was:
- A.
Department based
- B.
Information based
- C.
Electronically based
- D.
Analytically based
Correct Answer
A. Department basedExplanation
The traditional model of HIM practice was department-based, meaning that the organization and management of health information was structured around specific departments within a healthcare facility. This model involved each department being responsible for their own documentation and record-keeping, with limited coordination and communication between departments. This approach allowed for a more focused and specialized approach to health information management, but it also had limitations in terms of efficiency and collaboration between departments.Rate this question:
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- 5.
The new model of HIM practice is:
- A.
Information focused
- B.
Record focused
- C.
Department focused
- D.
Traditionally focused
Correct Answer
A. Information focusedExplanation
The new model of HIM practice is "Information focused" because it emphasizes the importance of managing and utilizing information effectively. This model recognizes that information is a valuable asset in healthcare, and HIM professionals play a crucial role in ensuring its accuracy, accessibility, and security. By focusing on information, HIM practice can contribute to improved patient care, data analytics, and decision-making processes in healthcare organizations. This approach aligns with the evolving digital landscape and the increasing reliance on electronic health records and health information exchange systems.Rate this question:
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- 6.
What evolving role oversees the process that begins at the time of documentation through billing?
- A.
HIM director
- B.
Health record reviewer
- C.
Health data analyst
- D.
Revenue cycle management
Correct Answer
D. Revenue cycle managementExplanation
Revenue cycle management is the correct answer because it is the process that oversees the entire revenue cycle, starting from documentation through billing. This role is responsible for ensuring that all necessary documentation is collected, coded, and billed correctly to ensure proper reimbursement for healthcare services provided. The revenue cycle management team also monitors and analyzes the financial performance of the organization, identifies areas for improvement, and implements strategies to optimize revenue generation.Rate this question:
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- 7.
The organization that accredits HIM programs is:
- A.
Joint Commission
- B.
CAHIIM
- C.
AHIIMA
- D.
CCHIIM
Correct Answer
B. CAHIIMExplanation
CAHIIM is the correct answer because it is the organization that accredits HIM (Health Information Management) programs. The other options, such as Joint Commission, AHIIMA, and CCHIIM, are not specifically responsible for accrediting HIM programs. Joint Commission is mainly focused on accrediting healthcare organizations, while AHIIMA and CCHIIM are professional associations related to health information management, but they do not accredit programs. Therefore, CAHIIM is the most appropriate choice for the accrediting organization.Rate this question:
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- 8.
What evolving role assesses quality in health record banking?
- A.
Physician Group Consultant
- B.
Health record reviewer
- C.
Health data analyst
- D.
Terminology manager
Correct Answer
B. Health record reviewerExplanation
A health record reviewer is responsible for assessing the quality of health records in a health record banking system. They review the accuracy, completeness, and compliance of the records to ensure that they meet the required standards. This role plays a crucial part in maintaining the integrity of the health records and ensuring that they are reliable for healthcare providers and patients.Rate this question:
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- 9.
The primary focus of AHIMMA is to:
- A.
Ensure that health records are complete
- B.
Implement an electronic health record in hospitals
- C.
Foster professional development of its members
- D.
Set and implement standards
Correct Answer
C. Foster professional development of its membersExplanation
AHIMA, which stands for the American Health Information Management Association, is an organization that focuses on the professional development of its members. They provide resources, education, and networking opportunities to help their members grow and excel in the field of health information management. While ensuring complete health records and implementing electronic health records are important aspects of AHIMA's work, their primary focus is on fostering the professional development of their members. This includes promoting best practices, advocating for the profession, and supporting the growth and advancement of health information management professionals.Rate this question:
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- 10.
Active members of AHIMMA include those who:
- A.
Hold and AHIMA credential
- B.
Are graduate members
- C.
Are currently students in an accredited HIM program
- D.
Are senior members
Correct Answer
D. Are senior membersExplanation
Senior members are included as active members of AHIMMA. This implies that senior members meet the criteria to be considered active members. The question does not mention any other specific groups or criteria, so it can be inferred that senior members are one of the categories of active members in AHIMMA.Rate this question:
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- 11.
Which of the following functions as the legislative body of AHIMA?
- A.
Board of Directors
- B.
House of Delegates
- C.
CCHIIM
- D.
CAHIIM
Correct Answer
B. House of DelegatesExplanation
The House of Delegates functions as the legislative body of AHIMA. This means that it is responsible for making decisions and creating policies that govern the organization. The House of Delegates consists of elected representatives from AHIMA's state associations and other constituent organizations. They meet annually to discuss and vote on important issues, such as changes to AHIMA's bylaws, code of ethics, and strategic plan. The House of Delegates plays a crucial role in shaping the direction and priorities of AHIMA, making it the correct answer to the question.Rate this question:
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- 12.
Which of the following promotes education and research?
- A.
CCHIIM
- B.
CAHIIM
- C.
AHIMA
- D.
AHIMA Foundation
Correct Answer
D. AHIMA FoundationExplanation
The AHIMA Foundation promotes education and research in the field of health information management. AHIMA, the American Health Information Management Association, is a professional association that also supports education and research in this field. However, the AHIMA Foundation specifically focuses on these areas and provides scholarships, grants, and resources to advance education and research initiatives. CCHIIM and CAHIIM are not directly involved in promoting education and research, making AHIMA Foundation the correct answer.Rate this question:
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- 13.
The virtual network used by AHIMA members is:
- A.
Certification
- B.
Fellowship
- C.
House of Delegates
- D.
Communities of Practice
Correct Answer
D. Communities of PracticeExplanation
The virtual network used by AHIMA members is "Communities of Practice." This is a platform where AHIMA members can connect, collaborate, and share knowledge with other professionals in their specific areas of interest or expertise. It allows them to engage in discussions, access resources, and seek advice from peers, ultimately enhancing their professional development and promoting best practices in health information management. The other options listed (Certification, Fellowship, House of Delegates) do not specifically refer to the virtual network used by AHIMA members.Rate this question:
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- 14.
We had 324 Medicare patients last month. This statement represents which of the following:
- A.
Information
- B.
Data
- C.
Content of the PHR
- D.
Patient-specific information
Correct Answer
B. DataExplanation
The statement "We had 324 Medicare patients last month" represents data. Data refers to raw facts and figures that are collected and recorded. In this case, the number of Medicare patients (324) is a piece of information that has been collected and can be analyzed or used for various purposes.Rate this question:
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- 15.
I am a patient. My medical history including information from myself and my physicians is stored on the Internet. This is an example of which of the following:
- A.
Health record
- B.
EHR
- C.
PHR
- D.
Data
Correct Answer
C. PHRExplanation
The given scenario describes a personal health record (PHR), which is an electronic record of an individual's medical history. In this case, the patient's information, including data from themselves and their physicians, is stored on the Internet. A PHR allows individuals to access and manage their own health information, making it a suitable explanation for the answer choice PHR.Rate this question:
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- 16.
Which of the following is an example of a primary purpose of the medical record?
- A.
Education
- B.
Policy making
- C.
Research
- D.
Patient care management
Correct Answer
D. Patient care managementExplanation
The primary purpose of the medical record is to facilitate patient care management. The medical record contains important information about a patient's medical history, diagnoses, treatments, and medications, which helps healthcare providers make informed decisions and provide appropriate care. It serves as a communication tool between healthcare professionals, ensuring continuity of care and coordination among different healthcare settings. Additionally, the medical record allows for documentation of patient progress, monitoring of treatment effectiveness, and evaluation of outcomes, all of which contribute to effective patient care management.Rate this question:
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- 17.
Examples of patient care delivery usage of the medical record include which of the following uses?
- A.
Developing of practice guidelines
- B.
Communication between caregivers
- C.
Reimbursement of patient care
- D.
Getting patients involved in their own care
Correct Answer
B. Communication between caregiversExplanation
The medical record is used for communication between caregivers as it serves as a centralized source of patient information that can be accessed by multiple healthcare professionals involved in the patient's care. This allows for efficient and effective communication, ensuring that all caregivers have access to the most up-to-date information about the patient's condition, treatment plan, and any changes in their care. This facilitates coordination and collaboration among the healthcare team, leading to better patient outcomes.Rate this question:
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- 18.
Critique this statement: The PHR and EHR are synonyms.
- A.
True. Both are controlled by the patient.
- B.
False. PHR is controlled by care providers and EHR by patient.
- C.
False. PHR controlled by patient and EHR by care providers.
- D.
True. Both controlled by health care providers.
Correct Answer
C. False. PHR controlled by patient and EHR by care providers.Explanation
The correct answer is False. PHR is controlled by the patient and EHR is controlled by care providers. This is because PHR (Personal Health Record) is a health record maintained by the individual patient, where they have control over the information and can choose what to include or exclude. On the other hand, EHR (Electronic Health Record) is a digital version of a patient's medical history, maintained by healthcare providers, and is used for sharing information among different healthcare professionals involved in the patient's care.Rate this question:
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- 19.
The health care record is the principal repository for data and information about the healthcare services provided to individual patients.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
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.Rate this question:
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- 20.
The lab test "hemoglobin: 14.6 gm/110ml" is considered information.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The lab test result "hemoglobin: 14.6 gm/110ml" is not considered information because it lacks context and meaning. Information is data that has been processed and interpreted to provide meaning and understanding. In this case, the lab test result alone does not provide any context or interpretation, making it incomplete and not considered information.Rate this question:
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- 21.
All the primary purposes of the health record are associated directly with the provision of patient care.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The primary purposes of the health record are not solely associated with the provision of patient care. While patient care is an important aspect, health records also serve other purposes such as legal documentation, research, quality improvement, and billing. These additional purposes demonstrate that the health record has a broader scope beyond just patient care. Therefore, the statement that all primary purposes of the health record are associated directly with the provision of patient care is false.Rate this question:
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- 22.
Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is not considered a secondary purpose of the health record. The primary purpose of the health record is to provide healthcare professionals with a comprehensive and accurate account of a patient's medical history and treatment. However, submitting documentation to a third-party payer is a necessary step in the billing process and is therefore considered a primary purpose of the health record.Rate this question:
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- 23.
Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The use of the health record to study the effectiveness of a given drug is not considered a primary use of the health record. While health records can be used for research purposes, the primary use of health records is to document and track patient health information for clinical and administrative purposes. The primary focus of health records is to support patient care, not to study the effectiveness of drugs.Rate this question:
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- 24.
Which of the following users of the health record is an example of an institutional user?
- A.
Third-party payer
- B.
Clinical investigator
- C.
Physician
- D.
Employer
Correct Answer
A. Third-party payerExplanation
A third-party payer refers to an organization or entity, such as an insurance company or government agency, that is responsible for paying healthcare expenses on behalf of the patient. They are considered an institutional user because they have a formal role in the healthcare system and access to health records for the purpose of processing claims and making payment decisions.Rate this question:
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- 25.
Which of the following users would utilize aggregate data?
- A.
Patient care providers
- B.
Coding and billing staff
- C.
Law enforcement officers
- D.
Patient care managers and support staff
Correct Answer
D. Patient care managers and support staffExplanation
Patient care managers and support staff would utilize aggregate data because they need to analyze and evaluate the overall patient care outcomes, trends, and patterns. By looking at aggregated data, they can identify areas for improvement, make informed decisions, and develop strategies to enhance patient care quality and efficiency. This data helps them monitor and manage the performance of healthcare providers, allocate resources effectively, and ensure that the patients receive the best possible care.Rate this question:
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- 26.
I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
- A.
Healthcare delivery
- B.
Medical review
- C.
Research
- D.
Education
Correct Answer
C. ResearchExplanation
Based on the given information, the organization mentioned in the question utilizes health record data to prove or disprove hypotheses related to disease. This indicates that the organization is involved in conducting research. The other options such as healthcare delivery, medical review, and education do not specifically mention the use of health record data for hypothesis testing, making them less likely to be the correct answer. Therefore, the correct answer is research.Rate this question:
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- 27.
Critique the following statement: A user of health records includes only care providers who document in the health record or refer to it for patient care.
- A.
True as defined by IOM.
- B.
False. Info used for other purposes such as analysis.
- C.
True as defined by AMIMA.
- D.
False. Info is also used for patients to document their own health records.
Correct Answer
B. False. Info used for other purposes such as analysis.Explanation
The correct answer is False. The statement is critiqued because it claims that the only users of health records are care providers who document in the record or refer to it for patient care. However, this is incorrect as health information is also used for other purposes, such as analysis. This means that individuals or organizations outside of care providers can access and utilize health records for various reasons, including research, public health monitoring, and policy development. Therefore, the statement is false.Rate this question:
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- 28.
I work for CMS: how would I use the health record?
- A.
Make decisions on healthcare reimbursement
- B.
Medical research
- C.
Issuing Hospital and medical staff licenses
- D.
Accrediting healthcare organizations
Correct Answer
A. Make decisions on healthcare reimbursementExplanation
As an employee of CMS (Centers for Medicare & Medicaid Services), you would use the health record to make decisions on healthcare reimbursement. This means that you would review the health records of patients and determine the appropriate amount of reimbursement that healthcare providers should receive for the services they have provided. This is an important task as it ensures that healthcare providers are fairly compensated for their services while also ensuring that CMS manages its reimbursement budget effectively.Rate this question:
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- 29.
A physical therapist documenting in the health record is an institutional health record user.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The statement is false because a physical therapist documenting in the health record is not necessarily an institutional health record user. While physical therapists may use health records as part of their job, they can also be individual health record users if they are documenting in a patient's personal health record. Therefore, the statement is not completely accurate.Rate this question:
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- 30.
An auditor who is employed by medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The statement is false because an auditor who is employed by Medicare and is reviewing a health record for a mortality study would be considered an organizational health record user, not an individual health record user. Individual health record users typically include healthcare providers, patients, or their authorized representatives.Rate this question:
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- 31.
CMS uses data to accredit hospitals.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
CMS stands for the Centers for Medicare and Medicaid Services, which is a federal agency that administers the Medicare and Medicaid programs. While CMS does play a role in accrediting hospitals, it does not solely rely on data to do so. Accreditation involves a comprehensive evaluation of a hospital's compliance with quality and safety standards, which includes on-site inspections, interviews with staff and patients, and review of documentation. Therefore, the statement "CMS uses data to accredit hospitals" is false.Rate this question:
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- 32.
Research organizations develop and test experimental patient care protocols.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
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.Rate this question:
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- 33.
Patients do not have the right to add missing information to the health record.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
Patients do have the right to add missing information to their health records. This allows them to provide additional details or correct any inaccuracies that may be present in their records. By allowing patients to add missing information, healthcare providers can ensure that the records are comprehensive and accurate, leading to better quality of care.Rate this question:
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- 34.
A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical test?
- A.
Clinical decision support
- B.
Electronic records
- C.
Results management
- D.
Order-entry/order management
Correct Answer
A. Clinical decision supportExplanation
This is an example of clinical decision support because the physician received a notification from the EHR system about a patient's lab test with a dangerously high value. Clinical decision support systems provide healthcare professionals with alerts, reminders, and recommendations to assist in making clinical decisions and improve patient care. In this case, the system alerted the physician about the high lab value, helping them make an informed decision regarding the patient's treatment or further testing.Rate this question:
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- 35.
I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called.
- A.
Data Relevancy
- B.
Security
- C.
Privacy
- D.
Confidentiality
Correct Answer
D. ConfidentialityExplanation
Confidentiality refers to the ethical and legal obligation of healthcare professionals to keep personal and sensitive information shared by patients confidential. In this scenario, the individual expects the physician to maintain the privacy of the embarrassing information disclosed, ensuring that it is not shared with anyone else without their consent. Confidentiality is crucial in establishing trust between patients and healthcare providers and maintaining the integrity of the doctor-patient relationship.Rate this question:
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- 36.
Someone suggested that we collect a patient's eye color. This was not implemented. Waht quality characteristic would be the justification for not collecting this information:
- A.
Accuracy
- B.
Consistency
- C.
Granularity
- D.
Relevancy
Correct Answer
D. RelevancyExplanation
The justification for not collecting a patient's eye color would be relevancy. Eye color is not relevant to the purpose or objective of collecting patient information in this context. It does not contribute to the accuracy, consistency, or granularity of the data that needs to be collected. Therefore, it is reasonable to exclude this information as it is not necessary or useful for the intended purpose.Rate this question:
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- 37.
It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic would be the justification for not doing this but rather sharing informaton between systems.
- A.
Accuracy
- B.
Consistency
- C.
Granularity
- D.
Relevancy
Correct Answer
B. ConsistencyExplanation
Consistency would be the justification for sharing information between systems instead of manually entering the patient's age. By sharing information between systems, the data will remain consistent across all systems, ensuring that the patient's age is accurately reflected in all relevant systems. This eliminates the possibility of errors or discrepancies that may occur when manually entering the age in multiple systems.Rate this question:
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- 38.
According to the AHIMA data quality model, what is the term used to describe how data is translated into informaton?
- A.
Data applications
- B.
Data collection
- C.
Data warehousing
- D.
Data analysis
Correct Answer
D. Data analysisExplanation
The term used to describe how data is translated into information according to the AHIMA data quality model is "data analysis." Data analysis involves examining, cleaning, transforming, and modeling data to discover useful information, draw conclusions, and support decision-making. It helps to uncover patterns, relationships, and trends within the data, enabling organizations to make informed decisions and take appropriate actions based on the insights gained from the analysis.Rate this question:
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- 39.
A characteristic of data whose values are defined at the appropriate level of detail is .
Correct Answer
granularityExplanation
Granularity refers to the level of detail or specificity at which data values are defined. When data values are defined at the appropriate level of detail, it means that they are specific and precise enough to accurately represent the information being captured. This ensures that the data is meaningful and useful for analysis and decision-making purposes.Rate this question:
- 40.
A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records is is called .
Correct Answer
securityExplanation
A program designed to protect patient privacy and prevent unauthorized access, alteration, or destruction of health records is called security. This program ensures that only authorized individuals can access and make changes to sensitive health information, thereby safeguarding patient privacy and preventing any potential breaches or data loss. Security measures such as encryption, access controls, and regular audits are implemented to maintain the confidentiality, integrity, and availability of health records.Rate this question:
- 41.
A characteristic of data where the data are useful is called .
Correct Answer
relevancyExplanation
The characteristic of data where the data are useful is called relevancy. Relevancy refers to the extent to which the data is applicable and pertinent to the problem or task at hand. When data is relevant, it provides meaningful insights and can be effectively used to make informed decisions or draw accurate conclusions. Relevancy ensures that the data aligns with the objectives and requirements of the analysis or decision-making process, increasing its value and usefulness.Rate this question:
- 42.
An individual's right to control access to his or her personal information is called .
Correct Answer
privacyExplanation
An individual's right to control access to his or her personal information is called privacy. Privacy refers to the ability of an individual to keep their personal information, activities, and communications private and protected from unauthorized access or intrusion. It encompasses the right to decide what information is shared, with whom, and under what circumstances. Privacy is essential for maintaining autonomy, personal security, and preserving individual rights and freedoms.Rate this question:
- 43.
A characteristic of data that includes every required data element is called .
Correct Answer
comprehensivenessExplanation
Comprehensiveness refers to the characteristic of data that includes every required data element. It means that the data is complete and contains all the necessary information. This ensures that there are no missing or incomplete data elements, allowing for a thorough and comprehensive analysis.Rate this question:
- 44.
Which two types of data are contained in the health record?
- A.
Nursing and Physician
- B.
Administrative and Clinical
- C.
Demographic and Financial
- D.
Surgical and Medical
Correct Answer
B. Administrative and ClinicalExplanation
The health record contains both administrative and clinical data. Administrative data includes information such as patient demographics, insurance details, and billing information. Clinical data, on the other hand, includes medical history, diagnoses, treatments, and test results. Both types of data are essential for managing and providing healthcare services effectively.Rate this question:
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- 45.
Which of the following terms refers to state or county regulations that healthcare facilities must meet to provide care?
- A.
Accreditation
- B.
Bylaws
- C.
Certification
- D.
Licensure
Correct Answer
D. LicensureExplanation
Licensure refers to the state or county regulations that healthcare facilities must meet in order to provide care. It is a mandatory process that ensures healthcare facilities meet certain standards and criteria set by the governing bodies. This involves obtaining a license or permit to operate and maintain the facility, which includes meeting specific requirements related to staffing, quality of care, safety measures, and other regulations. Licensure is crucial to ensure that healthcare facilities are operating legally and providing safe and quality care to patients.Rate this question:
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- 46.
Which of the following would not be found in a medical history?
- A.
Chief complaint
- B.
Vital signs
- C.
Present Illness
- D.
Review of Symptoms
Correct Answer
B. Vital signsExplanation
Vital signs are not typically found in a medical history. A medical history typically includes information about the patient's chief complaint, present illness, and review of symptoms. Vital signs, such as blood pressure, heart rate, and temperature, are usually recorded during a physical examination or at the time of the patient's visit. They provide current information about the patient's health status and are not typically included in the medical history, which focuses on the patient's past medical events and conditions.Rate this question:
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- 47.
An attending physician requests the advice of a 2nd physician who then reviews the health record and examines the patient. The 2nd physician records impressions in what type of report?
- A.
Consultation
- B.
Progress Report
- C.
Operative Report
- D.
Discharge summary
Correct Answer
A. ConsultationExplanation
When an attending physician seeks the advice of a second physician and the second physician reviews the health record and examines the patient, the second physician records their impressions in a consultation report. This report serves as a means of communication between the two physicians, providing the second physician's expert opinion and recommendations based on their assessment of the patient's condition and medical history. The consultation report helps to facilitate collaboration and ensure continuity of care for the patient.Rate this question:
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- 48.
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
- A.
Flow record
- B.
Vital Signs record
- C.
Care plan
- D.
Surgical note
Correct Answer
C. Care planExplanation
A care plan is a specialized type of progress note that provides healthcare professionals with their impressions of patient problems along with detailed treatment action steps. It outlines the specific goals, interventions, and outcomes that are necessary for the patient's care. This document helps to ensure that all healthcare professionals involved in the patient's treatment are on the same page and can effectively coordinate their efforts. It serves as a roadmap for the patient's care and helps to ensure that their needs are being addressed in a comprehensive and organized manner.Rate this question:
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- 49.
Written or spoken consent to proceed with care is classified as:
- A.
Expressed consent
- B.
Acknowledgement
- C.
Advance directive
- D.
Implied consent
Correct Answer
A. Expressed consentExplanation
Expressed consent refers to the explicit permission given by a patient, either verbally or in writing, to proceed with a specific medical treatment or procedure. This type of consent is clear and unambiguous, leaving no room for interpretation. It ensures that the patient fully understands the nature of the care being provided and voluntarily agrees to it. Expressed consent is an important ethical and legal requirement in healthcare, as it respects the autonomy and rights of the patient.Rate this question:
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- 50.
Which report provides info on tissue removed during a procedure?
- A.
Operative report
- B.
Laboratory report
- C.
Pathology report
- D.
Anesthesia report
Correct Answer
C. Pathology reportExplanation
The pathology report provides information on tissue removed during a procedure. It includes details about the examination of the tissue sample by a pathologist, who analyzes it under a microscope to determine if there are any abnormalities or diseases present. This report is crucial in diagnosing and treating various medical conditions, as it helps healthcare professionals understand the nature of the tissue and make informed decisions about further treatment or intervention.Rate this question:
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