Registered Health Information Technician! Trivia Test! Quiz
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Are you on your way to becoming a registered health information technician? If you said yes, you are in luck as the quiz below is precisely what you need to refresh your memory on record keeping and what someone in your position is expected to do when it comes to access and details. How about you check it out and see how good you will do.
- 1.Which was the first major U.S. impetus for improvig hostipal health records?
- A.
Organization of the Ameican Health Information Management Association
- B.
Establishment of the JCAHO's numerous accreditation programs
- C.
Opening of the first imcorporated hosipital, known as Pennsylvania Hospital
- D.
Creation of the american College of Surgeons' hospital standardization program
- 2.A rubber stamp of Dr. Day's signature is acceptable for use if
- A.
It is stored in the health information department and is used ony by Dr. Day
- B.
It is used by Dr. Day and her clinical staff because seh gave them permission to do so
- C.
Dr. Day signed a statement regarding its use; the statement is stored with the facility's administration
- D.
It is utilized only Dr. Day and the other physicians involved in her group practice
- 3.The integrated health record format is identified by its
- A.
Arrangement according to the source of the information
- B.
Association of treatment and therapies with patient problems
- C.
Organization of reports in strict chronological date order
- D.
Standarized forms as recommended by the JCAHO
- 4.Regulations about physician completion of health records are developed by the
- A.
Health information management department
- B.
Acute care facility's medical staff
- C.
Health care facility's governing body
- D.
Hospital's administrative offices
- 5.Which of the following demonstrates the personal use of the health record?
- A.
Diagnostic index that contains ICD-9-CM codes on Sally Smith
- B.
Utilization review committee minutes concerning patient Sally Smith
- C.
Sally Smith's emergency department record dated January 1
- D.
Emergency department log containing a January 1 entry for Sally Smith
- 6.
- A.
Information from Sally Smith's record included in a hospital statistical report
- B.
JCAHO survey of 100 records, including that of Sally Smith
- C.
Quality assurance study that contains information from Sally Smith
- D.
Malpractice case brought to trial that includes Sally Smith's record as evidence
- 7.Susan is a nurse who brings to your attention an error in the health record. She is uncertain how to make the correction. What would Susan's first step be in amending an error in a health record?
- A.
Drawing a single line through the error
- B.
Obliterating the incorrect document
- C.
Documenting the reason for the error
- D.
Obtaining the supervisor's co-signature
- 8.A final progress note may be substituted for a discharge summary when a (an)
- A.
Patient's hospitalization is under 48 hours' duration with minor problems
- B.
Circumcised newborn who develops an infection is discharged within 48 hours
- C.
Obstetrical patient delivers a healthy female newborn via cesarean section
- D.
Expected death of a terminal patient occurs within 48 hours of admission
- 9.The reanalysis of health records refers to
- A.
Analysis after health providers have worked on records, but prior to permanent filing
- B.
The assembly of the health record upon receipt from the facility's nursing units
- C.
Authentication of incomplete health records after initial analysis has been done
- D.
Computerized abstracting of health records after the provider has completed them
- 10.Reports that summarize administration of therapeutic radiation are documented
- A.
At the conclusion of the administration of each radiation therapy session
- B.
On a weekly basis, summarizing several radiation therapies administered
- C.
By the practitioiner administering the radiation therapy, at least monthly
- D.
At the end of the therapeutic radiation threatment for the particular patient
- 11.A postanesthesia evaluation is documented in the patient's record by the practitioner administering the anesthetic
- A.
Immediatley upon conclusion of the surgery
- B.
Within 24 hours after they surgery is performed
- C.
Within 48 hours after the surgery is performed
- D.
And authenticated by the patient's surgeon
- 12.The major advantages of the problem-oriented health record include all of the following EXCEPT:
- A.
It requires the attending physician to consider all of the patient's problems
- B.
It is easily accepted by physicians, nurses, and allied health professionals
- C.
It clearly indicates the goals and methods of the physician in treating the patient
- D.
It allows physicians and others to follow the course of any one problem more easily
- 13.The master patient index should be kept
- A.
For 25 years
- B.
For 10 years
- C.
For 5 years
- D.
Permanently
- 14.With alphabetical filing, which of the following names would be filed first?
- A.
S. Peter Jones
- B.
Steven Peter Jones
- C.
Stephen Peter Jones
- D.
S. Jones
- 15.Divorce complicates which type of numbering system?
- A.
Social security
- B.
Family
- C.
Unit
- D.
Serial-unit
- 16.Which system makes it easiest to purge records for microfilming?
- A.
Terminal digit filing
- B.
Serial-unit numbering
- C.
Unit numbering
- D.
Straight numeric filing
- 17.Which would be considered a major component of the record control function?
- A.
Requisition slip
- B.
Master patient index
- C.
Number index
- D.
File shelving
- 18.Which represents records filed within a primary section in terminal digit order?
- A.
00-00-52, 01-00-52, 02-00-52, 03-00-52
- B.
00-00-52, 00-00-53, 00-00-54, 00-00-55
- C.
00-00-52, 01-00-53, 02-00-54, 03-00-55
- D.
00-01-52, 00-02-53, 00-03-54, 00-04-55
- 19.Which would be the chief criterion for determining record inactivity?
- A.
Statute of limitations for the state in which health records are generated
- B.
Amount of space available for efficient storage of newer health records
- C.
Number of filing personnel available to effectively retrieve or refile records
- D.
Equipment used to store records in the health information department
- 20.The terminal digit file area requires 2000 file guides. What is the pattern of file guides?
- A.
00-00-00, 00-05-00, 00-10-00, 00-15-00
- B.
00-00-00, 00-50-00, 01-00-00, 01-50-00
- C.
00-00-00, 00-00-05, 00-00-10, 00-00-15
- D.
00-00-00, 00-00-50, 00-01-00, 00-01-50
- 21.The four major sections of a problem-oriented health record are:
- A.
Database, problem list, initial plans, progress notes
- B.
Problem list, SOAP notes, nursing notes, graphic sheets
- C.
History and physical, problem list, SOAP notes, resume
- D.
Initial plans, problem list, SOAP notes, nursing notes
- 22.The inpatient's record generally begins in the
- A.
Facility's admitting department
- B.
Attendig physician's office
- C.
Hospital nursing station
- D.
Preadmission testing department
- 23.Which of the following would be found in a history report?
- A.
Review of systems
- B.
Differential diagnosis
- C.
Blood pressure and pulse
- D.
The patient's appearance
- 24.The diagnosis recorded at the conclusion of the history and physical is the
- A.
Provisional diagnosis
- B.
Principal diagnosis
- C.
Primary diagnosis
- D.
Chief diagnosis
- 25.Color coding of health record folders helps prevent
- A.
Misnumbering of health records
- B.
Misfiling of health record folders
- C.
Misinterpretation of record content
- D.
Misplacement of forms in the record
- 26.Which organizations' directives establish minimum contents of a health record?
- A.
JCAHO, state licensing regulations, Conditions of Participation
- B.
State health department rules, Conditions of Participation, JCAHO
- C.
Conditions of Participation, JCAHO, Memo of Understanding
- D.
State licensing regulations, JCAHO, Memo of Understanding
- 27.Progress notes
- A.
Are to be documented at least one daily for each patient in the acute care facility
- B.
May or may not contain an admission note focumented by the attending physician
- C.
Include a discharge note that is documented at the conclusion of the patient's stay
- D.
Should consist of information documented in the history of physical examination
- 28.Quantitative analysis of the health record would include review for
- A.
Required authentication of all entries
- B.
Use of abbreviations on the face sheet
- C.
Potentially compensable events
- D.
Consistency in documentation of provider entries
- 29.An infant's record is
- A.
Filed with the mother's record only if the infant was a premature newborn
- B.
Separate from the mother's record and contains a few routine forms and reports
- C.
Filed with the mother's record if the infant is normal (i.e., healthy newborn)
- D.
Separate from them other's record if she experienced no delivery complications
- 30.If a patient falls while in the hospital, an incident form is generated and
- A.
A copy is filled in the patient's health record with the original forwarded to administration
- B.
Reference ismade in the health record that an incident report was generated
- C.
Documentation of the fall and treatment rendered is recorded inthe patient's health record
- D.
The risk manager meets with the patient to discuss this potentially compensable event
- 31.Which filing system organizes records in strict chronological order?
- A.
Terminial digit
- B.
Middle digit
- C.
Stright numeric
- D.
Serial numeric
- 32.The major advantage of straight numeric filing is
- A.
Ease in training of employees who file
- B.
Increase in health record confidentiality
- C.
Ability to monitor file clerk filing activities
- D.
Reduction in misfiles of health records
- 33.The terminal digit number filed first in the following series is
- A.
50-63-24
- B.
75-63-24
- C.
75-61-23
- D.
45-52-24
- 34.Which would provide a chronological listing of all patient admissions?
- A.
Master patientindex
- B.
Computer abstracts
- C.
Patient register
- D.
Number control log
- 35.Which type of microfilm has the greatest storage density?
- A.
Aperture cards
- B.
Roll film
- C.
Microfiche
- D.
Microfilm jackets
- 36.A cancer registry program must acheive which follow-up rate to receive approval by the American College of Surgeons?
- A.
70%
- B.
80%
- C.
90%
- D.
100%
- 37.The best application for bar coding in the health information department is
- A.
Coding diagnoses
- B.
Medical transcription
- C.
Quantitative analysis
- D.
Health record tracking
- 38.Birth and death certificates should be maintained by the facility
- A.
Permanently
- B.
For 25 years
- C.
For 15 years
- D.
For 10 years
- 39.The chief complaint included in a history and physical examination report is a statement made by the
- A.
Family
- B.
Nurse
- C.
Patient
- D.
Physician
- 40.Which would be considered an ancillary department?
- A.
Patient billing/collections
- B.
Environmental services
- C.
Biomedical maintenance
- D.
Clinical laboratory/pathology
- 41.Which statement would be documented in the physical examination report?
- A.
Occasional headache
- B.
Palpable axillary node
- C.
History of cholecystectomy
- D.
Pain in right upper quadrant
- 42.Which is the most important consideration in designing a form?
- A.
Spacing needed for typing
- B.
Purpose and need for it
- C.
Number of copies included
- D.
Information to be documented
- 43.Which is documented in the physical examination report?
- A.
Review of systems
- B.
Present illness
- C.
General survey
- D.
Chief complaint
- 44.All would be contained in thephysical examination report EXCEPT:
- A.
Rebound tenderness
- B.
Rales and rhonchi
- C.
Thrist and dizziness
- D.
Negative Romberg sign
- 45.Standing orders
- A.
Must be authenticated by the physician after being filed in the chart
- B.
Can be excluded from the record if they are posted in the nursing unit
- C.
May be presigned by the physician prior to dupicating the orders
- D.
Need to be signed only if the attending physician alters the orders
- 46.A hospital administrator requests the health information management department to provide a report detailing the number of incompleted discharged health records during the past 6 months. Such a report would be the result of a(an)
- A.
Survey of diagnostic and procedural indexes
- B.
Review of discharge lists for the past six months
- C.
Analysis of health records for deficiencies
- D.
Breakdown of records according to entry omissions
- 47.The JCAHO requires creation of a new record for emergency patients
- A.
Upon the patient's first visit to the emergency department
- B.
Each time the patient is seen in the emergency department
- C.
When the patient is diagnosed with a different condition
- D.
If the patient has changed his or her primary physician
- 48.The first step in developing a problem-oriented record is
- A.
Obtaining a patient database
- B.
Documenting the problem list
- C.
Recording SOAP progress notes
- D.
Writing initial plans for the patient
- 49.The P in the SOAP note of the problem-oriented record refers to the
- A.
Patient's progress that has been demonstrated in response to treatment
- B.
Diagnostic, therapeutic, and educational plans that are being developed
- C.
Documentation of a particular problem in the patient's progress note
- D.
Physical assessment conducted on the patient and documented
- 50.Patients admitted to the hospital on September 18th were issued the following patient nubmers: 9010, 2053, 9011, 9012, 3155, 0381. Which numbering system is being used?
- A.
Serial
- B.
Unit
- C.
Serial-unit
- D.
Terminal digit
- 51.Which modification of the unit numbering system includes pseudonumbers
- A.
Family numbering
- B.
Serial-unit numbering
- C.
Serial numbering
- D.
Social security numbering
- 52.Unitized microforms include all of the following EXCPET:
- A.
Jackets
- B.
Ultrafiche
- C.
Rotary
- D.
Microfiche
- 53.A disease index organized patient data according to the
- A.
Classification system used by the facility
- B.
Numbering system used by the facility
- C.
Filing system used by the facility
- D.
Registration method used by the facility
- 54.How long should annual statistical reports based on monthly analyses of hospital services be kept?
- A.
Permanently
- B.
25 years
- C.
10 years
- D.
5 years
- 55.How would the last name, St. John, be filed in an alphabetical file?
- A.
St. John
- B.
Stjohn
- C.
John, St.
- D.
Saint John
- 56.Anytown Medical Center uses a decentralized system for record keeping. The next number in the serial system for inpatient hospital admissions is 16888. The next number to be assigned in the outpatient clinic is unit number 17845. Mary Jones's last number on outpatient admissions was 10921 and on hospital admission was 15824. What patient number will be assigned to Mary Jones if she returns to the hospital as an outpatient?
- A.
10921
- B.
17845
- C.
16888
- D.
10922
- 57.Which number was most recently assigned to a new patient by the admitting department of a facility that uses unit numbering to assign numbers and terminal digit filing to file records?
- A.
44 10 76
- B.
76 02 76
- C.
56 0076
- D.
89 03 76
- 58.Which best describes the organization of the source-oriented record on the nursing unit?
- A.
Reports are filed in chronological order
- B.
The forms are in reverse chronological order
- C.
The record integrated regarding reports
- D.
It has a goal-orientedformat to facilitate treatment
- 59.Inpatient discharges total 1,763 in one month; 521 of these discharged health records are complete at discharge. Calculate the month's incomplete health record rate.
- A.
3.38%
- B.
29.55%
- C.
70.45%
- D.
76.13%
- 60.Which is the most important use of a number index?
- A.
Control of patient numbers assigned
- B.
Planning for patient number assignment
- C.
Retrieval of records according to patient number
- D.
Listing of patients and their final diagnoses
- 61.A department maintains records in hard copy form instead of microfilming; it also has limited space for record storage. Which would the department benefit most from?
- A.
Movable open shelving units
- B.
Stationary open shelving untis
- C.
Computerized health record
- D.
Seven-drawer file cabinets
- 62.If a record cannot be completed because of the death of a physician, the health information practitioner should
- A.
File the incomplete record in the department's permanent file section
- B.
Forward the record to the facility's medical staff president for completion
- C.
Refer the incomplete record to the health record committee for action
- D.
Request that the physician who took over the practice complete the record
- 63.A complete autopsy protocol or report is made part of the health record within
- A.
30 days
- B.
2 weeks
- C.
60 days
- D.
6 months
- 64.Pathology (tissue) reports must be completed on
- A.
Diseased tissue only that is removed at surgery
- B.
All tissue removed during a surgical procedure
- C.
Cancer tissue only or tissue that might be cancerous
- D.
Tissue sent to the pathology at the discretion of the surgeon
- 65.A question on the documentation practices of a particular physician arises through health information department analysis. The health information practitioner should first notify the
- A.
Chief of the medical staff
- B.
Hospital administrator
- C.
Physician in question
- D.
Health record committee
- 66.When documenting SOAP notes, reference is made to the problem list by
- A.
Recording the number and title of the appropriate problem prior to recording the SOAP note
- B.
Soaping the progress note in that particular section of the patient's health record
- C.
Duplicating the problem list so that it is filed ahead of the referenced SOAP note
- D.
Documenting the problem letter and its title before the note is written in the record
- 67.Which problem-oriented record portion incorporates the history and physical?
- A.
Problem list
- B.
Database
- C.
SOAP notes
- D.
Initial plans
- 68.Veterans Health Admininstration facilities consistently use which of the following as a basis for their numbering system?
- A.
Social security number as unit number
- B.
Family numbering for all outpatients
- C.
Serial-unit numbering and filing system
- D.
Straight numberic filing and numbering
- 69.A family numbering system is most useful in
- A.
Children's hospitals
- B.
Neighborhood health centers
- C.
Rehabilitation hospitals
- D.
Proprietary hospitals
- 70.With which filing system is quality control most difficult?
- A.
Unit
- B.
Middle digit
- C.
Straight numeric
- D.
Serial-unit
- 71.The middle digit number filed last in the following series is
- A.
97-26-52
- B.
96-27-51
- C.
95-27-52
- D.
96-27-50
- 72.For records of medium thickness, a fule guide should be provided for every
- A.
25 records
- B.
50 records
- C.
100 records
- D.
200 records
- 73.File guides are more permanent with which filing system?
- A.
Stright numeric
- B.
Terminal digit
- C.
Middle digit
- D.
Serial-unit
- 74.The more information abstracted into a disease and operation index, the
- A.
Less time spent retrieving appropriate records
- B.
More time spent retrieving appropriate records
- C.
Less cost in preparing and utilizing the index
- D.
Less time spent in preparing the indices
- 75.A terminal digit file guide is labeled: 40/30.The 40 is considered
- A.
Primary
- B.
Secondary
- C.
Tertiary
- D.
Terminal
- 76.A final note serves as a discharge summary in minor cases requiring less than
- A.
24 hours of hospitalization
- B.
36 hours of hospitalization
- C.
48 hours of hospitalization
- D.
72 hours of hospitalization
- 77.Dr. Dawson performs an operation on a patient and realizes that there is a backlog in transcription turnaround time of operative reports. According to the JCAHO standards, he should
- A.
Document a comprehensive progress note following surgery
- B.
Dictate the operative report
- C.
Wait until the transcroption department catches up before he dictates
- D.
Notify the HIM supervisor regarding the transcription delay
- 78.As HIM Director, you have been asked to report the incomplete record rate for the month of October at the medical staff meeting. There were 2,250 discharges and 200 incomplete records in the month of October. What would the incomplete record rate be?
- A.
.08%
- B.
11%
- C.
8.8%
- D.
.11%
- 79.According to JCAHO requirements, a Type 1 recommendation may be given if the total number os health records delinquent exceeds what percentage of the average monthly discharges?
- A.
25%
- B.
50%
- C.
75%
- D.
100%
- 80.All of the following are types of cancer registries EXCEPT:
- A.
Procedure registry
- B.
Population based cancer registry
- C.
Hospital cancer registry
- D.
Special-purpose registry
- 81.The chronological listing of all patients in a cancer/tumor registry is called the
- A.
Tumor registry
- B.
Accession registry
- C.
Case finding
- D.
Case eligibility data
- 82.Which is responsible for coordinating all hospital clinical activities?
- A.
Hospital administration
- B.
Executive Committee
- C.
Nursing staff
- D.
JCAHO
- 83.Which allows family members who normally provide care to a person to take a break from providing that care?
- A.
Community care
- B.
Respite care
- C.
Rehab care
- D.
Hospice care
- 84.Which is a distinctive feature of health maintenance organizations (HMO's)?
- A.
There is utilization of a fee-for-service system
- B.
Fixed premiums are prepaid for health services
- C.
Their mission is to bring health care to the indigent
- D.
Seven days per week, 12-16 hours per day care is provided
- 85.All of the following are cinsedered long-term care facilities EXCEPT:
- A.
Assisted living facility
- B.
Substance abuse facility
- C.
Independent living facility
- D.
Domiciliary facility
- 86.Part of the accreditation survey process is listed below in responses A to E. Identify the first step that is out of order
- A.
The interested facility must submit an application and complete a questionnaire
- B.
An on-site survey is conducted; the team consists of health care professionals
- C.
Surveryors conduct a summation conference with representatives of the facility
- D.
The surveryors file their finding in a written report to the accreditation agency
- E.
Representatives of the facility have an opportunity to comment on adverse findings
- 87.A physician who has newly relocated to the area applied and was accepted as an active staff member at the local hospital. The physician will
- A.
Apply for reappointment and/or renewal of privileges within 2 years
- B.
Be exempt from serving on medical staff committeess for 2 years
- C.
Work under the direct supervision of another active staff member
- D.
Report directly to the hospital administrator of the health care facility
- 88.Mrs. Hughston is transported to the hospital after complaining of sever right lower quadrant pain. She is evaluated and undergoes laboratory tests, which prove to be negative. She is discharged to be seen by her primary care physician in his office.
- A.
Ambulatory surgery
- B.
Ancillary services
- C.
Emergency department
- D.
Outpatient department
- 89.Sally Sims is seen in the hospital and undergoes a bilateral mammogram because this type of radiographic equipment is not available in her physician's office.
- A.
Ambulatory surgery
- B.
Ancillary services
- C.
Emergency department
- D.
Outpatient department
- 90.Henry Franklin undergoes a right inguinal herniorraphy at 7:00 A.M. and is discharged at noon to return home in order to recuperate.
- A.
Ambulatory surgery
- B.
Ancillary services
- C.
Emergency department
- D.
Outpatient department
- 91.Mary Forbes is registered for her weekly physical therapy and undergoes treatment consisting of whirlpool baths and diathermy.
- A.
Ambulatory surgery
- B.
Ancillary services
- C.
Emergency department
- D.
Outpatient department
- 92.Which statement is characteristic of a group practice?
- A.
It consists of a single specialty or multi-specialty and privides comprehensive
- B.
It has management responsibility for providing comprehensive prepaid patient care
- C.
It is an organized outpatient department physically separate from the hospital
- D.
It is a freestanding facility that provides surgical services only to the patients
- 93.A satellite ambulatory care unit
- A.
May or may not be associated with a hospital
- B.
Is physically separate from the hospital
- C.
Can be attached to the hospital itself
- D.
Privides comprehensive care for patients
- 94.Mary Jones sustained a laceration to her hand while on the job and was seen in the facotry's clinic where the hand was evaluated by the nurse. Ms. Jones was sent to the hospital's emergency department for suturing. This visit to the factory's clinic is a form of
- A.
Freestanding ambulatory care
- B.
Hospital outpatient care
- C.
On-site ambulatory care
- D.
Satellite ambulatory care
- 95.Which is the name of the data set developed by the DHHS and approved by the National Committee on Vital and Health Statistics?
- A.
ASTM E1384
- B.
UACDS
- C.
UCDS
- D.
UHDDS
- 96.Hospice patients spend the majority of their hospice stay at home. As a result,
- A.
Many patients receive home care services as part of hospice care
- B.
A family member is required to be the primary care person in the home
- C.
Curative care can be privided to the patient in a convenient manner
- D.
It is difficult to arrange for inpatient services when they are deemed necessary
- 97.All of the following are physicians EXCEPT:
- A.
Ophthalmologists
- B.
Osteopaths
- C.
Anesthesiologist
- D.
Optometrists
- 98.CARF accredits
- A.
Home health agencies
- B.
Respite care programs
- C.
Neighborhood health centers
- D.
Rehabilitation facilities
- 99.An ambulatory care encounter is defined as
- A.
The patient's visit to the facility's outpatient department
- B.
A specific indentifiable act of service provided to a patient
- C.
Direct contact between a patient and a health care provider
- D.
The course of care a patient receives for a medical problem
- 100.A nongovernment-owned hospital can be sponsered by any of the following EXCEPT:
- A.
Municipalities
- B.
Churches
- C.
Corporations
- D.
Individuals
- 101.Peer Review Organizations obtain government contracts to evaluate the necessity and quality of health services rendered to Medicare patients. Reviews are conducted and judgments are based primarily on the
- A.
Contract negotiated between patient and Medicare
- B.
Itemized bill submitted by the health care facility
- C.
Health care facility's quality management reports
- D.
Documentation contained within the health record
- 102.Which is an example of a medical staff rule and regulation?
- A.
Descriptive policy of medical staff organization
- B.
Practice of electing medical staff officers
- C.
Written plan for internal disaster coverage
- D.
Procedure for amending record documentation
- 103.On January 15, the patient underwent an intravenous pyelogram performed by the x-ray technician and interpreted by the radiologist, who also met with the patient briefly; urinalysis performed by the lab technician and interpreted by the pathologist; and one hour of gait training was conducted by the physical therapist in the Physical Theropy Department. How many occasions of service were provided?
- A.
One
- B.
Two
- C.
Three
- D.
Four
- E.
Five
- 104.Which statement bwlow representsa current trend in the provision of ambulatory care?
- A.
Ambulatory health care costs will continue to increase dramatically
- B.
Access to ambulatory health care services will be limited geographically
- C.
Ambulatory health care is being selected as an alternate form of care
- D.
Technological breakthroughs will limit ambulatory health care services
- 105.Which health maintenance organization model requires employed physicains to treat patients in the organization's facilities?
- A.
Closed
- B.
Group
- C.
Practice
- D.
Staff
- 106.The term nursing facility is being applied to facilities participating in the Medicaid program and replaces the term
- A.
Custodial care facility
- B.
Intermediate care facility
- C.
Long-term facility
- D.
Skilled care facility
- 107.Compliance by a long-term care facility with which of the following would be considered voluntary?
- A.
JCAHO
- B.
COP
- C.
SOH
- D.
OBRA
- 108.Utilization review of hospice services uses objective criteria to monitor concerns. Review each statement below and select the one that would be considered utilization review monitoring.
- A.
Routine collection of information pertaining to interdisciplinary team services
- B.
Identification of problems regarding care delivery to a hospice patient population
- C.
Documentation of quality assurance program findings resulting in action taken
- D.
Evaluation of appropriateness of level of hospice and team services services provided
- 109.A physician who is anactive member in one hospital and applies to admit an occasional patient to another is applying for what kind of medical staff membership at the second facility?
- A.
Active
- B.
Consulting
- C.
Courtesy
- D.
Honorary
- 110.A multidisciplinary team approach in mental health care allows for participation in monitoring and socumenting the patient's progress during and response to treatment. Which documentation system would best allow for the above process?
- A.
Integrated record
- B.
Patient management
- C.
Problem-oriented
- D.
Source-oriented
- 111.A health care facility receives notification from the Joint Commission of Accreditation of Healthcare Organizations that it has received an accreditation with commendation.This means that:
- A.
The facility was in almost total compliance with the JCAHO standards
- B.
Within an 18-month time frame the facility will undergo self-assessment
- C.
A plan of correction must be completed by the facility within 6 months
- D.
Reaccreditation will be unneccessary in the future as it is automatically renewable
- 112.Which gives legal approval for a facility to offer services?
- A.
Accrediation
- B.
Certification
- C.
Licensure
- D.
Regulation
- 113.Upon review of discharged health records, the analysis clerk notices that one physician in consistent in his lack of timely discharge summary documentation. He has previously been notified of this problem. Next, the analysis clerk should
- A.
Speak directly to the physician responsible
- B.
Notify the health record committee of the findings
- C.
Bring the situation to the attention of administration
- D.
Talk with her supervisor about the situation
- 114.Revisions of report forms created for use in the record must be approved by the
- A.
Hospital administrator
- B.
HIM committee
- C.
Health information manager
- D.
State department of health
- 115.A factory guaranteed that all employees would seek care at the local hispital and was able to negotiate a special reduced rate for care rendered. This is a(an)
- A.
Health maintenance organization
- B.
Independent practice associateion
- C.
Point-of-service plan
- D.
Preferred provider organization
- 116.Which form would provide the basic facts about a long-term care resident who has been transferred from a hospital?
- A.
Admission assessment
- B.
Admitting evaluation
- C.
Comprehensive care plan
- D.
Referral statement
- 117.An accident report was generated on Joe Poole when he was found on the floor next to his nursing facility bed. Mr. Poole was evaluated and found to be unharmed by the presumed fall. The staff responsible for caring for Mr. Poole completed an accident report and
- A.
Filed it in the clinical record and documented a progress note about the resident's fall
- B.
Forwarded it to the nursing facility administrator's executive office for safekeeping
- C.
Gave it to the patient's family for use in any possible litigation regarding the fall
- D.
Documented a clinical record progress not and forwarded the report to the CEO
- 118.The release of health records that contain information about a drug addiction for which the patient sought treatment is controlled by
- A.
Federal regulation
- B.
JCAHO
- C.
Medicare COP
- D.
State statutes
- 119.A minimum data set is mandated for use in certified long-term care facilities. The federal requirements that address this document are found under
- A.
Medicare COP
- B.
CFR 483.20
- C.
PL 94-63
- D.
ASTM E1384
- 120.The increase in home health care services being offered has resulted in a (n)
- A.
Decrease in acute care facility lengths of stay
- B.
Decrease in number of home health patients
- C.
Increase in the country's costs of health care
- D.
Increase in long-term care facility admissions
- 121.The JCAHO requires mental health care facilities to conduct several types of quality assurance reviews. Review the list below and select the type of review that would be more characteristic of that conducted in a mental health care facility than a hospital.
- A.
Review of medication errors
- B.
Review of experimental drugs
- C.
Review of adverse effects
- D.
Review of drug records
- 122.Which has ultimate authority and responsiblility for providing proper care to hospital patients?
- A.
Governing board
- B.
Hospital administrator
- C.
Medical staff
- D.
Nursing staff
- 123.Sally Smith underwent emergency surgery in the hospital's day surgery unit and stayed a total of 18 hours. The care rendered during this time was
- A.
Ambulatory care
- B.
Ancillary care
- C.
Emergency care
- D.
Inpatient care
- 124.A facility that has a medical staff consisting of MD's and DO's desires American Osteopathic Association accreditation status. It is also currently accredited by the Joint Commission on Accreditation of Healthcare Organizations. The facility
- A.
Must use the term osteopathic in the facility's title and on it's stationery
- B.
Is mandated by federal law to ask permission of the JCAHO before proceding
- C.
Will find that the AOA accreditation process is similar to that of the JCAHO
- D.
Can expect to be granted up to a 5-year accreditation status by the AOA
- 125.A local hospital expanded its services offered to the community and operates an urgent care center across town in addition to the hospital.This would now be considered a
- A.
Multihospital system
- B.
Single hospital ownership
- C.
Corporation-owned facility
- D.
Voluntary community facility
- 126.A departmentalized medical staff is organized according to service. What is the title of the individual who is responsible for directing the functions of each service?
- A.
Chairperson
- B.
Supervisor
- C.
Coordinator
- D.
Administrator
- 127.Medicare would categorize a county health department home health agency as
- A.
Provider-based
- B.
Proprietary
- C.
Private nonprofit
- D.
Government
- 128.The health information manager who investigates the establishment of a policy for mental health record retention should first
- A.
Meet with the facility's administration to solicit their suggestions
- B.
Survey clinical staff to determine their needs to review original records
- C.
Evaluate the amount of space available in the clinical record department
- D.
Check the state mental health code for record retention requirements
- 129.Home health care agencies have established a protion of the record that can be maintained in the home. Information contained in this record would include all EXCEPT:
- A.
Emergency plans
- B.
Patient instructions
- C.
Plan of treatment
- D.
Agency staff names
- 130.An 85-year old female home health patient requires assistance with daily bathing, weekly housecleaning, and daily preparation of one meal. She is recovering from recent hip replacement surgery on the right. She has completely recovered from the left hip replacement surgery she underwent 3 months ago. The home health agency reviewed her request and assigned a caregiver. Unfortunately, a home health aide was unavailable for this assignment; the agency sent a nurse to perform the above tasks. This is an example of
- A.
Cost overutilization
- B.
Cost underutilization
- C.
Essential medical care
- D.
Medical necessity
- 131.Many long-term care facilities perform chart thinning. This means that
- A.
Lightweight folders are used for discharged records because chart activity levels will be low in long-term care facilities
- B.
Only basic information retained in the permanent long-term care health record after the required retention period
- C.
Material is removed from the active portion of the record and kept in a central location of the health care facility
- D.
Patients with multiple admissions to the facility (and multiple charts) have the current record available on the unit
- 132.Rehabilitative care requires coordination of health disciplines to facilitate a successful patient outcome. A critical factor in the coordination of the rehabilitation process is
- A.
Case management
- B.
Discharge planning
- C.
Establishment of goals
- D.
Preadmission evaluation
- 133.Because the clinical record is a confidential document, release of information must be handled in such a way that no unauthorized person has access to the record. Another consideration is the situation in which a patient is transferred from one facility to another. The transferring facility fowards copies of records to the receiving facility; this information from the transferring facility is placed in the receiving facility's health record. Upon discharge of the patient from the second facility, the insurance campany responsible for paying for the stay requests copies of any and all records on this particular patient. How should the receiving facility handle the rerelease of copies of the transferring facility's health record?
- A.
Release only that information generated during patient reatment at the receiving facility; do not rerelease information obtained from previous settings
- B.
Release the transferring facility's health record as requested after first obtaining permission from their health information management department
- C.
Release any information requested because the contract established between the transferring and receiving facilities would allow for this
- D.
Release information from the transferring facility's health record after first instructing the insurance company to obtain patient permission to do so
- 134.Who has primary responsibility for the home health care client's plan of care?
- A.
A home health care agency nurse who cares for the patient
- B.
A local hospital that has previously treated the patient
- C.
The family member responsible for the patient's care at home
- D.
The patient's attending physician (who sees the patient in the office)
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