Chima Mock Test Practice Questions! Quiz

A health record that uses both manual and electronic processes is described as a hybrid health record. This means that the record combines both paper-based and digital methods of storing and managing health information. The term "hybrid" suggests a combination of two different elements, in this case, manual and electronic processes.

Tolerance would not be one of CHIMA's values because the other three options, leadership, integrity, and excellence, are commonly recognized as core values in many organizations. Tolerance, on the other hand, may not align with CHIMA's values or may not be considered a priority for the organization.

The purpose of regionalization in healthcare includes controlling costs and integrating health care services, improving system planning and providing greater accountability, as well as enhancing public participation in decision-making and emphasizing population health. All of these objectives are important in creating a more efficient and effective healthcare system.

The departmental manager should initially address the HIM professional's chronic lateness and poor work performance. As the immediate supervisor, the departmental manager is responsible for managing and overseeing the performance of their team members. They have the authority to address performance issues, provide feedback, and implement corrective actions if necessary. The CHIMA Code of Ethics is a professional code of conduct that guides HIM professionals' ethical behavior but does not specifically address performance issues. The staff members union and human resources department may become involved if the issues persist or require further intervention.

The other options listed are all considered health record documentation best practices. However, the statement that documentation should take place within an hour of the event that is being recorded is not a best practice. While timely documentation is important, there is no specific time frame within which documentation must occur. The focus should be on ensuring that the documentation is true, complete, clear, concise, and legible, includes the date and time of the entry, and is authenticated by the person who prepared it.

The most effective corrective action would be to review and possibly reengineer the retrieval process to decrease retrieval time. This would involve analyzing the current process, identifying any inefficiencies or bottlenecks, and making necessary changes to streamline the process and reduce delays. Offering a prize to the employee who locates the requested records first may create a competitive environment but may not address the underlying issues causing the delay. Allowing the requesters to retrieve the records themselves may not be feasible or efficient in a busy emergency department. Increasing file area staff may help to some extent but may not address the root cause of the delay.

When an ethical complaint is made against a CHIM professional, the complaint is investigated by the Professional Ethics Committee. This committee is responsible for reviewing and addressing ethical concerns raised against CHIM professionals. They ensure that the professional standards and code of ethics are upheld and take appropriate actions if any violations are found. The committee consists of experienced professionals who are knowledgeable about the industry and its ethical practices. They play a crucial role in maintaining the integrity and reputation of the CHIM profession.

LOHIM is the correct answer because it stands for "Learning Outcomes for Health Information Management" and is the title of the document that contains the core HIM curriculum content that must be taught in all accredited HIM programs in Canada. The LOHIM document outlines the essential knowledge and skills that HIM professionals need to possess in order to practice effectively in the field. It serves as a guide for educators and program administrators in developing and delivering HIM courses and programs.

Based on the concept of progressive discipline, the next step after a verbal warning would be a written warning and reprimand. Progressive discipline is a systematic approach where disciplinary actions escalate in severity if an employee continues to violate workplace policies or rules. In this case, since the employee is consistently late for work even after a verbal warning, a written warning and reprimand would be the appropriate next step to clearly document the issue and emphasize the importance of punctuality.

Reviewing a random sample of each employee's work monthly would be the most effective approach to monitor the accuracy of coding. This method allows for a regular and ongoing evaluation of the employees' work without being too burdensome or time-consuming. By reviewing a random sample, it ensures that all employees have an equal chance of being assessed, providing a fair and unbiased assessment of their coding accuracy. Additionally, reviewing the work on a monthly basis allows for timely feedback and identification of any potential issues or areas for improvement.

As the new Manager of Health Information Services, it is important to ensure that the department policy and procedure manual reflects current employee practices. Leaving the policy as written in the manual would not address the issue of incongruence and may lead to confusion or noncompliance. Contacting the hospital attorney may be necessary in certain situations, but it is not the appropriate action in this case. Enforcing the existing policy without revising it would not address the incongruence. Therefore, the best course of action is to revise the policy appropriately and document the date of the change to ensure that it aligns with current employee practices.

Mary is not required to release the extra documentation because the facility has the right to interpret a request and apply the minimum standard rule. This means that Mary followed the guidelines and provided all the necessary information based on what was requested. She confirmed with her supervisor, indicating that she took the necessary steps to ensure she fulfilled the request correctly. The fact that the requestor still believes additional documentation is needed does not override the facility's right to interpret the request and apply their own standards.

Both original and revised documentation must be retained as part of the record. This means that even after correcting any errors in the documentation, the original version of the document should still be kept along with the revised version. This is important for maintaining a complete and accurate record of the patient's care and treatment. It also ensures transparency and accountability in case there are any questions or disputes regarding the documentation.

The supervisor should refer the record to the Risk Manager for further review and removal of the incident report. This is the best practice because the incident report may contain sensitive information that should not be included in the patient's medical record. The Risk Manager is responsible for assessing and managing potential risks and can determine the appropriate course of action regarding the incident report.

The hospital should provide the records to Dr. Brown since he is treating the patient. As a treating physician, Dr. Brown has a legitimate need for the patient's medical records in order to provide appropriate care and treatment. Access to relevant medical information is crucial for effective healthcare management.

Consultation reports should be placed in a health record because they provide important information about a patient's medical history, diagnosis, and treatment plan. These reports are typically generated by a healthcare provider after a consultation with the patient, and they help to ensure continuity of care and facilitate communication between healthcare professionals. Incident reports, independent medical examination reports, and reports to government ministries may contain relevant information but are not typically included in a patient's health record.

Lack of skilled human resources would be considered as an operational risk. This type of risk arises from the potential failure of internal processes, systems, or human resources within an organization. In this case, the lack of skilled human resources can lead to operational inefficiencies, decreased productivity, and potential errors or mistakes in the execution of tasks. It can impact the overall operational performance and success of the organization.

Coding data in a way that increases the facility's resource intensity weight (RIW) suggests a focus on improving the quality of the data. By increasing the RIW, the coding process aims to enhance the accuracy, reliability, and usefulness of the data. This ethical dilemma revolves around the decision of prioritizing data quality over other considerations such as privacy, secondary use, or risk.

A living will is an example of an advance directive because it is a legal document that allows individuals to express their wishes regarding medical treatment in the event that they become unable to communicate their preferences. It outlines specific instructions about the type of medical care they would like to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation. This document helps healthcare providers and family members make decisions that align with the individual's values and wishes when they are unable to do so themselves.

If the patient had been discharged before the notice of privacy practice acknowledgment was signed, the appropriate response would be to try to get it signed. However, if the patient cannot be reached or refuses to sign, it is important to document the action taken. This documentation is necessary to show that attempts were made to obtain the signed acknowledgment and to ensure that the healthcare provider has fulfilled their responsibility in informing the patient about their privacy rights.

An impact analysis is the type of assessment that would be done to assess the effects of a new medical staff, program, diagnostic technology, or intervention types on the financial and other consequences. It involves evaluating the potential outcomes and consequences of implementing a new initiative or change in order to understand its overall impact on various aspects. This assessment helps in making informed decisions and understanding the potential benefits or drawbacks of the proposed changes.

The first step in Glover's seven-step process for examining an ethical dilemma is to define the ethical question. This involves clearly identifying and understanding the specific ethical issue or problem that needs to be addressed. By defining the ethical question, one can focus on the core problem at hand and begin to analyze it from an ethical standpoint. This step helps to provide clarity and direction in the decision-making process when faced with an ethical dilemma.

The correct answer is the Canadian Association of Medical Record Librarians. This is because the question is asking for the original name of the Canadian Health Information Management Association (CHIMA), and out of the given options, the Canadian Association of Medical Record Librarians is the only one that matches the original name.

The correct answer is PIA. PIA stands for Privacy Impact Assessment, which is a process that helps departments and agencies evaluate whether new technologies, information systems, initiatives, or proposed programs and policies meet the established privacy requirements. It involves identifying and assessing the potential privacy risks and impacts associated with the implementation of these initiatives and ensuring that appropriate measures are taken to mitigate those risks and protect individual privacy.

The stillborn infant's clinical documentation would be filed in the mother's record because the mother was the patient receiving care during the delivery. The infant's record would not be separate from the mother's record as the infant did not have a separate health record.

The primary objection to auto authentication of entries in a health record is that evidence cannot be provided that the physician reviewed and approved each report. This means that there is no way to ensure the accuracy and legitimacy of the information entered into the health record. Without the physician's review and approval, there is a risk of errors or false information being recorded, which can have serious consequences for patient care.

The best method to verify that the software will work as marketed is to test the software prior to purchase. By testing the software, the Assistant Director of Record Processing can assess its functionality, performance, and compatibility with the department's requirements. This will provide first-hand experience and ensure that the software meets their needs before making a purchase decision. Visiting the vendor's headquarters or performing a vendor reference check may provide additional information, but testing the software directly is the most effective way to verify its performance. Reading consumer reports can also be helpful, but it may not provide specific insights relevant to the HIM Department's chart tracking system.

Risk Management is not a domain of practice for CHIMA because it is not directly related to the management and utilization of health information. CHIMA focuses on areas such as Electronic Health Information Management (e‐HIM), Data Quality, and Health Information Management Standards, which are more directly related to the collection, analysis, and use of health information. Risk management, on the other hand, deals with identifying, assessing, and mitigating potential risks and hazards in various organizational contexts, which is not specific to health information management.

An improper disclosure of patient information to unauthorized individuals, agencies, or news media can be considered an invasion of privacy because it violates the patient's right to keep their personal and medical information confidential. This breach of privacy can cause harm to the individual by exposing sensitive information that should only be shared with authorized healthcare professionals. Invasion of privacy is the appropriate term to describe this violation, as it encompasses the unauthorized disclosure of personal information.

The correct answer is benchmarking. Benchmarking is the process of comparing one's own performance or practices against industry standards or best practices. In this case, the national HIM publication requests statistics from practitioners to summarize and publish them in graphic form. This allows practitioners to compare their facility's department functions with others in the industry, providing a benchmark for performance evaluation and improvement.

In emergency situations, when immediate medical attention is required to save a person's life or prevent further harm, consent is not needed from the patient or their legal guardian. The principle of implied consent applies, which means that the healthcare provider can provide necessary treatment without seeking explicit consent. In this case, since William is unconscious and in need of urgent treatment, the healthcare provider does not need to seek consent from his mother, girlfriend, or anyone else.

In the seven-step process for considering ethical dilemmas, the second step is to identify the facts. This involves gathering all relevant information and understanding the specific details of the situation at hand. By identifying the facts, individuals can have a clear understanding of the context and circumstances surrounding the ethical dilemma, which is crucial for making informed decisions and considering the potential implications of different choices.

Accidental privacy breaches occur when data is collected, shared, altered, accessed, or destroyed unintentionally. This can happen due to human error, system glitches, or technical issues. Unlike malicious breaches, accidental breaches do not involve any deliberate intent to harm or exploit the data. Instead, they are often the result of mistakes or oversights. Accidental breaches can still have significant consequences, as they may lead to unauthorized access or exposure of sensitive information. It is important for organizations to implement proper safeguards and protocols to minimize the risk of accidental privacy breaches.

The most appropriate course of action would be to discuss your concerns with the supervisor of coding and direct her to address this issue immediately. This option addresses the problem directly by involving the supervisor, who is responsible for managing the coders. By discussing the concerns and instructing the supervisor to address the issue, it ensures that the coder receives the necessary instructions and guidance to review the entire record for correct assignment of codes. This approach promotes accountability and helps maintain the quality and accuracy of the coding process.

Electrocardiograms (ECGs) are diagnostic tools used to measure the electrical activity of the heart, not a data visualization technique. Scatter plots, heatmaps, and Gantt charts are commonly used to visually represent and analyze healthcare data. Scatter plots show the relationship between two variables, heatmaps display data using color variations, and Gantt charts illustrate project schedules and timelines.

Physical safeguards are measures implemented to protect physical assets and resources. In this case, the correct answer is "1 and 3 only" because option 1 includes the use of an alarm system and option 3 includes flood protection. These measures help to ensure the physical security of the premises and protect against potential threats such as theft, unauthorized access, and damage caused by natural disasters like floods. Option 2, which refers to tools to control access to computer systems, and option 4, which mentions a firewall, are not considered physical safeguards but rather fall under the category of logical or technical safeguards.

While all the options are important for maintaining data integrity in a health information management system, audit trails and access controls are the most effective method. Audit trails track who accessed or modified the data, providing a record that can be reviewed for any discrepancies. Access controls limit who can view or alter the information, reducing the risk of unauthorized changes. These methods directly address the integrity and security of the data.

Scope creep refers to the phenomenon where the project's scope gradually expands beyond its original boundaries. In this scenario, several departments are requesting additions to the project, indicating that the project's scope is expanding. This is a common occurrence in projects, where stakeholders may request additional features or requirements, leading to scope creep.

The project justification should include the project scope, which outlines the goals and objectives of the project. It should also specify the resources needed, such as manpower, equipment, and budget, to successfully complete the project. Additionally, the justification should mention the amount of time required to complete the project, including any deadlines or milestones.

A written reprimand expressing disapproval of unethical conduct by a member, but without loss of membership or registration status is called censure. Censure is a formal expression of disapproval or criticism, typically issued by a governing body or organization. It serves as a way to publicly reprimand and express disapproval of unethical behavior without imposing harsher penalties such as probation, expulsion, or suspension.

Statutory law refers to the rules and principles established by legislative bodies. These laws are enacted by the government and are written down in statutes or codes. They are created to regulate various aspects of society and are applicable to everyone within a jurisdiction. Administrative law, case law, and common law are different types of laws that are not determined by legislative bodies, making them incorrect choices.

The phase of the risk management process that involves ensuring that adverse events are continuously reported, investigated, and managed, and that risks are identified is monitoring and review. This phase involves regularly monitoring and reviewing the effectiveness of risk controls, identifying any new risks that may arise, and ensuring that appropriate actions are taken to address them. It also involves reviewing incident reports and conducting investigations to understand the root causes of adverse events and implementing measures to prevent their recurrence. By continuously monitoring and reviewing the risk management process, organizations can proactively identify and address potential risks and improve their overall risk management effectiveness.

This principle of comprehensiveness requires provinces to fund 100% of the cost of all insured health services provided by hospitals, medical practitioners, and dentists. It means that all necessary health services, regardless of the specific type or provider, should be covered and funded by the provinces. This ensures that individuals have access to a wide range of health services without financial barriers, promoting equitable healthcare for all.

Probation is the disciplinary direction that would include mandatory participation in professional counseling. When an individual is put on probation, they are given a chance to rectify their behavior or actions under certain conditions. In this case, one of the conditions of probation is mandatory participation in professional counseling. This requirement aims to address any underlying issues or concerns that may have contributed to the disciplinary action and help the individual improve their professional conduct.

A Gantt chart is a visual tool that displays the steps and completion schedule for each phase of a project. It provides a timeline view of tasks, allowing the director to see the sequence of activities and their duration. In the context of converting a filing system to a terminal digit filing system, the director can use a Gantt chart to plan and track the various steps involved in the conversion process. This chart will help the director allocate resources, set deadlines, and monitor the progress of the project.

The external context related to e-health solutions includes factors that are beyond the control of the organization or individual implementing the solutions. Political context refers to the influence of government policies, regulations, and political environment on e-health solutions. This can include laws related to privacy and data protection, funding and reimbursement policies, and government initiatives promoting e-health adoption. It is important to consider the political context when developing and implementing e-health solutions to ensure compliance with regulations and to align with government priorities.

The contribution to the quality of patient care is not considered a challenge in the adoption of an electronic health record system. This implies that implementing an electronic health record system is believed to have a positive impact on the quality of patient care. The other options, such as the design of the workflow and processes, physician willingness to adopt, and legal and regulatory issues, are all recognized challenges that can hinder the adoption of an electronic health record system.

Managers of health information departments often prepare two types of budgets: the capital budget and the operational or revenue and expense budget. The capital budget focuses on long-term investments and expenditures related to equipment, infrastructure, and facilities. On the other hand, the operational or revenue and expense budget focuses on day-to-day expenses, revenue generation, and operational activities. These two budgets are crucial for managers to effectively plan and allocate resources in the health information department.

The correct answer is "Privacy laws." Privacy laws impose legal obligations on health information custodians or trustees to put appropriate privacy policies and procedures in place. These laws are designed to protect the privacy and confidentiality of individuals' personal health information. They require custodians and trustees to establish safeguards to prevent unauthorized access, use, or disclosure of health information. By complying with privacy laws, custodians and trustees ensure that they are handling personal health information in a responsible and secure manner, respecting individuals' privacy rights.