Final Review - HITT 1301 - Health Data Content & Structure (Jesko)

  1. Version control of documents in the EHR requires Policy and procedures to control which version is displayed
  2. The computer system that may serve as the MPI function is the
    Patient registration system
  3. What evolving role oversees the revenue cycle from documentation through billing?
    Revenue cycle manager
  4. Examples of patient care delivery usage of the medical record include which of the following uses...
    Communication between caregivers
  5. We had 324 Medicare patients last month.  This statement represents which of the following:
  6. Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
    Care plan
  7. Name the two major types of data that are contained in the health record
    Health records contain a wide range of information, but most information within a health record can be grouped into two main categories:  administrative or demographic data and clinical data (
  8. Registration record
    Documents demographic information about the patient
  9. Physical examination
    Contains the providers findings based on an examination of the patient
  10. Physician Order
    Document the physicians instructions to other parties involved in providing the patients care, including orders for medication and diagnostic and therapeutic procedures
  11. Reports of diagnostic and therapeutic procedures
    Describe the procedures performed and give the names of clinicians and other providers, include the findings of x rays, mammograms, ultrasounds, scans, laboratory tests, and other diagnostic procedures
  12. Consultation
    Document opinions about a patients condition furnished by providers other than the attending physician
  13. Consents, authorization, and acknowledgements
    Document the patients agreement to undergo treatment or services, permission to release confidential information, or recognition that information has been received
  14. Medical History
    Document the patients current and past health status
  15. Patient instructions
    Document the instructions for follow up care that the provider gives to the patient or the patients caregiver
  16. Clinical observation
    Provide a chronological summary of the patients illness and treatment as documented by physicians, nurses and allied health professionals
  17. Discharge summary
    Concisely summarizes the patients stay in the hospital
  18. I work for CMS; how would I use the health record
    Make decisions on healthcare reimbursement
  19. Which filing system is considered to be the most efficient?
    terminal-digit filling system
  20. The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:
    Unit numbering system
  21. Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in which of the following?
  22. The patient indicated that her pain is worse.  In which part of a SOAP note would this information be recorded
  23. An auditor who is employed by Medicare is reviewing a health record for a mortality study.  This auditor is an individual health record user
  24. An attending physician requests the advice of a second physician who then reviews the health record and examines the patient.  The second physician records impressions in what type of report?
  25. Data granularity
    A characteristic of data whose values are defined at the appropriate level of detail
  26. Security
    A program designed to protect patient privacy and to prevent unauthorized access, alteration, or destruction of health records
  27. Privacy
    An individuals right to control access to his or her personal information
  28. Data comprehensiveness
    A characteristic of data that includes every required data element
  29. Data relevancy
    A characteristic of data where the data are useful
  30. A physical therapist documenting in the health record is an institutional health record user
  31. A researcher uses data to determine the recommended treatment
  32. Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-55.  What filing system is being used if these numbers represent the health record numbers of three records filed together within the system
    Terminal digit filing
  33. Which of the following administrative documents provides information on the patient desire for healthcare for use if he/she is incapcitated?
    Advance directives
  34. The traditional model of HIM practice was:
    Department based
  35. Patients do not have the right to add missing information to the health record
  36. Which type of health record includes both paper and electronic components?
  37. Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record
  38. What evolving role assesses quality in health record banking?
    Health record reviewer
  39. Which of the following users would utilize aggregate data?
    Patient care managers and support staff
  40. Reviewing a health record for missing signatures and missing medical reports is called
  41. Which of the following reports provides information on tissue removed during a procedure?
    Pathology report
  42. The lab test "hemoglobin: gm/ ml" is considered information
  43. Paper records may require thinning in which two settings?
    Long term care and correctional services
  44. 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:
  45. Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient
    Emergency Care
  46. Which of the following is not considered patient demographic information?
    Admitting diagnosis
  47. A physician just received notification from an EHR system that a patients lab test had a dangerously high value.  This is an example of what kind of clinical tool?
    Clinical decision support
  48. The health record is the principal repository for data and information about the healthcare services provided to individual patients
  49. The new model of HIM practice is:
    Information focused
  50. CMS uses data to accredit hospitals
  51. The primary guide to locating a record in a numerical filing system is the
    Master patient index
  52. In a paper based system individual health records are organized in a pre established order.  This process is called:
  53. A registry is a secondary data source
  54. Which of the following is a disadvantage of an EHR over a paper based reports?
    Enables duplicate copies to be made easily
  55. Record retention should be based on
    State and AHIMA recommendations
  56. Financial and other Administrative Process are secondary purpose of the health record
  57. Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility policies are called:
    Delinquent records
  58. What evolving role oversees the revenue cycle from documentation through billing?
    Revenue cycle manager
  59. The computer system that may serve as the MPI function is the
    Patient registration system
  60. Which of the following users of the health record is an example of an institutional user?
    Third party payer
  61. Version control of documents in the EHR requires Policy and procedures to control which version is displayed
  62. Under the Patient Self-Determination Act of 1991, advance directives
  63. During retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin.  What type of review is this clerk performing?
  64. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of
  65. Which of the following is least likely to be identified by a deficiency analysis technician?
  66. The performance of qualitative analysis is an important tool in ensuring data quality.  These reviews evaluate
  67. In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients.  Even more alarming, was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies?  Fifteen percent of delinquent records show:
  68. A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records
  69. A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1.  Which of the following statements regarding the history and physical is true in this situation?  Completion and charting of the H&P indicates
    non-compliance with Joint commission standards
  70. Ultimate responsibility for the quality and completion of entries in the health records belongs to the
    attending physician
  71. Many of the principles of forms design apply to both paper-based and computer based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer
    based system must give careful consideration to
    bar codes placement
  72. Which of the following technologies works well with automated record tracking systems to speed the data entry process?
    bar codes
  73. Color coding of medical record folders is used to assist in the control of
  74. Joint Commission requires the attending physician to countersign health record documentation that is entered by
    interns/medical students
  75. In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent?
    the year the case was entered into the database of the registry
  76. The first cancer patient seen in your facility on January 1, 2010, was diagnosed with colon cancer, with no known history of previous malignancies.  The accession number assigned to this patient will be
  77. You are interested in identifying every reportable case of cancer from the previous year.  A key resource will be the facility's
    disease index
  78. You have been asked by a peer committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital.  Which secondary data source could be used to quickly gather this information?
    operation index
  79. Mary Schnering was admitted to Community Hospital on 1/3/11 and assigned a record number of 54-47-53. The patient was later admitted on 2/14/11 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/filing system is being used at Community Hospital?
  80. In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.  You must name each form for bar coding and indexing into a document management system.  The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is
    pathology report
  81. As a prerequisite to phasing in a new imaging system, what process would facilitate automatic indexing?
  82. Data-entry methodology should be considered when the information is to be keyed into a computer. The order of the form does not need to mirror the data-entry order to ensure that information is entered consistently
  83. Each form should have a concise title that
    clearly identifies the form's purpose.
  84. Your state regulations require records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be
    7 years
  85. Which set of records filed consecutively on a shelf displays terminal digit filing order?
    57-78-00, 57-78-01, 56-78-99
  86. What is the chief criterion for determining record inactivity?
    amount of space available for storage of newer records
  87. Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record?
    delegated use of computer key by radiology secretary
  88. Select the appropriate situation for which a final progress note may legitimately be
    substituted for a discharge summary in an inpatient medical record:
    Baby Boy Hiltz, born 1/2/2010, maintained normal status, discharged 1/4/2010
  89. In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments.  This information can be obtained most efficiently from
    R-ADT system
  90. Every case entered into the registry is assigned a unique accession number preceded by the accession year, or the year the case is entered into the database.   You are interested in identifying every reportable case of cancer from the previous  year.  A key resource will be the facility's
    disease index
  91. Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?
    yes - prior to surgery
  92. Patient data collection requirements vary according to healthcare setting.  A data element you would expect to be collected in the MDS but NOT in the UHDDS would be:
    cognitive patterns
  93. As supervisor of the Cancer Registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use
    accession register
  94. Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past six months?
    disease index
  95. A quality improvement team is focusing on the unacceptable number of unsigned doctors' orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be:
    developing an open-record review process
  96. Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatric facility are generally in the form of:
    concurrent chart review
  97. For a healthcare facility to meet its document destruction needs, the certificate of destruction should include all but which one of the following elements?
    patient notification
  98. Which of the following issues would be of LEAST concern when storing health records in off-site storage?
    filing order of the records
  99. Documentation of record destruction should include all but which one of the following?
    dates not covered in destruction
  100. For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
    problem list
Card Set
Final Review - HITT 1301 - Health Data Content & Structure (Jesko)
Final Review - HITT 1301 - Health Data Content & Structure (Jesko)