Deck 1: Registered Health Information Administrator

Question 1

The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate

A) quality of care through the use of pre-established criteria.
B) adverse effects and contraindications of drugs utilized during hospitalization.
C) potentially compensable events.
D) completeness, adequacy, and quality of documentation.

Answer 1

D

Question 2

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of

A) retrospective deficiency analysis.
B) special study audits.
C) concurrent chart review.
D) occurrence screening.

Answer 2

C

Question 3

The foundation for communicating all patient care goals in long-term care settings is the

A) legal assessment.
B) labor and delivery record.
C) interdisciplinary patient care plan.
D) Uniform Hospital Discharge Data Set.

Answer 3

C

Question 4

The minimum length of time for retaining original medical records is primarily governed by

A) Joint Commission.
B) medical staff.
C) state law.
D) readmission rates.

Question 5

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.

A) a new H&P is required for every inpatient admissions.
B) that you apologize for not noticing the H&P she provided.
C) the H&P copy is acceptable as long as she documents any interval changes.
D) Joint Commission standards do not allow copies of any kind in the original record.

Question 6

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of

A) fingerprint signatures.
B) voice recognition systems.
C) expert systems.
D) electronic signatures.

Question 7

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

A) interdisciplinary patient care plan.
B) discharge summary.
C) transfer record.
D) problem list.

Question 8

In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent?

A) the number of primary cancers reported for that patient
B) the year the case was entered into the database of the registry
C) the sequence number of the case
D) the stage of the tumor based upon the TNM system of staging

Question 9

Discharge summary documentation must include

A) a detailed history of the patient.
B) a note from social services or discharge planning.
C) significant findings during hospitalization.
D) correct codes for significant procedures

Question 10

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS would be

A) personal identification.
B) cognitive patterns.
C) procedures and dates.
D) principal diagnosis.

Question 11

In preparation for an HER, 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

A) recovery room record.
B) pathology report.
C) operative report.
D) discharge summary.

Question 12

A health record analyst needs to quickly compare all lab values during one hospitalization. The paper-based health record format best suited for this purpose is

A) problem-oriented.
B) source-oriented.
C) reverse chronological.
D) integrated.

Question 13

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

A) it is too easy to delegate use of computer passwords.
B) evidence cannot be provided that the physician actually reviewed and approved each report.
C) electronic signatures are not acceptable in every state.
D) tampering too often occurs with this method of authentication.

Question 14

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

A) prenatal record.
B) labor and delivery record.
C) postpartum record.
D) discharge summary.

Question 15

A good first step toward protecting the security of data contained in a health information computer system would be to

A) establish a good record tracking system.
B) define levels of security for different types of information, depending on sensitivity.
C) provide remote terminals for improved access to the record.
D) provide internet access to facility records.

Question 16

As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility's

A) disease index.
B) number control index.
C) physicians' index.
D) patient index.

Question 17

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the

A) doctors' progress notes.
B) integrated progress notes.
C) incident report.
D) nurses' notes.

Question 18

Joint Comission requires the attending physician to countersign health record documentation that is entered by

A) interns or medical students.
B) midwives.
C) consulting physicians.
D) physician partners.

Question 19

Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?

A) Health Record Committee.
B) Utilization Review Committee.
C) Risk Management Committee.
D) Joint Conference Committee.

Question 20

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

A) chief of staff.
B) attending physician.
C) HIM director.
D) risk manager.

Question 21

The first cancer patient seen in your facility on January 1, 2008, was diagnosed with colon cancer, with no known history of previous malignancies. Th eaccession number assigned to this patient is

A) 2008-0000/00.
B) 2008-0000/01.
C) 2008-0001/00.
D) 2008-0001/01.

Question 22

Which of the following is a form or view that is typically seen in the health record of a long-term care patient, but is rarely seen in records of a acute care patients?

A) pharmacy consultation.
B) medical consultation.
C) physical exam.
D) emergency record.

Question 23

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 would be

A) chief complaint.
B) condition on discharge.
C) time and means of arrival.
D) growth and development record.

Question 24

When developing a data collection system, the most effective approach first considers

A) the end user's needs.
B) applicable accreditation standards.
C) hardware requirements.
D) facility preference.

Question 25

You have been asked by a peer review 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?

A) disease index.
B) physician index.
C) master patient index.
D) operation index.

Question 26

As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that will contribnute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for decision support regarding drug dosages and contraindications. You think they are ready for a

A) computer-output-to-laser-disk system.
B) electronic medication administration record system.
C) electronic document management system.
D) computerized provider order-entry system.

Question 27

In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of Him department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards your first recommended change is to

A) have more frequent committee meetings.
B) have the committee report to the Executive Committee.
C) have a physician perform all the reviews.
D) provide for record reviews to be performed by an interdisciplinary team of care providers.

Question 28

In an acute care hospital, a complete history and physical may not be dictated for a new admission when

A) the patient is readmitted for a similar problem within 1 year.
B) the patient's stay is less than 24 hours.
C) the patient has an uneventful course in the hospital.
D) a legible copy of a recent H&P performed in the attending physician's office is available.

Question 29

Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should

A) complete a new cancer abstract.
B) assign a new accession number.
C) updated the follow-up file.
D) complete a new master index file.

Question 30

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 statement regarding the history and physical is ture in this situation? Completion and charting of the H&P indicates.

A) noncompliance with Joint Commission standards.
B) compliance with Joint Commission standards.
C) compliance with Medicare regulations.
D) compliance with Joint Commission standards for nonsurgical patients.

Question 31

The best example of point-of-care service and documentation is

A) using an automated tracking system to locate a record.
B) using occurrence screens to identify adverse events.
C) doctors using voice recognition systems to dictate radiology reports.
D) nurses using bedside terminals to record vital signs.

Question 32

For each report of care rendered to a patient, the health record entry should include the date plus the provider's name and

A) department.
B) discipline.
C) initials.
D) supervising physician.

Question 33

As the Data Security Officer for your institution, you plan to implement a log-on process for electronic signing that is LEAST susceptible to improper delegation of use. The method you will recommend is

A) password assigned by system administrator.
B) password assigned by user.
C) biometrics-based identifier.
D) encryption.

Question 34

As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it. Another step you will need to take is to

A) authorize access to information collected based on level of data sensitivity.
B) prevent all nonclinicians' access to any confidential information in the system.
C) establish firewalls to protect aggregate data collected within your facility.
D) establish passwords for all customers, both internal and external, who request access to the information in your system.

Question 35

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

A) placement of hospital logo.
B) signature line for authentication.
C) use of box design.
D) bar code placement.

Question 36

In creating a new form or computer view, the designer should be most driven by

A) QIO standards.
B) medical staff bylaws.
C) needs of the users.
D) flow of data on the page or screen.

Question 37

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

A) Minimum Data Set
B) Uniform Hospital Discharge Data Set
C) Conditions of Participation
D) Federal Register

Question 38

One distinct advantage of the HER over paper-based health records is the

A) ease of developing screen designs over from designs.
B) accessibility of the record by multiple data users.
C) standardized format.
D) ease of data collection

Question 39

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

A) CARF manual.
B) hospital bylaws.
C) Joint Commission accreditation manual.
D) Federal Register.

Question 40

A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the

A) physical findings.
B) lab and diagnostic test results.
C) time and means of arrival.
D) instructions for follow-up care.

Question 41

The old practice of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

A) quantitative record review.
B) clinical pertinence review.
C) concurrent record analysis.
D) point-of-care documentation.

Question 42

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was missed dose of insulin. What type of review is this clerk performing?

A) utilization review.
B) quantitative review.
C) legal review.
D) qualitative review.

Question 43

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

A) 24 hours.
B) 3 days.
C) 15 days.
D) 60 days.

Question 44

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

A) integrated progress notes.
B) interdisciplinary treatment plans.
C) source-oriented records.
D) SOAP notes.

Question 45

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

A) objective survey of body systems.
B) chief complaint.
C) family history.
D) subjective review of systems.

Question 46

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at

A) 12 hours after admission.
B) 24 hours after admission.
C) 12 hours after admission or prior to surgery.
D) 24 hours after admission or prior to surgery.

Question 47

Which of the following is least likely to be identified by the deficiency analysis clerk?

A) missing discharge summary
B) needs for physician authentication of two verbal orders
C) discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
D) x-ray report charted on the wrong record

Question 48

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely to include checking for documentation regarding

A) the presence or absence of such items as preoperative and postoperative diagnosis description of findings, and specimens removed.
B) whether a postoperative infection occurred and how it was treated.
C) the quality of follow-up care.
D) whether the severity of illness and/or intensity of service warranted acute level care.

Question 49

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

A) generic screens used by record abstractors.
B) Disease index.
C) R-ADT system.
D) Indicator monitoring program.

Question 50

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

A) chronic pain management.
B) palliative care.
C) brain injury management.
D) vocational evaluation.

Question 51

As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the

A) facility's data dictionary.
B) MDS.
C) Glossary of Health Care Terms.
D) UHDDS.

Question 52

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should

A) provide the dictated tape to his staff.
B) request a "stat" report.
C) write a detailed operative note in the record.
D) request that administration hire more transcriptions.

Question 53

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

A) tissue examination done by the pathologist
B) impressions of a cardiologist asked to determine whether patient is a good surgical risk
C) interpretation of a radiologic study
D) technical interpretation of electrocardiogram

Question 54

An example of objective entry in the health record supplied by a health care practitioner is the

A) past medical history.
B) physical assessment.
C) chief complaint.
D) review of systems.

Question 55

An example of a primary data source for health care statistics other than the patient health record is the

A) disease index.
B) accession register.
C) MPI.
D) hospital census.

Question 56

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?

A) yes, within 8 hours post-surgery.
B) no, as long as it is dictated before surgery.
C) yes, prior to surgery.
D) yes, within 24 hours post-surgery.

Question 57

Under which of the following conditions can an original patient health record by physically removed from the hospital?

A) when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital
B) when the directory of health records is acting in response to a subpoena duces tecum and takes the health record to court
C) when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record
D) when the record is taken to a physician's private office for a follow-up patient visit postdischarge

Question 58

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the

A) UHDDS.
B) MDS.
C) Uniform Clinical Data Set.
D) Uniform Ambulatory Core Data.

Question 59

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

A) interval summary.
B) consultation report.
C) advance directive.
D) interdisciplinary care plan.

Question 60

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

A) sciatica unimproved with hot pack therapy
B) patient moving about very cautiously, appears to be in pain
C) adjust pain medication; begin physical therapy tomorrow
D) patient states low back pain is as severe as it was on admission

Question 61

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult

A) Consolidated Manual for Hospitals
B) Federal Register
C) Policy and Procedure Manual
D) Hospital Bylaws, Rules, and Regulations

Question 62

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a

A) data warehouse.
B) regional health information organization.
C) continuum of care.
D) data retrieval portal group.

Question 63

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

A) database.
B) problem list.
C) initial plan.
D) progress notes.

Question 64

Which of the following is a type of laser technology that is ideal for health records because it stores data in a permanent capacity, prohibiting users from altering, misfiling, or erasing data?

A) EDI.
B) OCR.
C) WORM.
D) COM.

Question 65

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

A) peer review.
B) quantitative review.
C) qualitative review.
D) legal analysis.

Question 66

An important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Both technical and procedural methods will bed used with the CPR to control and manage confidential information. An example of a procedural method for protecting data is

A) confidentiality statements signed by all staff.
B) limiting access of certain screens based on the staff's need to know.
C) auditing capability of system to track data access.
D) computer backup systems

Question 67

A quality improvement team is focusing on the unacceptable number of unsigned doctors' order sin your facility. The most effective method for increasing the timelines of signatures on orders and positively impacting the patient care process would be

A) performing a retrospective review where all orders can be flagged at one time.
B) holding a printed order sheet on the medical care unit at least 24 hours post discharge to give the physician time to sign.
C) developing an open-record review process.
D) devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient's care.

Question 68

As information security officer, you are revising the policies at your rehabilitation facility for handling all patient clinical information. Your best resource for checking out specific accreditation standards and guidelines is the

A) Conditions of Participation for Rehabilitation Facilities
B) Medical Staff Bylaws, Rules, and Regulations
C) Joint Commission manual
D) CARF manual

Question 69

As supervisor of the cancer registry, you report the registry's annual caseloads to administration. The most efficient way to retrieve this information would be to use

A) patient abstracts.
B) patient index.
C) accession register.
D) follow-up files.

Question 70

Accreditation by Joint Commission is a voluntary activity for a facility and it is

A) a considered unnecessary by most health care facilities.
B) required for state licensure in all states.
C) conducted in each facility annually.
D) required for reimbursement of certain patient groups.

Question 71

Which of the following is a secondary data source that be used dsto quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

A) disease index.
B) patient register.
C) pediatric census sheet.
D) procedure index.

Question 72

Key reports in a health record, such as history and physicals, discharge summaries, and operative reports, are generally dictated and transcribed. This recommended standard contributes most to data

A) timeliness.
B) accuracy.
C) legibility.
D) security.

Question 73

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

A) DEEDS.
B) UHDDS.
C) MDS.
D) ORYX.

Question 74

A primary focus of screen format design in a health record computer application should be to ensure that

A) programmers develop standard screen formats for all hospitals.
B) the user is capturing essential data elements.
C) paper forms are easily converted to computer forms.
D) data fields can be randomly accessed.

Question 75

Which method of identification of authorship or authentication of entries would be in appropriate to use in a patient's health record?

A) written signature of the provider of care
B) identifiable initials of a nurse writing a nursing note
C) a unique identification code entered by the person making the report
D) delegated use of computer key by radiology secretary

Question 76

Which of the four distinct components of the problem-oriented record contains the medical and social history of the patient?

A) database.
B) problem list.
C) initial plan.
D) progress notes.

Question 77

Which of the following indices might be protected from unauthorized access through t he use of unique identifier codes assigned to members of the medical staff?

A) disease index.
B) procedure index.
C) master patient index.
D) physician index.

Question 78

In a manual record tracking system, outguides replace a file that has been checked out of the system. A secondary function of outguides is to

A) serve as a visual check for misfiled records.
B) expedite correct placement of refilled records.
C) enhance the use of file guides.
D) cross-reference a file that has been moved forward to a new number.

Question 79

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.

A) patient admitted with COPD 1/4/2008 and discharged 1/7/2008
B) Baby Boy Hiltz's born 1/5/2008, maintained normal status, discharged 1/7/2008
C) Baby Boy Hiltz's mother admitted 1/5/2008, C-section delivery, discharged 1/7/2008
D) Baby Boy Doe admitted 1/3/2008, died 1/4/2008

Question 80

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.

A) missing signatures on progress notes
B) missing discharge summaries
C) absence of SOAP format in progress notes
D) missing operative reports