Deck 3: Sources of Data

Question 1

All of the data that have been collected about an individual patient are called a

A) health record
B) SOAP note
C) history & physical (H&P)
D) discharge summary

Answer 1

health record

Question 2

A compilation of patient data that have been collected over time from different settings are called a

A) progress note
B) longitudinal record
C) plan of care
D) discharge summary

Answer 2

longitudinal record

Question 3

Which is NOT an example of socioeconomic data?

A) marital status
B) religion
C) gender
D) sexual orientation

Answer 3

gender

Question 4

Which is an example of demographic data?

A) patient name
B) marital status
C) primary care provider (PCP)
D) employer

Question 5

Which of the following is NOT an example of clinical data?

A) appendectomy 3 years ago
B) primary care provider (PCP)
C) blood pressure reading
D) family history of chronic depression

Question 6

Which individual or entity is billed first for health services?

A) the patient
B) the guarantor
C) the primary payer
D) the guardian

Question 7

A patient presented in the emergency department with unusual lesions on the skin, a fever, and dehydration. Which type of data is the most helpful to the physician developing a diagnosis?

A) demographic data
B) administrative data
C) socioeconomic data
D) financial data

Question 8

The physician's conclusion about the patient's condition is the

A) outcome
B) symptom
C) assessment
D) diagnosis

Question 9

Patient status such as inpatient, outpatient, or observation are examples of _________ data.

A) demographic
B) administrative
C) socioeconomic
D) financial

Question 10

Which is a distinguishing factor between emergent and urgent care?

A) risk to the patient's health
B) social status
C) health insurance coverage
D) patient has appointment

Question 11

What is the name for the personnel who coordinate the patient's care and activities?

A) patient access
B) registrar
C) case management
D) health records services

Question 12

Which patient would be most likely to draw the attention of a Centers for Medicare and Medicaid Services auditor?

A) a patient who stays the night in the emergency department
B) a patient who is admitted, then discharged the next day
C) a patient on observation status for 28 hours
D) a patient who is treated without first obtaining demographic data

Question 13

_________ is the term for the physician's process of eliminating a potential diagnosis.

A) Plan of care
B) Precertification
C) Rule out
D) Outcome

Question 14

The clerk enters code 43, meaning the patient was sent to a Veteran's Administration hospital, as part of the ______________ data element.

A) progress note
B) SOAP note
C) discharge disposition
D) outcome and assessment

Question 15

Which is NOT one of the typical elements of an inpatient admission record?

A) home telephone number
B) religion
C) primary payer
D) vital signs

Question 16

The extent and complexity of a history and physical are dictated by:

A) Joint Commission guidelines.
B) facility policy
C) what the provider deems pertinent to the patient's problem
D) managed care guidelines

Question 17

What is/are the area(s) of focus for the provider performing a problem-focused physical examination?

A) All body areas and organ systems.
B) The head, neck, chest, and abdomen
C) The patient's general appearance and his or her vital signs
D) The body area(s) or organ system(s) affected

Question 18

In acute care, how often are physician's progress notes documented?

A) at least hourly
B) at least daily
C) at least every 48 hours
D) at least every 72 hours

Question 19

Obstetrical records differ from other types of acute care records because:

A) prenatal care data is collected earlier and transferred to the hospital.
B) obstetricians are not required by The Joint Commission (TJC) to collect a patient history and physical.
C) the newborn is considered an admission.
D) childbirth is not considered a disease.

Question 20

All of the following are always required elements of a physician's order, EXCEPT:

A) Date of the order.
B) physician's signature.
C) Time of the order.
D) reason/rationale for the order.

Question 21

Which must the recorder read back to the provider for confirmation?

A) order to admit
B) telephone order (TO)
C) order for Schedule I drugs
D) order for discharge

Question 22

According to TJC standards, when must the physician's operative report be completed?

A) prior to the procedure
B) during the procedure
C) immediately after the procedure
D) within 30 days of the patient's discharge

Question 23

Which documentation records the patient's status during a surgical procedure?

A) physician's order
B) operative report
C) nursing progress note
D) anesthesia report

Question 24

Which department reviews admissions to see if they are appropriate for the patient?

A) utilization review (UR)
B) risk management (RM)
C) health information management (HIM)
D) institutional review board (IRB)

Question 25

A case manager is usually a

A) nurse
B) physician
C) medical assistant
D) health information technician

Question 26

Utilization review staff work with the physicians to make sure documentation supports the __________, which estimates the length of an inpatient stay.

A) clinical pathway
B) working DRG
C) chief complaint
D) discharge disposition

Question 27

An example of a stand-alone facility with an average length of stay of over 30 days is a(n)

A) ambulatory surgery center (ASC)
B) acute care hospital
C) long-term care (LTC) facility
D) medical mall

Question 28

The minimum data set used in emergency departments is the

A) Uniform Hospital Discharge Data Set (UHDDS)
B) Uniform Ambulatory Care Data Set (UACDS)
C) Data Elements for Emergency Department Systems (DEEDS)
D) Resident Assessment Instrument (RAI)

Question 29

The minimum data set used for ambulatory care settings is the

A) Uniform Hospital Discharge Data Set (UHDDS)
B) Uniform Ambulatory Care Data Set (UACDS)
C) Data Elements for Emergency Department Systems (DEEDS)
D) Resident Assessment Instrument (RAI)

Question 30

Using ______________ technology, images or video of a patient is recorded to be viewed by a specialist later.

A) industrial rehabilitation
B) synchronous videoconferencing
C) store-and-forward
D) remote patient monitoring

Question 31

Rehabilitation physical therapy occurs under the direction of a:

A) phlebotomist.
B) physiatrist.
C) psychiatrist.
D) psychologist.

Question 32

Self-care, driving, and shopping are types of

A) activities of daily living (ADLs)
B) palliative care
C) maximum functions
D) hospice

Question 33

Which term describes a unit of health care in an ambulatory setting?

A) discharge
B) treatment
C) admission
D) encounter

Question 34

Which is an ambulatory care service?

A) lab work performed on an inpatient
B) vaginal delivery of a newborn
C) MRI performed at an imaging center
D) Group therapy session for residents at a state psychiatric facility

Question 35

A patient went to a clinic. He saw a physician, had an x-ray, then got a blood test. This patient can be said to have had _____ visit(s) and _____ encounter(s).

A) two; two
B) three; one
C) one; four
D) one; three

Question 36

Ambulatory care accreditation is offered by The Joint Commission (TJC) and:

A) Accreditation Association for Ambulatory Health Care (AAAHC).
B) The Centers for Medicare and Medicaid (CMS).
C) Community Health Accreditation Program (CHAP).
D) National Center for Injury Prevention and Control (NCIPC).

Question 37

Patients requiring care who are unable to make an appointment with their primary care provider (PCP) should visit the

A) emergency department
B) urgent care center
C) skilled nursing facility
D) respite care center

Question 38

Which is a data element of the Uniform Ambulatory Care Data Set (UACDS)?

A) time of the encounter
B) phone number
C) triage level
D) total charges

Question 39

Which is a data element of the Uniform Ambulatory Care Data Set (UACDS)?

A) gender identity
B) referring professional
C) current medications
D) disposition

Question 40

A patient with no significant medical history other than alcohol dependence was admitted to the detoxification unit of an acute care facility. After 3 days of successful treatment for alcohol withdrawal, what is the likely next phase of treatment?

A) Place patient in restraints so they cannot continue to be harmful to themselves.
B) Transfer patient to an alcohol rehabilitation facility.
C) Transfer patient from the detoxification unit to a medical unit within the same facility.
D) Arranging respite care for the patient's family.

Question 41

Reimbursement for patients in hospice care is typically based on:

A) the time and date of the order for hospice care to the time and date of death.
B) a 71-day average length of stay
C) the 6-month rule as certified by the physician.
D) a 24-day median length of stay

Question 42

What type of facility provides cognitive remediation?

A) behavioral health
B) dialysis center
C) physical therapy
D) rehabilitation

Question 43

The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 to

A) prevent hospitals from refusing to treat indigent patients and transferring them to charity care hospitals.
B) enable the hospital to apply for reimbursement from CMS for services rendered to indigent patients.
C) require hospitals to provide community services during nonpeak, routine daytime hours.
D) ensure that indigent patients are not billed for EMTALA authorized services.

Question 44

Which is true of inpatient surgery?

A) it costs less than ambulatory surgical services
B) services are performed by physician assistants rather than surgeons
C) the Centers for Medicare and Medicaid Services require it for certain procedures
D) it is becoming more frequently utilized

Question 45

Which setting lags behind others in the adoption of the electronic health record?

A) behavioral health
B) dialysis center
C) long-term care
D) ambulatory surgery

Question 46

Which setting utilizes the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)?

A) behavioral health
B) hospice
C) long-term care
D) telehealth

Question 47

What is the purpose of respite care?

A) to offer relief to caregivers of the chronically ill
B) to provide comfort measure to those with a terminal illness
C) to offer relief to patient s with chronic renal failure
D) to return patients to maximum functioning in activities of daily living

Question 48

Which technology simplifies home health care documentation?

A) the electronic health record (EHR)
B) document imaging
C) remote patient monitoring (RPM)
D) picture archiving and communication system (PACS)

Question 49

The provider's evaluation of the patient is the _________.

Question 50

The medical record number (MRN) is part of the _________ data.

Question 51

During the ____________ process, the hospital staff check whether the patient has insurance and whether it will pay for the services requested by the physician.

Question 52

An infection identified after _____ hours of hospitalization is called nosocomial or hospital acquired infections (HAI).

Question 53

Medicare requires a plan of care for patients admitted to hospice within ____ hours of admission.

Question 54

A woman who went to the wholesale club and got a flu shot receives services in the ___________ care setting, which offers treatment for minor illnesses offered in stores, supermarkets, and pharmacies.

Question 55

The abbreviation for the mandated minimum data set for home health care patients is the ________.

Question 56

The _________________, abbreviated RAP, is a large volume of data used to continually develop the patient plan of care in the long-term care setting, in which the patient's condition is regularly reevaluated.

Question 57

The accrediting agencies for home health care are The Joint Commission (TJC) and CHAP, which stands for the __________.

Question 58

A community health center is a type of _________ that provides primary or secondary care in a specific geographic area. accessible to populations that have challenges with accessing health care.

Question 59

In a physician's office, the receptionist or medical secretary usually collects demographic and ___________ data.

Question 60

The Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal agency that provides key resources on ___________ health issues.

Question 61

The system of prioritizing patients by severity of illness is called __________.

Question 62

A _______________ has knowledge of office procedures, scheduling, and filing, as well as some basic clinical knowledge.

Question 63

The insurance company often makes the patient select a(n) ___________ care provider, who delivers routine care and evaluates the need for a specialist's care.

Question 64

The setting in which palliative health care services are rendered to the terminally ill, their families, and their friends is _________.

Question 65

Radiology and laboratory tests require a physician _________ and diagnosis to support the purpose of the test.

Question 66

Match the clinical personnel with their responsibility:

-Physician

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 67

Match the clinical personnel with their responsibility:

-Nursing staff

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 68

Match the clinical personnel with their responsibility:

-Pathologist

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 69

Match the clinical personnel with their responsibility:

-Patient registration

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 70

Match the clinical personnel with their responsibility:

-Medical Staff Office

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 71

Match the clinical personnel with their responsibility:

-Obstetrician's office

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 72

Match the clinical personnel with their responsibility:

-Laboratory

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 73

Match the clinical personnel with their responsibility:

-Radiology

A) test showing a nosocomial infection
B) vital signs
C) CT scan
D) autopsy report
E) primary and secondary payer
F) physician identification database
G) order to admit
H) progress of pregnancy

Question 74

Match the clinical personnel with their responsibility:

-Answers telephone and records appointments

A) advance practice registered nurse (APRN)
B) medical assistant
C) medical secretary
D) phlebotomist
E) registered nurse

Question 75

Match the clinical personnel with their responsibility:

-Specializes in venipuncture for diagnostic testing

A) advance practice registered nurse (APRN)
B) medical assistant
C) medical secretary
D) phlebotomist
E) registered nurse

Question 76

Match the health care setting with the corresponding patient:

-Patient visits three times a week for therapy to treat end-stage renal disease

A) dialysis center
B) long-term care (LTC) facility
C) behavioral health center
D) hospice
E) rehabilitation facility
F) skilled nursing facility (SNF)
G) ambulatory surgery center (ASC)
H) physician's office
I) urgent care center
J) emergency department

Question 77

Match the health care setting with the corresponding patient:

-Patient was diagnosed with terminal disease that requires palliative care

A) dialysis center
B) long-term care (LTC) facility
C) behavioral health center
D) hospice
E) rehabilitation facility
F) skilled nursing facility (SNF)
G) ambulatory surgery center (ASC)
H) physician's office
I) urgent care center
J) emergency department

Question 78

Match the health care setting with the corresponding patient:

-Patient visits the PCP for a well-baby checkup

A) dialysis center
B) long-term care (LTC) facility
C) behavioral health center
D) hospice
E) rehabilitation facility
F) skilled nursing facility (SNF)
G) ambulatory surgery center (ASC)
H) physician's office
I) urgent care center
J) emergency department

Question 79

Match the health care setting with the corresponding patient:

-Patient needs to visit his or her PCP, but no appointments are available, so the patient visits this center

A) dialysis center
B) long-term care (LTC) facility
C) behavioral health center
D) hospice
E) rehabilitation facility
F) skilled nursing facility (SNF)
G) ambulatory surgery center (ASC)
H) physician's office
I) urgent care center
J) emergency department

Question 80

Match the health care setting with the corresponding patient:

-Patient presents with a gunshot wound to the arm

A) dialysis center
B) long-term care (LTC) facility
C) behavioral health center
D) hospice
E) rehabilitation facility
F) skilled nursing facility (SNF)
G) ambulatory surgery center (ASC)
H) physician's office
I) urgent care center
J) emergency department