Deck 5: Health Information Management Processing

Question 1

Upon review of a record, the analyst determines that the physician has not signed several progress notes. This record fails to reflect the data quality characteristic of:

A) Accuracy
B) Timeliness
C) Completeness
D) Both b and c

Answer 1

Both b and c

Question 2

The following include ways electronic health records can assist in tracking chart completion EXCEPT:

A) Point of care documentation
B) Physician authentication
C) Progress notes
D) Nursing assessments

Answer 2

Progress notes

Question 3

What is the most efficient way to track changes to a patient's electronic health record?

A) Keeping a paper log of changes
B) Detective control review
C) Reviewing the error report
D) Reviewing the audit trail

Answer 3

Reviewing the audit trail

Question 4

The data quality characteristic associated with the collection of data in its entirety is:

A) Completeness
B) Reliability
C) Timeliness
D) Validity

Question 5

What is the most common problem associated with paper records that is not found when managing electronic health records?

A) Loose sheets management
B) Disorganized patient records
C) Missing documentation
D) Lack of documentation

Question 6

What is the most important step in ensuring data quality?

A) Software maintenance
B) Data entry
C) Data analysis
D) Timeliness of recording

Question 7

Which of the following is a detective control?

A) A nurse alerts a physician that a patient is allergic to an ordered medication.
B) The nursing supervisor reviews a chart to ensure that medication administration notes were properly entered.
C) The HIM department sends a physician a list of the physician's incomplete charts.
D) A coder reviews a record in order to assign a clinical code.

Question 8

Which of the following processes will not be performed for electronic health records?

A) Chart analysis
B) Retrospective review
C) Error corrections
D) Chart assembly

Question 9

A patient's record was not completed as of the 26th day after the patient's discharge from the hospital. This record is considered:

A) Deficient
B) Delinquent
C) In process
D) Invalid

Question 10

The data quality characteristic associated with the capture of data concurrently with its observation is:

A) Completeness
B) Reliability
C) Timeliness
D) Validity

Question 11

In an electronic environment, changes to a patient's record should be tracked in:

A) An audit trail
B) An exception file
C) A duplicate file
D) Nowhere; electronic changes completely wipe out prior entries.

Question 12

The process of recording data into an information system is called:

A) Data entry
B) Utilization review
C) Detective control
D) Collection

Question 13

The following are types of internal controls EXCEPT _____ controls.

A) Preventive
B) Retrospective
C) Corrective
D) Detective

Question 14

When a patient is being treated for a health-related issue, regardless of the health care setting, the physician must state the patient's ___________.

A) Symptoms
B) Procedures
C) Therapeutic treatment
D) Diagnosis

Question 15

Which one of the following activities can be considered a preventive control?

A) Retrospective chart review
B) Concurrent chart review
C) Detective chart review
D) Documentation training review

Question 16

Which of the following controls cannot take place retrospectively?

A) Corrective
B) Detective
C) Preventive
D) All of the above

Question 17

The health information management department can verify which patient records are available for processing by referring to the:

A) Admission register
B) Audit trail
C) Discharge register
D) Exception list

Question 18

The system of organizing the contents of paper-based inpatient records, postdischarge, the same way they are kept on the nursing units is called:

A) Audit trail
B) Detective controls
C) Postdischarge processing
D) Universal chart order

Question 19

TJC requires that acute care records be completed:

A) Within 15 days of discharge
B) In whatever time period the facility requires
C) Within 30 days of discharge
D) In whatever time period the state requires

Question 20

Which of the following is a corrective control?

A) A nurse alerts a physician that a patient is allergic to an ordered medication.
B) The nursing supervisor reviews a chart to ensure that medications were administered on a timely basis.
C) The HIM department sends a physician a list of the physician's incomplete charts.
D) A coder reviews a record in order to assign a clinical code.

Question 21

Which of the following is a preventive control?

A) A nurse alerts a physician that a patient is allergic to an ordered medication
B) The nursing supervisor reviews a chart to ensure that medications were administered on a timely basis
C) The HIM department sends a physician a list of the physician's incomplete charts
D) A coder reviews a record in order to assign a clinical code

Question 22

What is the correct way to modify a medical record?

A) Use white out
B) Scratch out the error and have the physician initial it
C) Put one line through the error and write the correct data near it
D) Black out the error and indicate the time

Question 23

The set of procedures by which a paper record is reorganized into a standard order for further processing is:

A) Assembly
B) Quantitative analysis
C) Point-of-care documentation
D) Advance directive

Question 24

A computer can create a log of processing and access activities called an ________.

Question 25

All of the following are steps in postdischarge processing EXCEPT:

A) Coding
B) Abstracting
C) Chart retrieval
D) Concurrent analysis

Question 26

Which of the following patients can be found on a discharge register for 5/1/12?

A) A patient who was admitted to the hospital on 5/1/12 and discharged on 5/2/12
B) A patient who was admitted to the hospital on 5/1/12 and died on 5/2/12
C) A patient who was admitted to the hospital on 4/30/12 and discharged on 5/1/12
D) A patient who was dead on arrival on 5/1/12

Question 27

The postdischarge process begins with which of the following steps:

A) Assembling the patient chart
B) Analyzing the patient chart for deficiencies
C) Reviewing the discharge register
D) Requesting the physician's signature on deficient forms

Question 28

Control over records in process can be maintained using:

A) Batch control record and deficiency sheets
B) Central staging area and deficiency sheets
C) Batch control record and central staging area
D) Deficiency sheets and loose sheets

Question 29

Which of the following is a benefit of concurrent coding?

A) Allows the facility to bill the insurance company prior to discharge
B) Ensures that all clinical personnel are aware of the admitting diagnosis
C) Gives the physician the correct principal diagnosis
D) Helps determine the estimated length of the patient's hospital stay

Question 30

Developing a universal chart order will theoretically eliminate which one of the following HIM functions?

A) Chart analysis
B) Deficiency detection
C) Chart assembly
D) Retrospective review

Question 31

Another word for an incomplete system is a ______________.

Question 32

Quantitative analysis is usually performed by:

A) An allied health professional
B) A nurse case manager
C) An HIM professional
D) A unit care nurse

Question 33

A detective control function designed to identify incomplete data in a record is ________.

Question 34

Acute care facilities are permitted to have delinquent records, but the number of delinquent records must not exceed:

A) 2% of the average monthly discharges
B) 50 records
C) 50% of the average monthly discharges
D) 9 records

Question 35

A list of deficient or other problem data, usually generated by a computer, is an __________.

Question 36

A written document, like a living will, that specifies a patient's wishes for his/her care and dictates power of attorney, for the purpose of providing clear instructions in the event the patient is unable to do so is an _________.

Question 37

All of the following are routinely identified during quantitative analysis EXCEPT:

A) Missing signature on a physician progress note
B) Discharge report has not been dictated
C) Requested cardiology consultation was not performed
D) H&P was dictated and transcribed on the third day of the admission

Question 38

Which of the following is NOT a guiding principle in quantitative analysis?

A) Authentication
B) Completeness
C) Existence
D) Relevancy

Question 39

Important topics to include in staff training on HIPAA Privacy and Security Rules include all of the following EXCEPT:

A) How to guard against threats of computer viruses or hackers and where to report suspicious activity
B) Management of passwords: how often they will change and sanctions for sharing passwords
C) Ways to bypass automatic log-offs so users do not have to enter their password at a terminal
D) Education on how to dispose of protected health information (PHI) information on paper or electronic media such as optical disks

Question 40

A paper record must be ______ before it can be analyzed.

Question 41

Data that have been obtained, recorded, and/or reported within a predetermined period satisfy the data quality characteristic of ___________.

Question 42

Required elements of a record that are missing are called __________.

Question 43

List the forms that are present, in one way or another, in every acute care health record. What is the most useful way to organize those forms in a record while it is on the nursing unit? Postdischarge? Why do some organizations want the record to be organized differently predischarge and postdischarge?

Question 44

The data quality characteristic of data being present or existing in its entirety is __________.

Question 45

An original signature on a report that is then scanned into an electronic document is a __________.

Question 46

___________ procedures govern the storage of records, including duration, location, security, and access.

Question 47

TThe representation of diagnoses and procedures as alphanumerical values in order to capture them in the database is called ___________.

Question 48

In a paper-based record, errors are corrected __________ and writing the correct data near it. It is important not to obscure the erroneous data.

Question 49

___________ is the process of determining the cause of an error.

Question 50

What processing problems can occur if an organization implements a universal chart order? How is the issue of record organization resolved in a computer-based record?

Question 51

Clinicians can evidence supervision of subordinate personnel by ___________ the subordinates' documentation.

Question 52

You have just checked in all of the records received from the nursing unit. One record that was received is not on your discharge register. What could have happened? How do you determine what to do with the extra record?

Question 53

What is the purpose of a discharge register? How is it used in postdischarge processing? How else could it be used?

Question 54

A review of individual user access codes to determine who had access to patient health information and to ensure the access was deemed necessary for patient care is called an ___________.

Question 55

In a paper environment, records must physically move from the patient care area to the HIM department for processing and storage. Give two examples of how that movement can occur.

Question 56

Parts of paper records that arrive in the HIM department separately from the main record are often called ______________.

Question 57

Since the HIM department is primarily concerned with postdischarge processing, of what use is the admission register to this department?

Question 58

The process of recording elements into a collection device is called _________.

Question 59

Assignment of ICD-10-CM codes to clinical data while the patient is still being treated is ______________.

Question 60

In a paper record environment, _______________ refers to the maintenance of the same page order both predischarge and postdischarge.

Question 61

List and define the data quality characteristics that were discussed in the text.

Question 62

Is a computer-based record completely paperless? Why or why not?

Question 63

Name the steps in ensuring completeness of the medical record and the purpose of each step.

Question 64

What is the difference between concurrent and retrospective analysis? What are the benefits to either?

Question 65

What internal control roles are played in the HIM department? Your answer should include, but not be limited to, identification of the function and the specific internal control role that it plays.

Question 66

List and define the three fundamental types of internal control. Give a postdischarge processing example of each.

Question 67

Given your knowledge of rehabilitation and long-term care, how do you think documentation issues and HIM processing issues differ in these facilities from those in acute care?

Question 68

When the HIM department obtains control of the records, a process must be in place to determine whether all records have been received. Describe this process.

Question 69

There is a logical order to postdischarge processing. List the postdischarge processing steps, in order, beginning with obtaining control of the record.