Question 1

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

Accepted Answer

Ongoing record reviews are conducted to evaluate the completeness, adequacy, and quality of documentation in health records. This is important to ensure that the data in the records is accurate and reflects the care provided to patients. Quality of care, adverse effects of drugs, and potentially compensable events may also be identified through these reviews, but they are not the primary focus.

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

Accepted Answer

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatry facility are generally in the form of concurrent chart review, which involves ongoing review of patient care while it is being provided. Retrospective deficiency analysis is looking back at patient records to identify errors, while special study audits involve examining a specific issue or area of concern. Occurrence screening is another retrospective method used to identify adverse events or specific medical errors. However, concurrent chart review is the most appropriate choice for the given scenario.

Question 3

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

Accepted Answer

The interdisciplinary patient care plan is the foundation for communicating all patient care goals in long-term care settings. It involves collaboration among all members of the care team and outlines specific interventions and goals for the patient's care. The other options listed do not pertain to long-term care settings or are not directly related to communicating patient care goals.

Question 4

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

Accepted Answer

The minimum length of time for retaining original medical records is primarily governed by state law. Each state has its own regulations on how long medical providers must keep patient records before they can be destroyed or purged. These laws are in place to protect patient privacy and ensure that important medical information is available if needed for future treatment.

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.

Accepted Answer

The H&P copy is acceptable as long as Dr. Crossman documents any interval changes, as per Joint Commission standards.

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

Accepted Answer

Electronic signatures would be the best choice for a completely computerized patient record system. Similar to personal signature stamps, electronic signatures can provide authentication of entries in the electronic record. However, electronic signatures can also include additional security measures, such as multi-factor authentication and digital certificates, to ensure the identity of the person signing the record.

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

Accepted Answer

Ambulatory care providers focus on the ongoing management of chronic conditions and prevention of illness, rather than the treatment of acute conditions. Therefore, they rely on the problem list, which is a summary of the patient's current and past health conditions, to ensure continuity of care. The interdisciplinary patient care plan, discharge summary, and transfer record are more relevant to acute care services.

Question 8

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

Accepted Answer

The "99" prefix in a tumor registry accession register typically represents the year the case was entered into the database of the registry. This prefix is commonly used to help identify and track cases over time.

Question 9

Discharge summary documentation must include

Accepted Answer

Discharge summaries must include significant findings during hospitalization to provide a clear understanding of the patient's condition and treatment during their stay.

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

Accepted Answer

The MDS (Minimum Data Set) is a standardized assessment tool used in long-term care settings to collect information on a resident's functional abilities, cognitive patterns, and health conditions. Cognitive patterns would be included in the MDS but not in the UHDDS (Uniform Hospital Discharge Data Set), which is used to collect data in acute care settings and primarily focuses on demographic information, procedures, and diagnoses related to the hospital stay. Personal identification would be collected in both settings, while procedures and diagnoses would be collected in both settings but using different coding systems.

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

Accepted Answer

The document includes a microscopic description of tissue excised during surgery, which makes it a pathology report. The other options (recovery room record, operative report, discharge summary) do not specifically relate to pathology results.

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

Accepted Answer

A source-oriented format organizes information by the source of the information, such as lab reports, making it easier to compare all lab values during one hospitalization.

Question 13

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

Accepted Answer

The Joint Commission does not allow auto authentication of entries in a health record because evidence cannot be provided that the physician actually reviewed and approved each report. This can lead to potential medical errors and patient safety risks.

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

Accepted Answer

The best place to locate the menstrual history, number of pregnancies, and number of living children on an OB patient is in the prenatal record. This information is typically collected during the initial prenatal visit and is recorded in the prenatal record. The labor and delivery record, postpartum record, and discharge summary may provide additional information, but these records are more focused on the actual delivery and immediate postpartum period.

Question 15

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

Accepted Answer

Defining levels of security for different types of information, depending on sensitivity, would ensure that only authorized personnel have access to sensitive information, and that appropriate measures are undertaken to prevent data breaches. Establishing a good record tracking system would be helpful, but it wouldn't necessarily protect the security of the data. Providing remote terminals or internet access could compromise the security of the system by allowing unauthorized access or increasing the risk of cyberattacks.

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

Accepted Answer

The disease index is a key resource for identifying reportable cases of cancer as it lists diagnoses for patients treated at the facility, including cancer cases.

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

Accepted Answer

The incident report is most likely to contain a full report of the patient's fall, including witness reports and probable reasons for the fall. The doctors' progress notes and nurses' notes may contain some information about the fall, but not as comprehensive as the incident report. The integrated progress notes may also contain some information about the fall but are not likely to contain eyewitness reports.

Question 18

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

Accepted Answer

According to Joint Commission, documentation entered by interns or medical students must be countersigned by the attending physician.

Question 19

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

Accepted Answer

The Health Record Committee is typically responsible for overseeing the management and quality of health records, including monitoring trends in delinquent health record percentages.

Question 20

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

Accepted Answer

The attending physician is ultimately responsible for the quality and completion of entries in a patient's health record as they are the ones who diagnose, treat, and manage the patient's care. The chief of staff may have oversight responsibilities, but they are not involved in the day-to-day documentation of patient care. The HIM director is responsible for managing the health record system but is not responsible for the content within the records. The risk manager may be involved in mitigating risk related to documentation, but they do not have primary responsibility for the completion and accuracy of the records.

Exam 1: Registered Health Information Administrator