Question 1

What would be the most cost-effective and prudent course of action for the storage or disposition of 250,0000 records at a large teaching and research hospital?

Accepted Answer

The answer of What would be the most cost-effective and...

Question 2

An example of a primary data source is the

Accepted Answer

The health record is considered a primary data source as it contains firsthand information about a patient's medical history and treatment. The physician index, cancer registry, and hospital statistical report all contain collected and summarized data from multiple sources, making them secondary data sources.

Question 3

A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the

Accepted Answer

Filing of loose materials is directly related to the organization and management of health records, ensuring they are complete and easily retrievable.

Question 4

A patient who is taking the drug Antivert may have a diagnosis of

Accepted Answer

Antivert is a brand name for the drug meclizine, which is used to treat or prevent nausea, vomiting, and dizziness caused by motion sickness or certain inner ear problems. Therefore, the patient taking Antivert may have a diagnosis of dizziness.

Question 5

Which one of the following describes the electronic health record's impact on the record retrieval function?

Accepted Answer

The answer of Which one of the following describes the...

Question 6

Which of the following is a valid ICD-9-CM principal diagnosis code?

Accepted Answer

A valid principal diagnosis code must represent the main reason for the patient's encounter and is typically related to a disease or illness. Option A is a valid code, but it represents the outcome of delivery, not a disease or illness. Option C represents an external cause of injury or poisoning and is not a valid principal diagnosis code. Option D is a code for a specific type of tumor, not a principal diagnosis code. Option B is a valid code for a single live birth in a hospital, which could be the reason for a patient's encounter.

Question 7

A physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign

Accepted Answer

The coder should assign an unlisted procedure code located in the eye and ocular adnexa section, as this is the most appropriate option given the situation. Unlisted procedure codes are used when there is not a specific code available for the procedure performed. In this case, since the physician performed a surgical procedure on the eye orbit of a Medicare patient and there is not a specific code available for the procedure, the most appropriate option is to use an unlisted procedure code in the eye and ocular adnexa section. This will allow for accurate reporting and reimbursement for the procedure.

Question 8

A system of preferred terminology for naming diseases processes is known as a

Accepted Answer

Medical nomenclature is a system of preferred terminology used for naming disease processes.

Question 9

The steps in developing a record retention program include all but which one of the following?

Accepted Answer

The steps in developing a record retention program include determining the format and location of storage, assigning each record a retention period, and destroying records that are no longer needed. However, notifying the courts of the destruction is not a necessary step in developing a record retention program as it only applies to specific legal requirements.

Question 10

What data cannot be retrieved from the MEDPAR?

Accepted Answer

The MEDPAR only includes data on Medicare patients, so non-Medicare patient data cannot be retrieved.

Question 11

Which one of the following is NOT considered a challenge in the adoption of an electronic health record system?

Accepted Answer

Contribution to the quality of patient care is generally considered a benefit, not a challenge, in the adoption of an electronic health record system. The other options are commonly cited as challenges that can hinder adoption and implementation.

Question 12

According to AHIMA's recommended retention standards, which one of  the following types of health information does NOT need to be retained permanently?

Accepted Answer

The physician index does not need to be retained permanently according to AHIMA's recommended retention standards, unlike registers of births, surgical procedures, and deaths which are typically retained permanently.

Question 13

Fetal monitoring strips are part of the _________ record and should be maintained ______.

Accepted Answer

Fetal monitoring strips are part of the mother's medical record and should be maintained according to the length of time required for a minor's records, as they are related to the birth process and maternal care.

Question 14

The total number of records filed during the month is 2,500 and, upon completion of a filing accurate study, 90 records were not found. What is the accuracy of filing?

Accepted Answer

Accuracy of filing = (Number of records filed - Number of records not found) / Number of records filed
= (2500-90)/2500
= 2410/2500
= 0.964
= 96% (rounded to nearest whole number)

Question 15

When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract?

Accepted Answer

The type of reader or printer needed to view the microfilm is not necessary to include in the contract. The other factors, such as cost, provision for destruction of original records, and confidentiality of information being filmed, are important to include in the contract.

Question 16

Which one of the following is NOT a strategy when purchasing an electronic health record system?

Accepted Answer

The strategy of broadening the vendor field and selecting several vendors of choice is not a recommended approach when purchasing an electronic health record system. Instead, it is recommended to carefully identify system requirements, perform a cost-benefit analysis, and engage stakeholders from different organizational levels to ensure successful implementation and adoption of the EHR system.

Question 17

Which of the following is NOT included as a part of the minimum data maintained in the MPI?

Accepted Answer

The principal diagnosis is not included as a part of the minimum data maintained in the MPI. The other options (B, C, and D) are all included as part of the minimum data maintained in the MPI.

Question 18

Robert Thompson was seen in the outpatient department with a chronic cough and the record states "rule out lung cancer." What should be coded as the patient's diagnosis?

Accepted Answer

The correct diagnosis to code is the symptom, "chronic cough," as "rule out lung cancer" indicates a suspected condition that has not been confirmed.

Question 19

A health care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the

Accepted Answer

The birth defects registry would contain data on infants born with cleft lip and/or cleft palate, as it is mandated in many states for healthcare providers to report cases of birth defects to this type of registry. The other options may not specifically include information on whether or not a child has a cleft lip or cleft palate.

Question 20

For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which one of the following elements?

Accepted Answer

Patient notification is not typically included in a certificate of destruction, which is a document provided by the vendor or service provider that confirms that the documents have been securely destroyed in compliance with relevant regulations and standards. The other elements listed are commonly included in a certificate of destruction. The unique and serialized transaction number is used to track the documents and provide an audit trail, while the location of destruction confirms that the documents were destroyed on site. Acceptance of fiduciary responsibility is important because it holds the vendor or service provider accountable for protecting the confidentiality and security of the documents.

Exam 1: Registered Health Information Administrator