Question 1

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

Accepted Answer

The first two digits of the accession number represent the year the patient was first seen, which is 2008 in this case. The third and fourth digits represent the sequence number of the patient seen in that year, starting with 0001. Since this was the first patient seen in 2008, the sequence number would be 0001, making the accession number 2008-0001. The last two digits represent the number of specimens collected for that patient, which would be 00 if the patient only has one biopsy specimen collected, as in this case. Therefore, the correct accession number assigned to this patient would be 2008-0001/00, making the best choice for the answer C.

Question 2

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?

Accepted Answer

Pharmacy consultations are more common in long-term care settings due to the ongoing medication management needs of residents, whereas acute care focuses more on immediate treatment and stabilization.

Question 3

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

Accepted Answer

Growth and development records are unique to infant and children inpatient health records and would not be necessary to include in adult records. This information is important to track for younger patients in order to monitor their overall health and development.

Question 4

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

Accepted Answer

The most effective approach when developing a data collection system is to first consider the end user's needs. The system needs to be tailored to the users and their specific requirements to ensure it is useful and efficient. Considering accreditation standards, hardware requirements, and facility preferences is important, but they should be secondary to meeting the end user's needs.

Question 5

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?

Accepted Answer

The operation index would be the best choice as it contains information on all the surgeries performed in the hospital, including CABGs. The disease index and physician index would not provide specific information on surgeries performed, while the master patient index contains information on all patients, not just those who underwent CABG.

Question 6

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

Accepted Answer

Based on the scenario described, the best choice would be a computerized provider order-entry (CPOE) system. This system allows physicians to enter orders for medications and tests directly into the electronic health record, and provides decision support to help ensure that dosages and contraindications are appropriate for each patient. It is a crucial component for improving patient safety by reducing errors related to illegible handwriting and miscommunications between healthcare providers. The other options listed may have their own benefits, but they do not directly address the patient safety concerns mentioned in the scenario.

Question 7

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

Accepted Answer

Joint Commission standards emphasize the importance of interdisciplinary collaboration in healthcare, and providing for record reviews to be performed by an interdisciplinary team of care providers aligns with this emphasis. This approach can help to ensure that all aspects of patient care are being evaluated and can provide a more comprehensive perspective on the quality of care being provided. Additionally, involving physicians, nurses, and other care providers in the review process can help to promote buy-in and engagement with quality improvement efforts. Having more frequent committee meetings or reporting to a different committee may be beneficial, but these changes alone may not address the need for more interdisciplinary collaboration. Having a physician perform all the reviews may not be feasible given the time and resource constraints of busy clinicians, and may not align with the collaborative approach advocated by Joint Commission standards.

Question 8

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

Accepted Answer

If a legible copy of a recent H&P performed in the attending physician's office is available, it may be referenced instead of performing a complete history and physical at the time of admission. However, in all other scenarios (A, B, C), a complete history and physical must be performed for a new admission.

Question 9

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

Accepted Answer

The CTR should update the follow-up file for the patient who has been readmitted for further treatment of a previously diagnosed cancer. This is necessary to ensure that the patient's ongoing treatment and progress are accurately documented in the cancer registry. Completing a new cancer abstract or assigning a new accession number would not be necessary for a patient who has been readmitted for ongoing treatment of a previously diagnosed cancer. Completing a new master index file would also not be necessary as the patient has already been entered into the registry.

Question 10

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.

Accepted Answer

According to Joint Commission standards, the history and physical exam should be performed within 24 hours of admission or as soon as possible thereafter. In this situation, the H&P was performed four days after the patient's admission, indicating noncompliance with Joint Commission standards.

Question 11

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

Accepted Answer

Nurses using bedside terminals to record vital signs is the best example of point-of-care service and documentation as it allows for real-time recording and monitoring of important patient data directly at the bedside. This improves accuracy and efficiency of documentation and allows for prompt interventions if necessary.

Question 12

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

Accepted Answer

The answer of For each report of care rendered to...

Question 13

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

Accepted Answer

Biometrics-based identifier is the most secure log-on process for electronic signing as it uses unique physiological or behavioral characteristics of the user such as fingerprint, face recognition, iris scan, etc. This makes it almost impossible for anyone to improperly delegate use as the user needs to be physically present to authenticate their identity. Passwords, whether assigned by the system administrator or the user, can be easily guessed or shared, making them less secure. Encryption is an additional security measure that can be used in conjunction with the biometrics-based identifier to further strengthen the security of the log-on process.

Question 14

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

Accepted Answer

Authorizing access to information based on level of data sensitivity ensures that only those who have a legitimate need for access to the information can view it. This helps to protect the confidentiality and security of the data. Preventing all nonclinicians' access to any confidential information in the system may be too restrictive and prevent legitimate users from accessing necessary data. Establishing firewalls and passwords are also important security measures, but they do not address the issue of controlling access based on data sensitivity.

Question 15

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

Accepted Answer

When scanning and imaging paper records as part of a computer-based system, the use of bar codes for identification and tracking purposes is crucial. The placement of hospital logos, signature lines, and box designs are important considerations for the overall design of the form, but they do not specifically relate to the scanning and imaging process.

Question 16

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

Accepted Answer

The needs of the users should be the most crucial factor in creating a new form or computer view. The design should be user-friendly and intuitive, allowing users to easily input and access necessary information. While QIO standards and medical staff bylaws should also be taken into account, they should not take precedence over meeting the needs of the end-users. The flow of data on the page or screen is also an important consideration, but should be secondary to ensuring the user interface is easy to navigate.

Question 17

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?

Accepted Answer

The Uniform Hospital Discharge Data Set (UHDDS) provides standard definitions for data elements commonly collected in acute care hospitals, making it a valuable resource for developing a data dictionary.

Question 18

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

Accepted Answer

One of the main advantages of the HER is the accessibility of the record by multiple data users. With a paper-based system, it can be difficult to share information among healthcare professionals who are not physically present in the same location. However, with an electronic health record, multiple healthcare professionals can access the same record simultaneously from different locations, allowing for better coordination of care. Additionally, an HER can provide more comprehensive and standardized data, improving patient safety and quality of care. Although screen designs can be developed easily in an HER, it is not necessarily an advantage over paper-based health records. Data collection can also be facilitated with electronic systems, but this is not a distinct advantage over paper-based systems.

Question 19

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

Accepted Answer

The Federal Register is the official journal of the federal government of the United States that contains government agency rules, proposed rules, and public notices, including updates on Medicare payment requirements.

Question 20

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

Accepted Answer

The time and means of arrival are important information to document in an ER record because they inform triage decisions and can help identify potential emergencies. In an acute care record, this information is not as crucial because patients are typically admitted through scheduled appointments or transfers from other healthcare facilities. Physical findings, lab and diagnostic test results, and instructions for follow-up care are all expected to be recorded in both ER and acute care records.

Exam 1: Registered Health Information Administrator