Question 1

The old practice of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

Accepted Answer

The proposal to have the health care team enter data into the patient's record at the time and location of service is advocating for point-of-care documentation. This eliminates the need for retrospective analysis and leads to more accurate and timely records, ultimately improving patient care.

Question 2

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was missed dose of insulin. What type of review is this clerk performing?

Accepted Answer

The clerk is performing a qualitative review, as they are reviewing the quality of care provided and identifying potential areas for improvement (in this case, the missed dose of insulin).

Question 3

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

Accepted Answer

The answer of A pathologist on the Health Record Committee...

Question 4

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

Accepted Answer

Integrated progress notes involve multiple healthcare disciplines contributing to the same form, with sequential documentation of progress. This approach helps ensure that all healthcare providers have access to the same information and can collaborate effectively in the patient's care. Interdisciplinary treatment plans involve similar collaboration among healthcare providers, but may be documented separately from progress notes. Source-oriented records involve documenting information separately according to the source of the information (e.g., nursing notes, physician notes), while SOAP notes are a specific format for progress notes that include subjective, objective, assessment, and plan components.

Question 5

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

Accepted Answer

The objective survey of body systems is a critical part of the physical exam and must be captured accurately. The chief complaint, family history, and the subjective review of systems can also be important, but they do not have the same level of specificity and objective measurement as the objective survey of body systems.

Question 6

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at

Accepted Answer

According to the Joint Commission and Medicare Conditions of Participation, history and physical exam documentation should be completed within 24 hours after admission or prior to surgery, whichever comes first. This allows for timely and comprehensive documentation of the patient's condition and ensures that all necessary information is available for treatment decisions. Therefore, choice (D) is the best option.

Question 7

Which of the following is least likely to be identified by the deficiency analysis clerk?

Accepted Answer

A deficiency analysis clerk typically focuses on ensuring that all required documentation is present and complete in a medical record. Identifying discrepancies between diagnoses, such as between a surgeon's post-op diagnosis and a pathologist's diagnosis, usually requires clinical expertise beyond the scope of a deficiency analysis clerk's duties.

Question 8

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely to include checking for documentation regarding

Accepted Answer

The review of surgical records would likely include checking for documentation regarding preoperative and postoperative diagnosis descriptions, findings, and specimens removed to ensure completeness and accuracy of the record. The other options, such as postoperative infection treatment, follow-up care, and severity of illness, are also relevant but may not be the primary focus of a qualitative review of surgical records.

Question 9

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

Accepted Answer

The R-ADT (Registration-Admission, Discharge, and Transfer) system is commonly used in healthcare facilities to facilitate patient tracking and registration. It is specifically designed to capture patient movements, transfers, and discharges, making it an excellent choice for capturing patient transfer information to the oncology unit. The other options, generic screens, disease index, and indicator monitoring program, may not be as targeted or efficient for this specific information capture.

Question 10

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

Accepted Answer

CARF (Commission on Accreditation of Rehabilitation Facilities) primarily accredits facilities that provide rehabilitation services, including chronic pain management, brain injury management, and vocational evaluation. Palliative care is typically associated with hospice and end-of-life care, which is not the primary focus of CARF-accredited facilities.

Question 11

As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the

Accepted Answer

The facility's data dictionary is a complete listing of all data elements collected, stored, and used in that particular healthcare organization's information system. It would have information on the origin of data in a particular field and the security levels applicable to that field. The MDS is the Minimum Data Set used in long-term care facilities and would not be relevant in this situation. The Glossary of Health Care Terms may have some definitions and explanations but would not provide specific information on data origin and security levels. The UHDDS (Uniform Hospital Discharge Data Set) is related to hospital discharge data and would not be applicable in this situation.

Question 12

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should

Accepted Answer

When a transcription backlog exists and there are concerns about timely documentation, the best course of action is for the surgeon to write a detailed operative note in the record. This will ensure that important information about the surgery is documented and available to other healthcare providers involved in the patient's care. Providing the dictated tape or requesting a "stat" report may not be feasible or effective solutions in the face of a backlog, and requesting that administration hire more transcriptions may not be realistic in the short term.

Question 13

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

Accepted Answer

A consultation typically involves a specialist providing an opinion on a specific medical issue or question, such as whether a patient is a good surgical risk. Tissue examination by a pathologist, interpretation of radiologic studies, and technical interpretation of an electrocardiogram are all part of routine medical care and may not necessarily be considered consultations.

Question 14

An example of objective entry in the health record supplied by a health care practitioner is the

Accepted Answer

A physical assessment is an objective entry in a health record since it includes measurable information such as vital signs, height, weight, and physical exam findings. The other options (past medical history, chief complaint, and review of systems) may include subjective information reported by the patient, which is not considered objective.

Question 15

An example of a primary data source for health care statistics other than the patient health record is the

Accepted Answer

The hospital census is a primary data source for health care statistics as it provides information on the number of patients admitted, discharged, or transferred at a given time. Other primary data sources for health care statistics may include surveys, focus groups, and clinical trials. The disease index and accession register are examples of secondary data sources, while MPI (Master Patient Index) is a tool used to manage patient records and does not provide statistical data.

Question 16

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

Accepted Answer

According to Joint Commission standards, a complete history and physical must be documented prior to surgery.

Question 17

Under which of the following conditions can an original patient health record by physically removed from the hospital?

Accepted Answer

A subpoena duces tecum is a legal order requiring someone to bring documents to court, which can include a patient's health record.

Question 18

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the

Accepted Answer

OBRA led to the creation of the Minimum Data Set (MDS), which is a core assessment tool used in long-term care facilities to collect data on residents' health status and functional abilities. It includes assessments for physical, cognitive, and psychosocial functioning, as well as an evaluation of each resident's care plan. The other options listed (UHDDS, Uniform Clinical Data Set, Uniform Ambulatory Core Data) are not specific to long-term care and do not include the same type of comprehensive assessment information as the MDS.

Question 19

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

Accepted Answer

According to COP regulations, when a patient's health status changes significantly, a consultation report documenting the new information must be added to the health record. In this case, the potential surgical risk due to heat irregularities qualifies as a significant change in health status, and therefore a consultation report should be added.

Question 20

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

Accepted Answer

The subjective statement is the patient's own report of their symptoms or feelings. In this case, choice D includes the patient's statement about the severity of their low back pain, making it the subjective statement.

Exam 1: Registered Health Information Administrator