Question 1

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult

Accepted Answer

The Hospital Bylaws, Rules, and Regulations typically outline the qualifications and responsibilities of individuals authorized to record verbal orders, in accordance with Joint Commission standards and state law.

Question 2

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a

Accepted Answer

A regional health information organization (RHIO) would be the best choice to support the exchange of health information across the continuum within a geographical community. RHIOs are designed to bring together healthcare stakeholders (e.g. hospitals, clinics, providers, payers) to exchange patient health information electronically. RHIOs can enable the exchange of patient data in real-time and improve patient care coordination.

Question 3

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

Accepted Answer

The problem list serves as the index to documentation throughout the record. It lists all of the patient's active and resolved problems and helps track the progress and management of each problem over time. The database is the collection of patient information, the initial plan outlines the proposed treatment plan for each identified problem, and progress notes document the ongoing management and progress of each problem.

Question 4

Which of the following is a type of laser technology that is ideal for health records because it stores data in a permanent capacity, prohibiting users from altering, misfiling, or erasing data?

Accepted Answer

WORM (Write Once Read Many) laser technology is ideal for health records because it stores data in a permanent capacity, prohibiting users from altering, misfiling, or erasing data.

Question 5

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

Accepted Answer

Reviewing a medical record for documentation to support diagnoses is an example of a qualitative review, which focuses on the quality and completeness of documentation. Peer review involves fellow healthcare professionals reviewing the care provided to a patient, quantitative review involves analyzing data for numerical trends, and legal analysis involves reviewing the documentation for legal purposes.

Question 6

An important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Both technical and procedural methods will bed used with the CPR to control and manage confidential information. An example of a procedural method for protecting data is

Accepted Answer

Confidentiality statements signed by all staff are a procedural method to ensure that employees understand and commit to maintaining the confidentiality of data.

Question 7

A quality improvement team is focusing on the unacceptable number of unsigned doctors' order sin your facility. The most effective method for increasing the timelines of signatures on orders and positively impacting the patient care process would be

Accepted Answer

An open-record review process allows for real-time monitoring and immediate feedback, encouraging timely signatures and improving patient care.

Question 8

As information security officer, you are revising the policies at your rehabilitation facility for handling all patient clinical information. Your best resource for checking out specific accreditation standards and guidelines is the

Accepted Answer

The CARF manual is the best resource for checking out specific accreditation standards and guidelines for handling all patient clinical information at a rehabilitation facility.

Question 9

As supervisor of the cancer registry, you report the registry's annual caseloads to administration. The most efficient way to retrieve this information would be to use

Accepted Answer

The accession register is a chronological listing of all cancer cases entered into the registry, making it the most efficient tool for retrieving annual caseload information.

Question 10

Accreditation by Joint Commission is a voluntary activity for a facility and it is

Accepted Answer

Accreditation by Joint Commission is not required for state licensure in all states and is not conducted annually in each facility. However, it is required for reimbursement of certain patient groups, such as Medicare and Medicaid beneficiaries. Therefore, the best choice is D.

Question 11

Which of the following is a secondary data source that be used dsto quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

Accepted Answer

The disease index is a secondary data source that provides a list of all patients diagnosed with a specific disease, in this case diabetes. It is an efficient way to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months. The patient register and pediatric census sheet provide general information about patients and may not provide specific information about their diabetes treatment. The procedure index lists all medical procedures performed in a healthcare facility, which may not capture all diabetes treatments.

Question 12

Key reports in a health record, such as history and physicals, discharge summaries, and operative reports, are generally dictated and transcribed. This recommended standard contributes most to data

Accepted Answer

Dictation and transcription primarily ensure that the information is legible, as it converts spoken words into a typed format that is clear and readable.

Question 13

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

Accepted Answer

DEEDS (Data Elements for Emergency Department Systems) is a standardized data set that includes data elements for the management of emergency care patients. It is used specifically for the collection and management of data in emergency departments, making it the best choice for comparing trauma care services to other hospital-based emergency departments. UHDDS (Uniform Hospital Discharge Data Set) is a standardized data set for inpatient hospitalization, MDS (Minimum Data Set) is used for long-term care facilities, and ORYX is a JCAHO performance measurement system.

Question 14

A primary focus of screen format design in a health record computer application should be to ensure that

Accepted Answer

The primary focus of screen format design in a health record computer application should be to ensure that the user is capturing essential data elements. This means that the screen should be intuitive, easy to follow, and present necessary fields in a clear and concise manner to help reduce data entry errors and improve the overall quality of documentation. While data fields being randomly accessed is important, it is not the primary focus of screen format design. Standardized screen formats for all hospitals may not be practical or feasible, and designing computer forms to match paper forms is not always the best approach for optimal functionality.

Question 15

Which method of identification of authorship or authentication of entries would be in appropriate to use in a patient's health record?

Accepted Answer

Delegated use of a computer key by a radiology secretary would not be appropriate for identification of authorship or authentication of entries in a patient's health record as it does not provide a specific identifier for the individual. It is important to have a unique identifier for each individual who makes entries in a patient’s health record. The other choices (A, B, and C) provide specific identifiers for the individuals responsible for the entries.

Question 16

Which of the four distinct components of the problem-oriented record contains the medical and social history of the patient?

Accepted Answer

The database component of the problem-oriented record contains the medical and social history of the patient. This includes information such as past medical conditions, surgeries, medications, family history, and social history. The problem list includes the current and ongoing medical issues, the initial plan outlines the initial treatment plan, and the progress notes document the patient's ongoing status and any changes to the plan.

Question 17

Which of the following indices might be protected from unauthorized access through t he use of unique identifier codes assigned to members of the medical staff?

Accepted Answer

The physician index would be protected using unique identifier codes assigned to medical staff to ensure that only authorized personnel can access sensitive information related to physicians.

Question 18

In a manual record tracking system, outguides replace a file that has been checked out of the system. A secondary function of outguides is to

Accepted Answer

Outguides help ensure that when a file is returned, it is placed back in the correct location, thus expediting the correct placement of refilled records.

Question 19

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.

Accepted Answer

A final progress note can be used instead of a discharge summary for normal newborns with uncomplicated stays.

Question 20

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show.

Accepted Answer

The answer of In preparation for an upcoming site visit...

Exam 1: Registered Health Information Administrator