Question 1

If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to

Accepted Answer

When patients have identical last names, first names, and middle initials, the master patient index is typically arranged by date of birth to differentiate between them.

Question 2

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the

Accepted Answer

The National Practitioner Data Bank is a central repository of information on physician malpractice claims and disciplinary actions. Checking this database is an essential step in ensuring that physicians applying for membership have not had any serious issues in their past practice.

Question 3

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital.

Accepted Answer

The answer of Referring to the data in the previous...

Question 4

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

Accepted Answer

Review of systems is a series of questions asked by the physician to elicit information regarding the presence of symptoms that the patient may have forgotten to mention or that may have seemed unimportant. It is a subjective assessment of the patient's symptoms, in contrast to the physical exam, which is an objective assessment of the patient's physical state. Option A refers to the physical exam, while options B and C are not accurate descriptions of the review of systems.

Question 5

A quarterly review reveals the following data for Springfield Hospital:  What is the percentage of incomplete records during this quarter?

Accepted Answer

According to the given data, there were 244 incomplete records out of a total of 444 records. To find the percentage, we divide the number of incomplete records by the total number of records and then multiply by 100.

(244/444) * 100 = 54.95, which rounds up to 55%.

Therefore, the answer is A) 55%.

Question 6

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

Accepted Answer

The inconsistent data entries indicate that the data is not being reliably captured, leading to a compromise in data reliability.

Question 7

In an acute care facility, the responsibility for education physicians and other health care providers regarding proper documentation policies belongs to the

Accepted Answer

The responsibility for education physicians and other health care providers regarding proper documentation policies belongs to the health information manager. This individual is responsible for ensuring that medical records are complete, accurate, and kept confidential. They are also responsible for developing policies and procedures for proper documentation and ensuring that healthcare providers follow these policies.

Question 8

Documentation found in acute care health records should include core measure quality indications required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for pneumonia patients is

Accepted Answer

The blood culture before first antibiotic received is a core measure quality indicator for pneumonia patients. This indicator ensures appropriate diagnosis and treatment of the type of pneumonia the patient is experiencing. The other choices are not specific to pneumonia patients or are not core measures for pneumonia quality indicators.

Question 9

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

Accepted Answer

If a patient leaves against medical advice, it is important to document the circumstances of the leave in both the progress notes and the discharge summary. This ensures that there is a clear record of the situation for future reference and for communication with other members of the healthcare team. While incidents of leaving against medical advice may be reported to the Executive Committee or filed in an incident report, the primary documentation should be in the progress notes and discharge summary. Reporting as a potentially compensable event would depend on the specific circumstances and policies of the healthcare facility.

Question 10

What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, 14-32-79?

Accepted Answer

The records are filed in ascending order based on the entire number sequence, which indicates a straight numeric filing system.

Question 11

Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, updated, and recertify the patient as appropriate. The time frame for requiring this summary is at least every

Accepted Answer

The Centers for Medicare & Medicaid Services (CMS) requires that home health agencies provide a summary to the attending physician at least every 60 days for recertification of the patient's plan of care.

Question 12

For inpatients, the first data item collected of a clinical nature is usually

Accepted Answer

The admitting diagnosis is usually the first clinical data item collected for inpatients as it is necessary for determining the appropriate level of care and developing a treatment plan. The principal diagnosis may be determined later during the hospital stay after further evaluation and testing. Expected payer is a financial data item and review of systems is a more comprehensive assessment of the patient's symptoms and medical history, which may be collected later in the admission process.

Question 13

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets

Accepted Answer

Skilled nursing facilities are required to submit MDS data in accordance with CMS standards, therefore the software used must meet CMS standards. The other options listed are not directly related to MDS submissions.

Question 14

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

Accepted Answer

Medicare rules state that verbal orders must be accepted by persons authorized by hospital regulations and procedures. Option A is incorrect as the orders must be written within 48 hours, not 24. Option B is incorrect as any qualified health care professional can accept verbal orders, not just charge nurses. Option C is incorrect as the orders must be cosigned within 48 hours, not 12.

Question 15

You want to review the one document in your facility that will spell out the documentation requirements for patient records; designate the time frame for completion by the active medical staff; and indicate the penalties for failure to comply with these record standards. Your best resource will be

Accepted Answer

The medical staff rules and regulations typically outline the documentation requirements for patient records, the time frame for completion, and the penalties for non-compliance.

Question 16

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

Accepted Answer

While standing orders and telephone orders may be included in the health record, they are not required for every completed inpatient health record. Stop orders may only appear if orders were discontinued or altered during the patient's stay. However, a completed inpatient health record must include a discharge order to indicate that the patient has been officially released from the facility.

Question 17

Still referring to the information in the table in question number 88, which area represents the greatest area of concern for Springfield Hospital's compliance with Joint Commission standards?

Accepted Answer

The answer of Still referring to the information in the...

Question 18

If there are 150,000 records and the HIM Department receives 3,545 requests of records within a given period of time, what is the request rate?

Accepted Answer

The request rate is calculated by dividing the number of requests by the total number of records and then multiplying by 100 to get a percentage: (3,545 / 150,000) * 100 = 2.3633%, which rounds to 2.4%.

Question 19

One record documentation requirement shared by BOTH ascute care and emergency departments is

Accepted Answer

Both acute care and emergency departments must document the patient's condition on discharge. This is essential for continuity of care and providing appropriate follow-up care. Time and means of arrival and advance directives may be specific to emergency departments, while problem lists may be specific to acute care settings.

Question 20

Which one of the following is NOT a step in developing a record retention program?

Accepted Answer

Assigning all records the same retention period is not a step in developing a record retention program. Each type of record should have its own retention period based on legal or business requirements.

Exam 1: Registered Health Information Administrator