Question 1

If you want to begin with the type of material that has the highest error rate, you will start by working on problems with

Accepted Answer

The answer of If you want to begin with the...

Question 2

A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders valuable medications with cheap outdated ones purchased on the Internet, then sold the g' drugs for profit. Patients have been injured and the lawsuits are starting. Unfortunately, y facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of

Accepted Answer

The doctrine of respondeat superior holds employers responsible for the negligent acts of their employees committed within the scope of their employment. Therefore, the facility will be held responsible for the pharmacist's drug ring. Adjudicus res, res ipsa loquitur, and stare decisis are not relevant to this scenario.

Question 3

Sally is a HIM professional with many years of experience. Unlike some of her colleagues, loves the challenge of adapting to change. She is happy that HIPAA empowers the Secretary DHHS to adopt standards for electronically maintained health information. Sally hopes standardization under HIPAA will make it easier to design safeguards for electronic data, protect against unauthorized access,

Accepted Answer

The statement mentions that standardization under HIPAA will make it easier to design safeguards for electronic data and protect against unauthorized access, as well as prevent the corruption of electronically stored data and protect the integrity of information itself. Option C directly reflects this statement, making it the best choice. Options A and B do not fully encompass all aspects of the statement, and option D is not related to the topic at hand.

Question 4

An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and unconscious. What should be done?

Accepted Answer

In an emergency situation where the patient cannot provide consent, the doctrine of implied consent means that treatment can be provided if it is deemed necessary to save the patient's life or prevent serious harm. In this case, both the child and the mother require immediate medical attention and can be treated under implied consent until proper legal consent can be obtained.

Question 5

A 16-year-old male was treated at your facility for a closed head injury. The patient's 18- year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records?

Accepted Answer

Since the patient is 16 years old, he is considered a minor and therefore unable to legally sign the authorization for release of medical records. However, the patient's wife signed the consent for admission and treatment, which suggests that the couple may be legally married. In some states, minors who are legally married are considered emancipated and able to make their own medical decisions. Therefore, the patient himself should sign the authorization for release of medical records.

Question 6

Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA privacy rules?

Accepted Answer

The authorization is invalid if the expiration date has passed, according to HIPAA privacy rules. Therefore, the request should not be honored.

Question 7

Your facility is part of a community health information network and you belong to a committee charged with the responsibility of encouraging the uniform collection and reporting of data. Among your recommendations is the adoption of a common

Accepted Answer

Adopting a common data set is the best choice among the four options listed. A common data set provides a structured and standardized approach to collecting and reporting data, which facilitates data sharing and analysis across different healthcare organizations. It also helps to ensure that the data collected is relevant, accurate, and consistent, which improves the quality of patient care and public health research. While the other options listed (forms design, record format, data quality monitoring system) are important considerations for data collection, they are secondary to having a standardized data set.

Question 8

Codes act as a primary means of communication with third-party payers. You look forward to the day that you will use

Accepted Answer

A universal procedure coding system would simplify communication with third-party payers by standardizing codes across all healthcare settings.

Question 9

Referring again to the data collected on scanning errors, if you want to work on the type of material with the highest volume, you will work on problems with

Accepted Answer

According to the given data, the material with ID 11ec357f_2f78_d77f_b39c_552bdd928e59_C1078_00 has the highest volume of scanning errors and this material corresponds to lab slips. Hence, if you want to work on the type of material with the highest volume, you will work on problems with lab slips.

Question 10

A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to

Accepted Answer

The patient's psychiatric record may contain sensitive information that could potentially harm the patient if released without proper precautions. Therefore, it is important to contact the patient's attending physician first to discuss any potential risks and obtain their approval before releasing the record to the patient.

Question 11

You are providing an educational session to new hires at your hospital. You tell the new employees that hospital records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That's because the hospital record

Accepted Answer

The hospital record may be used as evidence in court because it was kept in the regular course of business, which makes it an exception to the hearsay rule. The fact that it is written rather than spoken, has not been tampered with, and is accurate and complete all contribute to its reliability and credibility as evidence, but they are not the primary reason it can be admitted in court.

Question 12

As the Information Security Officer at your facility, you have been asked to provide examples of technical security safeguards adopted as a result of HIPAA legislation. Which of the following would you provide?

Accepted Answer

Audit controls are a technical security safeguard required by HIPAA legislation. These controls provide a way to track and record accesses to electronic health information, including who accessed it and when. This information can be used to identify potential security breaches and help prevent future incidents. Evidence of security awareness training (B), surge protectors (C), and workstation use and location (D) are all important for maintaining security, but are not considered technical safeguards under HIPAA.

Question 13

Sally had three babies in 4 years and she considered that more than enough. During her hospitalization for her third delivery, Sally had a sterilization procedure performed. When the record is coded, the V-code for sterilization, V25.2 is

Accepted Answer

The V-code for sterilization, V25.2, should be used and sequenced as a secondary diagnosis. It is not the reason for admission and should not be the principal diagnosis. It is also not the only code used, as other diagnosis codes would be used to describe the reason for Sally's hospitalization (e.g. delivery, postpartum complications, etc.).

Question 14

A clerk brings you a question about a request for information. The patient was treated meningitis at age 3 (15 years ago). The patient is now 18. The patient's attorney is request information on the admission. You tell the clerk the information is

Accepted Answer

The information is available and can be released if the patient signs a consent form to authorize the release of their medical records. Since the patient is now 18 years old, they are legally able to sign the consent form on their own behalf, without requiring the signature of their parents.

Question 15

After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because

Accepted Answer

The answer of After your coders helped you rank the...

Question 16

A 19-year-old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the Army. The release of information clerk should

Accepted Answer

The release of information clerk should send the records as requested because the patient has the right to access their medical records and has provided a request for their release.

Question 17

Which of the following responsibilities would you expect to find on the job description of a facility's Information Security Officer, but NOT on the job description of Chief Privacy Officer?

Accepted Answer

The responsibility of conducting audit trails to monitor inappropriate access to system information is typically part of the job description of an Information Security Officer rather than a Chief Privacy Officer. The other responsibilities listed are typically shared by both positions or may even fall more under the purview of a Chief Privacy Officer.

Question 18

A 75- year-old patient was admitted for repair of a hiatal hernia, which was performed on the first day of admission. While recovering, the patient fell out of bed and sustained a fractured femur which was surgically reduced. Further complications included severe angina for which a cardiac catheterization and PTCA were performed. The principal procedure is

Accepted Answer

The principal procedure is the one that brought the patient into the hospital in the first place, which in this case is the repair of the hiatal hernia (herniorrhaphy). The other procedures were done as a result of complications which arose during the patient's recovery.

Question 19

A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect this data would be

Accepted Answer

A check sheet is the best choice for collecting data on the number of times a transcription unit has to leave sections of a report blank for various reasons. A check sheet is a simple tool used to collect and analyze data in real-time. In this case, the transcription unit can use a check sheet to tally the number of times they have to leave sections of a report blank, helping to identify patterns and areas for improvement. Force field analysis, decision matrix, and flowchart are not appropriate tools for this type of data collection.

Question 20

Joanie Howell presents to Dr. Franklin requesting rhinoplasty. Because Howell is covered by, Medicare, Dr. Franklin must provide Howell with

Accepted Answer

Since rhinoplasty may not be medically necessary, Dr. Franklin must provide Joanie Howell with an Advance Beneficiary Notice to inform her that Medicare may not cover the cost of the procedure. This is required under Medicare's rules for informed consent and to protect the patient from unexpected costs. The other options are not correct because they do not address the issue of informing the patient about Medicare coverage and the potential cost implications.

Exam 1: Registered Health Information Administrator