Question 1

The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure

Accepted Answer

The decision analysis matrix method provides consistent criteria for evaluating alternatives/vendors, ensuring that they are evaluated objectively.

Question 2

Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is

Accepted Answer

Giving each form an identifiable name, number, and revision date is crucial for forms control in this setting. This ensures that the correct version of a form is being used and prevents errors and confusion. Consistent formatting and providing instructions are also important, but not as critical as having clear identification of the form. Capturing every data item required by UHDDS is not relevant to forms control.

Question 3

Which of the following acts was passed to stimulate the development of standards to facilitate electronic maintenance and transmission of health information?

Accepted Answer

The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 and included provisions to stimulate the development of standards for electronic healthcare transactions, specifically to facilitate the maintenance and transmission of health information. The other acts listed do not pertain directly to electronic healthcare transactions or standards.

Question 4

Which of the following names would be filed first alphabetically?

Accepted Answer

Alphabetically, the first letter is prioritized, so "L" is the same for all options. The second letter is "o" for all options as well. Next, "v" is the same for all but option C, which has "v" followed by "e" ("ve" comes before "vi"). Therefore, Lovett, T.J. (Senior) would be filed first.

Question 5

Who is legally responsible for obtaining the patient's informed consent for surgery?

Accepted Answer

The surgeon performing the surgery is legally responsible for obtaining the patient's informed consent for surgery. They are responsible for explaining the benefits and risks of the procedure, as well as answering any questions the patient may have before the surgery. While other members of the healthcare team may assist in the informed consent process, ultimately it is the surgeon who has the primary responsibility.

Question 6

Your Pharmacy and Therapeutics Committee has asked you to find out more about a computerized order entry system that calculates drug dosages based on patient parameters (weight, age, etc.) and even suggests the best drug given the patient's diagnosis and current treatment. The committee is asking for information on a(n)

Accepted Answer

An expert system is a computer program that offers advice or solves problems in a specific domain by using a knowledge base of rules and experience to simulate the decision-making ability of a human expert. In this case, the computerized order entry system is using patient parameters and diagnosis to suggest the best drug, which is an example of an expert system.

Question 7

All of the following are elements of a contract EXCEPT

Accepted Answer

The four essential elements of a contract are offer/communication, acceptance, consideration/price, and a duty to perform or refrain from performing.

Question 8

In a terminal digit filing system, with all records in the system, which record numbers fall directly before and after the record number 25-31-99?

Accepted Answer

The answer of In a terminal digit filing system, with...

Question 9

According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent via facsimile transmission EXCEPT

Accepted Answer

AHIMA's Position on Transmission of Health Information recommends pre-programming the fax machine with destination sites, encrypting data if public channels are used for transmission, and contacting the recipient before and after transmission. However, the position does not recommend always following up by sending the original record by mail.

Question 10

A portion of a deficiency slip is reproduced below. This patient was discharged yesterday. Y greatest concern regarding deficiencies on this record would be the missing

Accepted Answer

The answer of A portion of a deficiency slip is...

Question 11

The ownership of the information contained in the physical medical/health record is considered to belong to the

Accepted Answer

The ownership of the information in a medical/health record belongs to the patient since it contains their personal health information. The hospital, physician, or insurance company may have access to the information but the patient retains ownership of their own health information.

Question 12

Under traditional rules of evidence, a medical/health record is considered __________ and is into evidence.

Accepted Answer

A medical/health record is considered hearsay and is inadmissible into evidence under traditional rules of evidence because it is an out-of-court statement offered to prove the truth of the matter asserted.

Question 13

Which patient numbering system(s) always assign(s) the next new number in the system to new or readmitted patient to his or her health history?

Accepted Answer

In both serial and serial-unit numbering systems, a new number is assigned to a patient each time they are admitted or treated, ensuring the next new number in the system is used.

Question 14

Upon learning that a court order violates state law, the HIM professional should

Accepted Answer

The HIM professional should immediately call the legal counsel for the healthcare institution to inform them of the situation. The legal counsel is responsible for handling legal matters for the healthcare institution and can take appropriate steps to address the court order that violates state law. Calling the judge or opposing attorney may not always be appropriate or effective, and ignoring the court order is not a viable option.

Question 15

A record documentation requirement shared by BOTH acute care and emergency departments

Accepted Answer

Condition on discharge is a documentation requirement shared by both acute care and emergency departments to ensure continuity of care and proper patient management after discharge.

Question 16

Internal disclosures of patient information for patient care purposes should be granted

Accepted Answer

Internal disclosures of patient information should only be granted on a need to know basis, meaning only those who need the information to provide adequate patient care should have access to the information. Legal counsel may have access to patient information, but only in certain circumstances, such as in a legal case involving the patient. All physicians on staff do not necessarily need access to patient information, only those directly involved in their care. Family members who are employees should not have access to patient information unless it is necessary for their job responsibilities and they have signed a confidentiality agreement.

Question 17

Your facility is storing scanned records for long-term storage on optical disk. The Risk Management Committee's Disaster Task Force has recommended that copies of the disks be stored at a facility across town. The administrator is concerned that records may be altered on the disks stored off-site. You tell the administrator

Accepted Answer

WORM (Write Once, Read Many) technology ensures that once data is written to the disk, it cannot be altered, making it secure for long-term storage.

Question 18

Annual costs for the only Release of Information Clerk at Happy Valley Hospital (salary benefits) are $36,429. The monthly cost for the copier used solely for ROl is $89 (supplies repairs). It costs the department $0.95 on average for ROI mailings (envelopes and posts; Happy Valley filled 687 requests for ROI last month. The cost per request for release information last month was

Accepted Answer

The answer of Annual costs for the only Release of...

Question 19

As the HIM Director at the Pediatric Clinic, you have just contracted with a firm that will scan your retired paper records to disk. You tell the administrator you would like to have retired records currently on microfilm scanned to disk, too. The administrator would like to keep those records on roll film to save the cost of the extra scanning. You tell the administrator you don't recommend this because

Accepted Answer

Maintaining old microfilm requires keeping an outdated reader-printer for access, which can be inconvenient and costly.

Question 20

A supervisor reviews a job to determine the required content, skills, knowledge, abilities, responsibilities for the position. The tasks are grouped and lines of responsibility and au are defined. The supervisor is writing a job

Accepted Answer

The supervisor is reviewing and defining the duties, responsibilities, and qualifications for the position, which is the process of creating a job description.

Exam 1: Registered Health Information Administrator