Hospital Management and Data Analysis, Exams of Nursing

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RHIA MOCK EXAM WITH CORRECT ANSWERS 2023-2024 100% VERIFED Each month the staff of the clinic with the lowest overall waiting time is awarded a free dessert in the Gulf side healthcare center cafeteria. take a look at the information listed above. the winner will be selected based on a. demonstrative clinical data b. comparative aggregate data c. objective individual data d. duplicate thematic data - Correct answer-b. comparative aggregate data a union campaign is being conducted at your facility. as a department manager, it is appropriate for you to tell employees that a. a strike is inevitable if the union wins b. wages will increase if the union is defeated c. you need the names of those involved in union activities d. you are opposed to the union - Correct answer-d. you are opposed to the union as the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. you will need to develop a professional relationship with a. the OIG b. MEDPAR representatives c. QIO physicians d. recovery audit contractors - Correct answer-d. recovery audit contractors employing the SOAP style of progress notes, choose the "assessment" statement from the following a. patient states low back pain with sciatica is as severe as it was on admission b. patient moving about very cautiously appears to be in pain c. adjust pain medication; begin physical therapy tomorrow. d. sciatica unimproved with hot pack therapy - Correct answer-d. sciatica unimproved with hot pack therapy in preparation for an EHR, you are conducting a total facility inventory of all forms currently used. you must name each for for bar coding and indexing. the unnamed document in front of you includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. the document type you give to this form is. a. prenatal record b. labor record c. delivery room record d. postpartum record - Correct answer-d. postpartum record. d. not typically maintained or documented as patient encounters. - Correct answer-a. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters the proposed national healthcare information network (NHIN) dimensions are graphically depicted in the diagram above. roman numeral are added to allow for the identification of specific areas. where would information concerning a patient's health insurance be located on this chart? a. I b. II c. III d. V - Correct answer-b. II The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. the first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. for this information you will consult the a. policy and procedure manual b. hospital's quality management plan. c. data dictionary d. hospital bylaws, rules, and regulations - Correct answer-d. hospital bylaws, rule, and regulations. Parker has type 1 diabetes with hypertension taht is currently controlled with medication. parker was admitted through the ED for an emergency appendectomy. following surgery, the patient developed an infection at the wound site that was treated with antibiotics. when making decision about sequencing the codes for this case, the coder should rely on definitions found in the a. UHDDS b. coding clinic c. CMS coding guidelines d. federal register - Correct answer-a. UHDDS Parker has type 1 diabetes with hypertension taht is currently controlled with medication. parker was admitted through the ED for an emergency appendectomy. following surgery, the patient developed an infection at the wound site that was treated with antibiotics. Parker's principal diagnosis is the a. complications of hypertension b. comorbidity of the wound infection c. comorbidity of type 1 diabets d. acute appendicitis - Correct answer-d. acute appendicitis Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Bake (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions a. in the discharge summary b. on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record. c. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record. d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record. - Correct answer-d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record The physician has documented the final diagnoses as acute myocardial infaraction, COPD, CHF, hypertension, atrial fibrillation, and status-post cholecystectomy. The following conditions should be reported: I10 Essential Hypertension, benign I10 Essential Hypertension, unspecified I11 Hypertension, heart disease, unspecified as to malignant or benign, with heart failure I21.3 Acute Myocardial infarction, unspecified site, initial episode of care I48.91 Atrial Fibrilation I50.9 Congestive Heart Failure, unspecified J44.9 Chronic Obstructive Pulmonary Disease Z90.89 Acquire absence of gallbladder a. I21.3, J44.9, I21.3, I48.91, Z90.89 b. I11, J44.9, I50.9, I10, I48.91 c. I11, J44.9, I50.9, I10, I48.91, Z90.89 d. I11, J44.9, I50.9, I10, I48.91 - Correct answer-B. I11, J44.9, I50.9, I10, I48.91 Mary is 6 weeks postmastectomy for carcinoma of the breast. she is admitted for chemotherapy. What is the correct sequencing of the codes C50.911 Malignant Neoplasm of the Breast Z85.3 Personal History of malignant neople of breast Z51.11 Encounter for antineoplastic chemotherapy Z08 Follow-up exam after surgery a. Z51.11, C50.911 b. Z51.11, Z85.3 c. Z08, Z51.11 d. Z85.3 - Correct answer-A. Z51.11, C50.911 Which of the following is coded as an adverse effect in ICD-9-CM? a. tinnitus due to allergic reaction after administration of ear drops b. mental retardation due to intracranial abscess c. rejection of transplanted kidney d. nonfunctioning pacemaker due to defective soldering - Correct answer-a. tinnitus due to allergice reaction after administration of ear drops which of the following scenarios identifies a pathologic fracture? a. greenstick fracture secondary to fall from -matthew had an idiosyncratic reaction between two properly administered prescription drugs a. josh b. ben c. bryan d. matthew - Correct answer-c. bryan Patient is admitted for elective cholecystectomy for treatment of chronic cholecystititis with cholelithiasis. prior to administration of general anesthesia, patient suffers cerebral thrombosis. surgery is subsequently canceled. code and sequence the coding from the following codes. I66.9 cerebral thrombosis without cerebral infarction K80.10 chronic cholecystitis with cholelithiasis Z53.09 Iatrogenic cerebrovascular infarction or hemorrhage OFT40ZZ Cholecystectomy, total a. I97.821, K80.10, OFT4OZZ b. K80.10, I66.9, Z53.09 C. I97.821, I66.9, Z53.09 d. I66.9, Z53.09 - Correct answer-b. K80.10, I66.9, Z53.09 The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. the coder would assign. a. a code for myocardial infarction b. a code for the patient's symptoms c. a code for an impending myocardial infarction d. no code for this condition - Correct answer-a. a code for myocardial infarction. staging a. refers to the monitoring of incidence and trends associated with a disease b. is continued medical surveillance of a case c. is a system for documenting the extent or spread of cancer d. designated the degree of differentiation of cells - Correct answer-c. is a system for documenting the extent or spread of cancer which of these conditions are always considered "present on admission" (POA)? a. congenital conditions b. E codes c. acute conditions d. possible, probable, or suspected conditions - Correct answer-a. congenital conditions in your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. when this occurs, who would be expected to authorize the release of the medical information documented in this episode of care to the patient's insurers? a. the patient b. a court-appointed guardian on behalf of the patient c. the custodial parent of the patient d. the patient's doctor on behalf of the patient - Correct answer-a. the patient history was obtained and a basic physical was done. physician completed life insurance physical form at patient's request. blood and urine were collected 99381- initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, new patient; infant (age under 1 year) 99386-initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, new patient; 40-64 years 99396- periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, established patient; 40-64 years 99450- basic life and/or disability examination that includes completion of a medical history following a life insurance pro forms a. 99450 b. 99386 c. 99396 d. 99381 - Correct answer-a. 99450 Patient was seen today for regular hemodialysis. no problems reported, tolerated procedure well. 90935- hemodialysis procedure with single physician evaluation 90937- hemodialysis procedure required repeated evalution with or without substantial revision of dialysis prescription 90945- dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacemtn therapies), with single physician evaluation 99354 prolonged physican service in the office or other outpatient setting requiring direct (face-to-face) contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service) a. 90937 b. 99354 c. 90945 d. 90935 - Correct answer-d. 90935 an established patient was seen by the physician in the office for DTaP vaccine and Hib 90471- immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90700-diptheria, tetanus toxoids, and acellular pertussis vaccine DTaP, when admistered to indivduals younger than 7 years, for intramuscular use 90720-diptheria, tetanus toxoids, and whole cell pertussis vaccine and hemophilus influenza B vaccine (DTP-Hib), for intramuscular use. 90721- diptheria, tetanus toxoids, and acellular pertussis vaccine and hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use 90748- Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use 99211- office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. usually, the presenting problems are minimal. typically 5 minutes are spent performing or supervising procedure a. 90721 b. 90720, 90471 c. 90700, 90748, 99211 d. 90471, 90721 - Correct answer-d. 90471, 90721 a patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist 77236- therapeutic radiology treatment planning; complex 77290- therapeutic radiology simulation-aided field setting; complex 77315- teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77334- treatment devices, design and construction; complex(irregular blocks, special shields, compensators, wedges, molds or casts) a. 77315 b. 77263 c. 77290 d. 7734 - Correct answer-b. 77263 a 4-year-old had a repair of an incarcerated inguinal hernia. this is the first time this child had been treated for this condition 49496- repair initial inguinal hernia full-term infant, under age 6 months, or preterm infant over 50 weeks' post 49501- repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or strangulated 49521- repair recurrent inguinal hernia, any age; incarcerated or strangulated 49553- repair initial femoral hernia, any age; incarcerated or strangulated a. 49553 b. 49496 c. 49521 d. 49501 - Correct answer-d. 49501 a quantitative drug assay was performed for a patient to determine digoxin level 80050- general health panel 80101- drug screen, qualtitative; single drug class method (e.g. immunoassay, enzyme assay), each drug class 80162- digoxin (therapeutic drug assay, quantitative examination) 80166- doxepin (therapeutic drug assay, quantitative examination) a. 80101 b. 80050 c. 80166 d. 80162 - Correct answer-d. 80162 provide the CPT code for anesthesia servcies for the transvenous insertion of a pacemaker 00530- anesthesia for permanent transvenous pacemaker insertion 00560- anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 33202- insertion of epicardial electrodes; open incision 33206- insertion or replacement of permanent pacemaker with transvenous electrodes; atrial a. 00560 b. 33202, 00530 c. 00530 d. 33206, 00560 - Correct answer-c. 00530 the transiptionists have collected data on the number and types of problems with the dictation equipment. the best tool to display the data they collected is a a. flowchart b. pareto chart c. gantt chart d. pert chart - Correct answer-b. pareto chart based on the information below, what was the net death rate at Seaside Hospital in January? Admission- 280 discharged to home- 212 discharge transfers-28 death less than 48 hours- 8 death greater than 48 hours- 6 a. 2.4% b. 2.8% c. 3.8% d.5.8% - Correct answer-a. 2.4% the formula used to calculate the percentage of ambulatory care visits made with same day appointments is a. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen with addvance appointments for the same period b. number of patients seen with advance appointments for a period x 100 divided by the number of patients seen with the same day appointments for the same period c. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen in the same period d. the answer cannot be calculated with the information provided - Correct answer-a. 125, 485 a patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of a. 45 days b. 46 days c. 47 days d, 48 days - Correct answer-c. 47 days release of information has increased its used of part-time prn clerical support in order to respond to increased requests for release of information. the budget variance report will reflect a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area b. the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support c. both the increases in revenue and increased costs for clerical support in ROI d. neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports - Correct answer-a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. you are heading a research study that includes a patient questionnaire. five of the questions will be answered using the following scale: a. stacked bar graph b. pie chart c. frequency table d. frequency polygon - Correct answer-c. frequency table your HMO manager has requested a report on the number of patient visits per year for preschool children. which of the age groupings below will you use for your report. a. 0-1 year, 1-2 years, 2-3 years, 3-4 years, 4-5 years b. less than 12 months, 12-24 months, 25-37 months, 38-50 months, 51- 63 months. c. greater than 12 months, 12-24 months, 25-37 months, 38- 50 months, less than 51 months d. 0-2 years, 3-4 years, 5 years - Correct answer-b. less than 12 months, 12- 24 months, 25-37 months, 38-50 months, 51-63 months. Collins Family Hospital had a bed count of 150 for the first 6 months of the year. on june 1, it added 15 beds when it opened a new wing. if you are given the average length of stay for the year, can you calculate the annual bed turnover rate? how? a. yes, using the direct method b. yes, using the indirect method. c. yes, using the joint commision method. d. no, there is insufficient data to complete the calculation - Correct answer- d. no, there is insufficient data to complete the calculation in a research study that includes a patient questionnaire, five of the questions will be answering using the following scale: 1-strongly agree 2- disagree 3-no opinion 4- agree 5-strongly agree the data collected using this scale are called a. cardinal data b. ordinal data c. nominal data d. continuous data - Correct answer-b. ordinal data gail smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. according to her sister, gail has had a recent medical history taken at the public health department. the physician on call is grateful that she can access this patient information using the area's a. EDMS system b. CPOE c. expert system d. RHIO - Correct answer-d. RHIO the patients family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered a. the best utilization of the hospital's resources. b. an inappropriate use of hospital resources c. a compassionate use of the hospital's resources d. appropriate provided it is limited to a few days - Correct answer-b. an inappropriate use of hospital resources the state is considering the closure of the Arcadia Hospital. in reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? a. daily census b. percentage of occupancy c. inpatient service days d. average length of stay - Correct answer-b. percentage of occupancy the census taken at midnight on August 1 showed 99 patients remaining in the hospital. on august 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. one of these patients was admitted in the morning and remained only 8 hours. how many inpatient service days were rendered on August 2? a. 94 the credentialing committee discovered the problems with dr. hernandez's hip replacements by a. sampling and reviewing dr. henandez's patient records b. reviewing dr. hernandez's physician profile c. querying the national physician data bank d. interviewing the chief of surgery - Correct answer-b. reviewing dr. hernandez's physician profile you are starting your new job as the sole HIM professional at a small psychiatric practice. the practice uses DSM for billing purposes. you find this "theoretically" reasonable because DSM a. is a widely used and accepted classification system b. codes are also valid ICD-10-CM codes c. codes are also valid CPT codees d. is the industry standard for physchiatric billing systems - Correct answer- b. codes are also valid ICD-10-CM codes as the information security office at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. which of the following would you provided. a. audit controls b. entity authentication c. chain-of-trust partner agreements d. workstation use and location - Correct answer-d. workstation use and location the MS-DRG weight in a particular case is 2,0671 and the hospital's payment rate is $3,027. how much would the hospital receive as reimbursement in this case? a. $3,027.00 b. $5,094.10 c. $6, 257.11 d. $960.00 - Correct answer-c. $6,257.11 a patient's husband slipped and fell in your HIM reception are and now he is suing the facility. you have to prepare detailed written answers to a long list of questions and send them to your hospital attorney. you will spend the afternoon working on a. affidavits b. allocutions c. interrogatories d. depostions - Correct answer-c. interrogatories use the information on errors in indexing of scanned material that you have collected and presented in the table below to answer the question if you want to begin with the type of material that has the highest error rate, you will start by working on problems with a. consultation reports b. lab slips c. correspondence d. other - Correct answer-a. consultation reports permission to respond c. contact the attending physician for permission to respond d. honor the authorization since the patient obviously approves of the release - Correct answer-a. do not honor because the authorization is invalid the hospital's strategic plan calls for having the entire health record contact recorded in discrete form within the next 10 years. which system will the HIM director most likely recommend in the early stages of the project as a transition strategy? a. electronic document management system b. clinical data repository system c. CPOE system d. speech recognition system - Correct answer-a. electronic document management system as the information security office at your facility, you have been asked to provide examples of technical security safeguards as a result of HIPAA legislation. which of the following would you provide? a. audit controls b. evidence of security awareness training c. surge protectors d. workstation use and location - Correct answer-a. audit controls 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 a. you expected the coders to put more emphasis on time pressure b. you thought limited training was the primary reason for the errors c. the rankings show surprising disagreement on the issue d. the results appear to violate the Pareto Principle - Correct answer-d. the results appear to violate the Pareto principle joanie howell presents to dr. franklin requesting rhinoplast. because howell is covered by medicare, dr. franklin must provide howell with a. a notice of exclusion, because rhinoplasty is not a medicare covered service b. an advance beneficiary notice, because rhinoplasty is not a medicare covered service c. a notice of exclusion, because howell's rhinoplasty may not be medically necessary. d. an advance beneficiary notice, because howell's rhinoplasty may not be medically necessary - Correct answer-d. an advance beneficiary notice because howell's rhinoplasty may not be medically necessary 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 a. send the records as requested b. inform the young man that specific reports must be identified in his request c. send a letter informing him that faxed requests are not accepted d. deny the request - Correct answer-a. send the records as requested C. OSHA d. CDC - Correct answer-a. ONC the chief of staff, chief of medicine, president of the governing body, and most departmental managers have already completed CQI training. unfortunately, the hospital admistrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training. a. this level of involvement is enough to meet joint commission standards b. the joint commission only expects involvement from clinical staff c. this will not do because it violates joint commission standards and CQI philosophy d. if you can talk him into training his staff, you can let him skip the training - Correct answer-c. this will not do because it violates joint commission standards and CQI philosophy use the information provided in the table above to calculate the delinquent rate. the delinquent rate a. cannot be determined b. is 36% c. is 50% d. is 71% - Correct answer-b. is 36% the percentage of records delinquent due to the absence of an operative report a. is 1.7% b. is 2.7% c. is 4.6 % d. cannot be determined from the information given - Correct answer-d. is 4.6% the purpose of the correct coding initiative is to a. increase fines and penalties for bundling services into comprehensive CPT codes b. restrict medicare reimbursement to hospitals for ancillary services c. teach coders how to unbundle codes d. detect and prevent payment for improperly coded services - Correct answer-d. detect and prevent payment for improperly coded services access to radiologic images has been imporved through the use of which of the following? a. LOINC b. PACS c. EDMS d. CPOE - Correct answer-b. PACS the difference between an institutional review board (IRB) and a hospital's ethics committee is that a. the IRB focuses on patient care only, and the ethics committee addresses both patient care and business practices b. the ethics committee reviews ethics complaints, and the IRB focuses on developing policies and procedures c. the IRB deals with the ethical treatment of human research subjects, and the ethics committee covers a wide range of issues d. the IRB is made up entirely of patient care providers, and the ethics committee is mulitdisciplinary - Correct answer-c. the IRB deals with the ethical treatment of human research subjects, and the ethics committee covers a wide range of issues a common goal of the office of the national coordinator for health information technology, RHIOs, and a national infrastructure for information is a. translating images into a digital format b. sharing information among providers c. transferring health information within a hospital system d. promoting telemedicine - Correct answer-b. sharing information among providers according to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is a. percuatneous b. incisional c. excisional d. punch - Correct answer-b. incisional your facility would like to improve physician documentation in order to allow improved coding. as coding supervisor, you have found it very effective to provide the physicians with a. a copy of the facility coding guidelines, along with written information on improved documentation b. the UHDDS and information on where each data element is collected and/or verified in your facility c. regular in-service presentations on documentation, including its importance and tips for improvement d. feedback on specific instances when improved documentation would improve coding - Correct answer-d. feedback on specific instances when improved documentation would improve coding a piece of objective data collected upon initial assessment of the patient is a. review of systems b. history of present illness c. chief complaint d. vital signs - Correct answer-d. vital signs you are the director of coding and billing at a large group practice. the practice manager stops by your office on his way to a planning meeting to b. a health care provider interested in the case c. the quality assurance committee for review purposes d. a third-party payer with a direct interest in the case - Correct answer-c. the quality assurance committee for review purposes your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model show above. the team asks if you see anything missing from the model. you tell them they. a. are missing a step requiring regular employee input into the process. b. are missing a step requiring reporting to the board of directors c. are missing a step requiring ongoing monitoring and reassessment d. aren't missing any steps, the model is a good one - Correct answer-c. are missing a step requiring ongoing monitoring and reassessment part of your job description is to educate physicians regarding proper documentation policies and standards. you are the a. information security manager b. clinical data specialist c. health information manager d. risk manager - Correct answer-c. health information manager your hospital has purchased a number of outpatient facilities. you have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. you begin by telling the committee their primary consideration when making retention decisions must be a. space considerations b. statutory requirements c. provider preferences d. professional standards - Correct answer-b. statutory requirements a major drug company wants to promote a fundraiser targeting patients with congestive heart failure. the drug company representative has requested a list of patients treated at your facility. as privacy and security officer, you tell them that a. they just need to send a written request for the list b. a prior authorization is required before any PHI can be released c. you will need to confer with the medical director d. if the fundraising was conducted by a business associate without authorization, and the funds were to benefit your facility (the covered entity), that you could disclose the information - Correct answer-b. a prior authorization is required before any PHI can be released 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 store off-site. you tell the administrator a. this is a legitimate concern; it should be addressed in the contract written with the storage facility b. this is not a concern because WORM technology makes it impossible to alter the documents c. this is a legitimate concern; perhaps the committee should consider storing duplicates in two locations in this facility d. this is not a concern; there is really no need to make and store duplicate disks as they are difficult to damage. - Correct answer-b. this is not a concern because WORM technology makes it impossible to alter the documents. the pharmacy and therapeutic 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. application system b. clinical decision support system c. ordering system d. practice parameters system - Correct answer-b. clinical decision support system a portion of a deficiency slip is reproduced below. this patient was discharged yesterday. your greatest concern regarding deficiencies on this record would be the missing. a. signature on the physical exam b. signature on the discharge summary c. diagnosis and procedures d. operative report - Correct answer-d. operative report in the past, joint commission standards have focused on promoting the use of facility approved abbreviation list to be used by hospitals care providers. with the advent of the commission's national patient safety goals, the focus has shifted to the a. prohibited use of any abbreviations b. flagrant use of specialty-specific abbreviations c. use of prohibited or "dangerous" abbreviations d. use of abbreviations used in the final diagnoses - Correct answer-c. use of prohibited or "dangerous" abbreviations annual costs for the only release of information clerk at jacksonville beach healthcare center (salary and benefits) are $36,429. the monthly cost for the copier used solely for ROI is $89 (supplies and repair). it costs the department $0.95 on average for ROI mailings (envelopes and postage). there were 687 requests filed for ROI last month. The cost per request for release of information last month was. a. $4.42 b. a supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. the tasks are grouped and lines of responsibility and authority are defined. the supervisor is writing a job. a. description b. analysis c. process d. detail - Correct answer-a. description the emergency department staff has complained that the clerical staff in your department is delaying stat reports. you decided to meet with your staff and develop a cause and effect diagram to determine possible reasons for the delay. you have explained the issue to your staff and have set up a blank cause and effect diagram. the next step is to a. discuss the importance of prompt delivery of stat reports b. determine whether there are internal conflicts in the area c. brainstorm possible reasons for delays in delivering the reports d. design a new system that will support prompt report delivery - Correct answer-c. brainstorm possible reasons for delays in delivering the reports as your meeting with the clerical staff on the stat report continues, one clerk suggests a possible reason for the delays i a lack of training concerning the nature of stat reports. on the cause and effect diagram, this would most appropriately be listed under a. personnel b. equipment c. materials d. methods - Correct answer-a. personnel you stop by the office to meet a friend for lunch. looking on her desk, you see the grid above. your friend is trying to. a. plan a conversion b. design a system c. analyze a workflow d. make a decision - Correct answer-d. make a decision the performance standard for coders is 28-33 workload units per day. workload units are calculated as follows: inpatient record=1 workload unit outpatient surgical procedure records= 0.75 workload units outpatient observation/emergency records=0.50 workload units one week's productivity information is shown in in the table above. what percentage of the coders is meeting the productivity standards? a. 100% b. 75% c. 50% d. 25% - Correct answer-a. 100% the coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. this crisis manager is particularly weak in which management function? everyone in the health information department has been working overtime to complete a major record conversion. the supervisor will have to plan for overtime pay for all personnel who are not a. hourly employees b. salaried exempt employees c. salaried nonexempt employees d. temporary employees - Correct answer-b. salaried exempt employees the coder works 7.5 hours per day. if a time standard is determined from sample observations to be 2.50 minutes per record for coding emergency room records, what is the daily standard for the number of records coded when a 15% fatigue factor is allowed? a. 153 records per day b. 180 records per day c. 192 records per day d. 200 records per day - Correct answer-a. 153 records per day the correspondence section of your department receives an average of 50 requests per day for release of information. it takes an average of 30 minutes to fulfill each request. using 6.5 productive hours per day as your standard, calculate the staffing needs for the correspondence. a. 3.8 FTE b. 2.5 FTE c. 3 FTE d. 4 FTE - Correct answer-a. 3.8 FTE your hospital takes advantage of the 8/80 exemption for health care facilities. assuming that no employee worked more than 8 hours in a day, which of the employees listed in the table below will be paid overtime this pay period? a. employees 101 and 105 b. employees 101, 102, and 105 c. employees 101, 104, and 105 - Correct answer-a. employees 101 and 105 you are conducting an educational session on benchmarking. you tell your audience that the key to benchmarking is to use the comparison to a. implement your QI process b. make recommendations for improvement c. improve your department's processes d. compare your department with another - Correct answer-c. improve your department's processes in conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to a. nationally known facilities b. larger facilities c. facilities within your corporation d. facilities with superior performance - Correct answer-facilities with superior performance you supervise five clerical employees who will be moving when a new wing of your facility is completed. when you meet with the architect to plan their space, you will ask for a. 200 square feet of space for you clerical staff b. 250 square feet of space for your clerical staff c. 300 square feet of space for your clerical staff d. 350 square feet of space for your clerical staff - Correct answer-c. 300 square feet for your clerical staff during the work sampling of a file clerk's activity, it is noted that the employee is speaking on the telephone during 76 of 300 observations. how much of the employee's time is spent on the phone if the employee works 7 hours a day? a. 1.77 hours b. 3.28% c. 3.94 hours d. 9.2% - Correct answer-1.77 hours how long will it take to complete the project described below? a. 12 days b. 17 days c. 20 days d. 29 days - Correct answer-d. 29 days the file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. there are a total of 4,500 records in the main file. what is the area's accuracy rate? a. 1.1% b. 8.9% c. 10.0% d. 88.9% - Correct answer-d. 88.9% encoding software is installed at your hospital 2 years ago. the coders are well trained on it and like using it. it functions well and only requires ICD code updates yearly. in terms of the information system life cycle phases, the coding system is likely in a. design phase b. implementation phase c. operation and maintenance phase d. obsolescence or decline phase - Correct answer-c. operation and maintenance phase the cfo of your facility asks you to prepare a budget for the fiscal year based on the past volume and expected capacity for the coming year. this process is an example of using the " " budgeting method a. rolling budget b. fixed budget c. flexible or statistics budget d. zero-based budget - Correct answer-b. fixed budget the committee that is preparing your acute care hospital for an electronic health record is planning for an imaging system for record archiving in the immediate future. they are looking for a solution for data interfacing or integration of the imaging system into other computer systems. you recommend a. data dictionary guidelines b. health level 7 standards c. regional health information organization guidelines d. joint commission standards - Correct answer-b. health level 7 standards your facility has decided to purchase an integrated patient information system. your part in the initial work plan is to develop system specifications that will ultimately be sent out to vendors who will potentially submit a bid on your system. you are working on the systems specs that will become part of the a. CPR b. IRB c. RFP d. CRS - Correct answer-c. RFP reference checks are conducted on potential employees to help assess the applicant's fit with the position and also to a. confirm the accuracy of information provided on the application b. uncover skills the applicant may have be neglected to report c. get another opinion on the applicant's emotional stability d. alert the past employer that the applicant is job hunting - Correct answer-a. confirm the accuracy of information provided on the application in order to perform their jobs, facility employees should have full and timely access only to the information they need to complete the task at hand. this is similiar to HIPAA's provision for a. a notice of privacy practices b. amending a record c. accessing need to know information only d. an informed consent - Correct answer-c. accessing need to know information only authentication is one of the components necessary to produce a legal document in an EHR. this means a. tracking changes in the EHR system. b. establishing access controls for individual employees c. creating audit trails d. identifying who created a document and when - Correct answer-d. identifying who created a document and when patients with diabetes participated in a study to determine the effectiveness of a new drug. the drug was taken at bedtime. the drug company expected patients taking glucodown to have a normal early morning fasting blood sugar level. the null hypothesis for the study follows there will be no difference in fasting early morning blood sugar levels between patients taking glucodown and patients take a placebo. half the patients were given glucodown. half were given a placebo. early morning fasting blood sugar levels are reported below. Based on the information, you would expect the researchers to a. accept the null hypothesis b. reject the null hypothesis c. restate the null hypothesis d. draw no conclusions - Correct answer-b. reject the null hypothesis patients with diabetes participated in a study to determine the effectiveness of a new drug. the drug was taken at bedtime. the drug company expected patients taking glucodown to have a normal early morning fasting blood sugar level. the null hypothesis for the study follows there will be no difference in fasting early morning blood sugar levels between patients taking glucodown and patients take a placebo. half the patients were given glucodown. half were given a placebo. early morning fasting blood sugar levels are reported below. the researches in the previous question wonder if there is any relationship between patient age and average fasting blood sugar. the best data display tool the researchers could use to look for a possible relationship would be a a. pareto diagram b. line graph c. scatter diagram d. cause and effect diagram - Correct answer-c. scatter diagram you have been asked to reduce your department's operating budget by 20%. in order to do so, you will have to effect reductions in your largest budget line. you will have to make cuts in a. equipment b. personnel c. supplies d. contracts - Correct answer-b. personnel take a look at the comparison of the two life cycles below. d. education - Correct answer-c. travel evidence-based management and decision making is an emerging model now used to make more informed decisions. the premise of this model is a. using intuition based on previous experience. b. using a decision tree with branches that show the alternatives c. using the best clinical and research practices available d. using an alternative that meets minimum requirements - Correct answer- c. using the best clinical and research practices available as a member of the project team for document imaging implementation, you were asked to provide the information in the grid above. this is an example of a a. pert diagram b. gantt chart c. pmbok chart d. work flow diaram - Correct answer-b. gantt chart a tool that is used to illustrate the various applications, support structures, and sequencing of implementation phases for a system is a a. work flow diagram b. migration path c. milestone chart. d. pertt diagram - Correct answer-b. migration path a uses a private tunnel through the internet as a transport medium between locations for secure access and transmission a. TCPIP protocol b. firewall c. hub. d. VPN - Correct answer-d. VPN a technique that uncovers new information from existing information by probing data sets is known as a. data mining b. system query language c. neural network analysis d. data warehousing - Correct answer-a. data mining your HIM department is moving to a new location and in order to arrange your employees and functions for optimal work flow efficiency and to decide which employees need to be placed close to each other, the tool you decide to use is a a. data flow diagram b. PERT chart c. proximity chart or movement diagram d. flow process chart. - Correct answer-d. flow process chart a P value of less than 0.05 is what researches commonly use to reject the null hypothesis. a smaller P value may place interpretation of the results of the study at risk fora a. sampling error b. stratification error c. type 1 (a) error d. type 2 (b) error - Correct answer-a. sampling error which of the following employees would be considered exempt under the fair labor standards act a. the head of the department of health information services who is involved in decision making and planning 90% of the time b. the coding supervisor who has responsibility for three employees and performs analysis and coding 80% of the time c. the departmental secretary who is responsible for performing a variety of clerical and administrative tasks d. the sole employee in the physicians workroom who has responsibility for maintaining and tracking medical record deficiencies - Correct answer-a. the head of the department of health information services who is involved in decision making and planning 90% of the time in order to prevent the accidental introduction of a virus into your facility's local area network, your facility has a policy that strictly prohibits a. doing personal work on the computer system, even during personal time. b. sharing disks from one workstation to another within the facility c. downloading executable files from electronic bulletin boards d. sending or receiving e-mail from addresses that have not be authorized - Correct answer-c. downloading executable files from electronic bulletin boards Documents organized into sections according to the provider's and departments that provide treatment (lab together, rad. together, clinical notes together) - Correct answer- Source-Oriented Health Record Divided into four parts: database, problem list, initial plan, progress notes (SOAP) - Correct answer-Problem-Oriented Health Record SOAP what does S stand for? - Correct answer-Subjective (patient's point of view) SOAP what does O stand for? - Correct answer-Objective (what the practitioner finds) SOAP what does A stand for? - Correct answer-Assessment (combine subjective and objective to make a conclusion) SOAP what does P stand for? - Correct answer-Plan (approach to be taken to resolve patient's problem Describes an entity or distinct characteristics about it - Correct answer-Database Attribute Associations between entities - Correct answer-Database Relationship Collection of bits make up a byte - Correct answer-Database Character A character such as a number, letter, or symbol - Correct answer-Byte Made up of several characters such as name, age, or gender - Correct answer- Database Field Made up of a series of fields about one person or thing - Correct answer- Database Record Made up of fields and records about an entity such as a patient - Correct answer- Database File What is another word for file or entity - Correct answer-Table What are fields in a database table? - Correct answer-Columns What are records in a database table? - Correct answer-Rows Database management system in which data are organized and managed as a collection of tables - Correct answer-Relational Model Database Uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways - Correct answer-Object Oriented Database Model Data is organized in tree's according to relationships (one to many) - Correct answer- Hierarchical Database Model Data is organized in tree's according to relationships (many to many) - Correct answer- Network Database Model Hardware, software, transmission, media, and database industry standards allow different computer vendor systems to communicate to each other - Correct answer- Open System Architecture Communication is possible only on one vendor's system - Correct answer-Closed System Architecture Physical equipment that makes up computers and computer systems - Correct answer- Hardware Mainframes, minicomputers, microcomputers - Correct answer-What are the 3 types of computers? Operating systems software and application software - Correct answer- Software Multiple devices connected via communications media and located in a small geographical area - Correct answer-Local Area Network (LAN) A computer network that connects separate institutions across a large geographical area - Correct answer-Wide Area Network (WAN) Private network that has its servers located inside a firewall - Correct answer- Intranet A patient's name identifies the patient record - Correct answer- Alphabetic Health Record Identification A number identifies the patient record - Correct answer-Numeric Identification A new number is assigned to the patient for each new encounter at the facility - Correct answer-Serial Numbering The patient retains the same number for every encounter at the facility - Correct answer-Unit Numbering A new number is assigned to the patient for each new encounter at the facility, but the former records are brought forward and filed under the new number - Correct answer- Serial-Unit Numbering Records filed in one location - Correct answer-Centralized Filing Records filed in multiple locations - Correct answer-Decentralized Filing Starts with last names and then includes first name and middle initial - Correct answer- Alphabetic Filing Filing charts in sequential order; the records start with the chart with the lowest number value and end with the chart with the highest number value - Correct answer-Straight Numeric Filing Numeric filing is divided into three parts and is read from right to left instead of left to right - Correct answer-Terminal Digit Filing Minimum of 10 years - Correct answer-What does AHA recommend for record retention? 10 years past the age of majority - Correct answer-When does AHA recommend record retention for a minor? Listing or arrangement of data in a designated order; contains special types of information, and purpose is to assist in location of desired information - Correct answer- Index Identifies all patients admitted to a health care facility for treatment, along with their identifying information - Correct answer-Master Patient Index (MPI) Chronological list of patient's identification numbers issued to patients - Correct answer- Number Index Provides every physician with a list of identifying medical cases - Correct answer- Physician Index List of diseases and conditions according to the classification system used in the facility - Correct answer-Disease Index List of surgical and procedural codes - Correct answer-Procedure or Operation Index Created to monitor various diseases and health problems with different goals and objectives - Correct answer-Registry Admission and Discharge Register -- How long retained and in what order? - Correct answer-Permanent in chronological order Maintained for 10 years; provides statistical data for caseload analysis and administrative reports - Correct answer-Operating Room Register Provide accessible information about births and deaths - Correct answer- Births and Deaths Register Monitors patients who enter the emergency room for services - Correct answer- Emergency Room Register System that monitors all types of cancer diagnosed or treated in an institution - Correct answer-Cancer or Tumor Registry Provides leadership in health care for the management of technology management systems - Correct answer-Health Care Information Management Systems Society (HIMSS) Supports national associations and health record professionals to improve health records - Correct answer-International Federation of Health Record Organizations (IFHRO) Costs are controlled by the managed-care plan's management of members' uses of services; providers are reimbursed by fee schedules - Correct answer-Managed Fee- For-Service Health care plan compensates providers with a lump-sum payment to compensate them for all services delivered to a patient for a specific illness and over a specific period of time - Correct answer-Episode of Care for reimbursement of physician services of beneficiaries covered under Medicare Part B - Correct answer-Resource-Based Relative Value Scale (RBRVS) Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances - Correct answer- Clinical Practice Guidelines Treatment recommendations often based on guidelines, step-by-step description of an accepted procedure - Correct answer-Clinical Protocols Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency - Correct answer-Critical Paths Structured plans of care - Correct answer-Clinical Pathways Multi-disciplinary standards that outline the processes of care and expected outcomes within predetermined time frames - Correct answer-Care Maps Recognition and enforcement of the rights and duties of private individuals and organizations - Correct answer-Private Law (Civil Law) An injury or wrong committed against an individual or his property. One party asserts wrongful conduct on part of the other and seeks compensation for harm suffered - Correct answer-Tort Legally enforceable agreements between two or more individuals - Correct answer- Contract Deals with relationships between private parties and the government (criminal law and government regulations) - Correct answer-Public Law Prohibits conduct considered injurious to society as a whole and provides for punishment of those found to have engaged in such conduct - Correct answer-Criminal Law A crime is an offense against a person or the public at large. A tort is a civil wrong against an individual - Correct answer-What is the difference between a CRIME and a TORT Statutory law written or enacted by bodies such as the U.S. Congress and state and local legislatures - Correct answer-Statutes Consists of principles that have evolved over time from court decisions resolving controversies - Correct answer-Common Law How long does AHIMA recommend keeping an adult patient health record? - Correct answer-10 years after most recent encounter How long does AHIMA recommend keeping a minor patient health record? - Correct answer-From the age of majority (usually 18) plus a statute of limitation governing medical malpractice lawsuits Who owns the physical health record? - Correct answer-The healthcare provider, physician, or hospital that maintains it Who owns the information within the health record? - Correct answer-The patient The right of an individual to be left alone - Correct answer-Privacy What are the three elements of privileged communication? - Correct answer-1. Relationship between patient and provider 2. Information must have been acquired through such a relationship 3. Information must have some connection with the provider's task of treating the patient Legal document in which patients name someone close to them to make decisions about their health care in the event they become incapacitated - Correct answer- Durable Power of Attorney Court order requiring someone to appear in court to give testimony - Correct answer- Subpoena What can happen if you disregard a subpoena? - Correct answer-You can be held in contempt of court A written order commanding a person to appear, give testimony, and bring all documents(records) described in the subpoena to court - Correct answer-Subpoena Duces Tecum Court order that requires a person to appear in court to testify - Correct answer- Subpoena Ad Testificandum Requires drug and alcohol abuse patient records to be kept confidential and not subject to disclosure except as provided by law - Correct answer-Drug Abuse and Treatment Act (1972) Heath Care Quality Improvement Act (1986) - Correct answer-Established the NPDB Requires that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their health record - Correct answer-Patient Self Determination Act (1990) Gives individuals some control over the information collected about them by the federal government - Correct answer-Privacy Act (1974) Created the Nursing Home Reform Act, which ensures residents of nursing homes receive quality care, requires provision of certain services, and establishes a residents' bill of rights - Correct answer-Omnibus Budget Reconciliation Act (1987) Introduced the Peer Review Organization (PRO) program as a component of Medicare law to ensure the quality of care rendered to patients - Correct answer-Tax Equity and Fiscal Responsibility Act (1936) TEFRA Stipulates that records can be admitted as evidence in a court of law if they were kept in the ordinary course of business. - Correct answer-Uniform Business Records as Evidence Act (1936) Serves as a model for state adoption and provides rules about health information management. As of 1996, only Montana and Washington had enacted this legislation - Correct answer-Uniform Healthcare Information Act (1985) DATA SETS ARE DEFINED AS A GROUP OF DATA ITEMS/ELEMENTS AND THEIR DEFINITIONS. EACH ELEMENT IN THE DATA SET COULD ALSO HAVE DEFINED VALUES. WHEN THE VALUE OF THE DATA SET IS DEFINED DATA COLLECTION AND MEASUREMENT OF THE DATA CAN OCCUR. - Correct answer-DATA SETS MEDICARE RESTRUCTURING OF REIMBURSEMENT OF INPATIENT HOSPITAL ADMISSIONS. - Correct answer-MS-DRG UNIFORM HOSPITAL DISCHARGE DATA SET- USED BY FEDERAL AND STATE AGENCIES TO COLLECT DATA ON INPATIENTS. - Correct answer- UHDDS NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS, ADVISORY BODY ON HEALTH DATA, STATISTICS, AND NATIONAL HEALTH INFORMATION POLICY. - Correct answer-NCVHS PREVENTION/INTERVENTION PROGRAMS, INFORM PUBLIC HEALTH MAKERS, IDENTIFY ISSUES OF CONCERN. - Correct answer-NEDSS AMERICAN SOCIETY FOR TESTING AND MATERIALS, NATIONAL STANDARDS DEVELOPMENT BODY. - Correct answer-ASTM AMERICAN MEDICAL INFORMATICS ASSOCIATION, PROVIDES LEADERSHIP IN THE DEVELOPMENT/IMPLEMENTATION OF INFORMATION SYSTEMS TO IMPROVE PATIENT CARE. - Correct answer-AMIA HEALTH INFORMATION MANAGEMENT AND SYSTEMS SOCIETY, FOCUSES ON OPTIMAL USE OF HEALTH CARE INFORMATION TECHNOLOGY AND MANAGEMENT SYSTEMS FOR THE BETTERMENT OF HUMAN HEALTH. - Correct answer-HIMSS AMERICAN ASSOCIATION FOR MEDICAL TRANSCRIPTION, COMMITTED TO THE CREATION OF QUALITY HEALTH RECORD REPORTS FROM DICTATION BY HEALTHCARE PROVIDERS. - Correct answer-AAMT AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, AGENCY, WHOSE FOCUS IS TO PRODUCE AND DISSEMINATE INFORMATION WHICH IMPROVES QUALITY, REDUCES COST, AND ENHANCES THE EFFECTIVENESS OF HEALTH CARE. - Correct answer-AHRQ How do you calculate net autopsy rate? - Correct answer-(Number of inpatients for a given period/Number of deaths of hospital patients whose bodies are available for autopsy) x 100 Determined the hospital has a duty to provide adequately trained medical staff to patients - Correct answer-Darling vs. Charleston case Selects medical staff members - Correct answer-Hospital's governing board Physician harm to a person - Correct answer-Assault Touching a person's body without permission - Correct answer-Battery Gives a person access by using his or her name - Correct answer-User-based access Based on what role a person plays (ex: nurse, physician, etc.) - Correct answer-Role- based access The most complex type of access that is based on who the person is, what role they are playing, and what they can access - Correct answer-Context- based access Covers policies, procedures, contracts, plans for security, and contingency plans - Correct answer-Administrative safeguards A technical safeguard that involves unique user ID, emergency access procedures, automatic log-off, and encryption and decryption of data - Correct answer-Access controls Simplified administration of health insurance and addressed electronic data interchange - Correct answer-HIPPA simplifcation administrative Keeping track of disclosures of patient information - Correct answer- Accounting of disclosures Every unit has the same chance of being included in the sample - Correct answer- Simple random sample Individuals sorted by subgroups like male and female - Correct answer-Stratified random sample Individuals selected from a list by drawing every nth unit - Correct answer- Systematic random sample Individuals divided by street - Correct answer-Cluster random sample A part of the System Development Life Cycle (SDLC) design phase - Correct answer- Request for proposal (RFP) A number of new cases occurring in a given time period - Correct answer- Incidence rate All cases, old and new, occurring in a given time period - Correct answer- Prevalence rate When an organization has acquired the "best" products from various vendors - Correct answer-Best-of-breed Virtually all applications are provided by a single vendor - Correct answer- Best-of-fit One physical topology of a network and uses a central hub as a traffic cop - Correct answer-Star topology or network The simplest network topology that connects one device to another along a "backbone" - Correct answer-Bus or line topology Used to develop information about groups of patients - Correct answer- Aggregate data Factual data that have been collected, combined, analyzed, interpreted, and converted into a form that can be used for a specific purpose - Correct answer-Information