Where can you find guidelines for the retention and destruction of healthcare
information?
a. Institute of Medicine
b. Municipal regulations
c. HIPAA
d. Accreditation standards - ANS-d. Accreditation standards
This functionality can result in confusion from incessant repetition of irrelevant clinical
data.
• Change
• Amendment
• Copy and paste
• Deletion - ANS-c. Copy and paste
Which of the following indexes would be used to compare the number and quality of
treatments for patients who underwent the same operation with different surgeons?
• Physician
• Master patient
• c. Procedure
d. Disease and operation - ANS-a. Physician
A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if
present for which type of patient records?
• Outpatient
• Emergency room
• c. Physician office
d. Inpatient - ANS-d. Inpatient
Who is responsible for ensuring the quality of health record documentation?
,a. Board of directors
b. Administrator
c. Provider
d. Health information management professional - ANS-c. Provider
Which of the following represents data flow for a hospital inpatient admission?
• Registration > diagnostic and procedure codes assigned > services performed >
charges recorded
• Registration > services performed > charges recorded > diagnostic and
procedure codes assigned
• Services performed > charges recorded > registration > diagnostic and procedure
codes assigned
• Diagnostic and procedure codes assigned > registration > services performed >
charges recorded - ANS-b. Registration > services performed > charges recorded >
diagnostic and procedure codes assigned
Which of the following is the goal of quantitative analysis performed by healthinformation
management (HIM) professionals?
• Ensuring the record is legible
• Identifying deficiencies early so they can be corrected
• Verifying that health professionals are providing appropriate care
• Checking to ensure bills are correct - ANS-b. Identifying deficiencies early so they
can be corrected
The process of providing proof of the authorship of health record documentation iscalled:
• Identification
• Standardization of data capture
• c. Standardization of abbreviations
d. Authentication - ANS-d. Authentication
Which of the following data sets would be most useful in developing a matrix for
identification of components of the legal health record?
• Document name, media type, source system, electronic storage start date, stop
printing start date
• Document name, media type
• Document name, medical record number, source system
• Document name, source system - ANS-a. Document name, media type, source
system, electronic storage start date, stop printing start date
According to the UHDDS definition, ethnicity should be recorded on a patient record as:
,a. Race of mother
b. Race of father
c. Hispanic, non-Hispanic
d. Free-text descriptor as reported by patient - ANS-c. Hispanic, non-Hispanic
Which of the following is a graphical display of the relationships between tables in a
database?
a. RDMS
b. SQL
c. ERD
d. SAS - ANS-c. ERD
The purpose of the data dictionary is to definitions and ensure consistency ofuse.
• Identify
• Standardize
• c. Create
d. Organize - ANS-b. Standardize
It is important for a healthcare entity to have addressing how to deal with corrections
made to erroneous entries in health records.
• Training sessions
• Policies and procedures
• Verbally communicated instructions
• A supervisory committee - ANS-b. Policies and procedures
Quality has several components, including appropriateness, technical excellence,
, and acceptability.
• Accuracy of diagnosis
• Continuous improvement
• c. Connectivity
d. Accessibility - ANS-d. Accessibility
Assign the correct CPT code for the following procedure: Patient is admitted to movethe
skin pocket for their pacemaker.
• 33223, Relocation of skin pocket for implantable defibrillator
• 33210, Insertion or replacement of temporary transvenous single chamber
cardiacelectrode or pacemaker catheter (separate procedure)
• 33212, Insertion of pacemaker pulse generator only; with existing single lead
• 33222, Relocation of skin pocket for pacemaker - ANS-d. 33222, Relocation of
skinpocket for pacemaker
, Bloodwork results from the laboratory information system, mammogram reports and
films from the radiology information system, and a listing of chemotherapy agents
administered to the patient from the pharmacy information system are all delivered into
the patient's EHR. These different information systems that feed information into the
EHR are known as:
• Interoperability
• Source systems
• Continuity of care records
• Clinical decision support systems - ANS-b. Source systems
Of the following, what is the most likely to happen to the health records of a physician's
patient when that physician leaves an office practice?
a. It will be sent to the state department of health.
b. It will be sent to outside storage.
c. It will be destroyed.
d. It will be retained by the practice. - ANS-d. It will be retained by the practice.
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing - ANS-a. Analysis
A barrier to effective computer-assisted coding is the:
• Resistance of physicians
• Resistance of HIM professionals
• c. Poor quality of documentation
d. Reduction of consistency without human coders - ANS-c. Poor quality of
documentation
To complete a comprehensive assessment and collect information for the MinimumData
Set for Long-Term Care, the coordinator must use which of the following?
• Core measure
• Resident Assessment Instrument
• c. Precertification
d. Record of transfer - ANS-b. Resident Assessment Instrument
What is a legal document that is used to specify whether the patient would like to be kept
on artificial life support if they become permanently unconscious or is otherwise dying
and unable to speak for themselves?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Hosmerit. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.99. You're not tied to anything after your purchase.