Professional review guide for the RHIA and RHIT Examination 2011 Edition

In preparation for an EHR, you are conducting a total facility inventory of inventory of all forms currently used. You must name each for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is:
A. recovery room record
B. pathology report
C. operative report
D. discharge summary
B (C and D) Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be:

A. personal identification.
B. cognitive patterns.
C. procedures and dates.
D. principal diagnosis.

B Answers A, C, and D represent items collected on Medicare inpatients according to UHDDS requirements. Only B represents a data item collected more typically in long-term care settings
and required in the MDS.

In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital 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 diagnosis.

C The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as “U” for unit, which can be mistaken for “O” or the number “4”. Spelling out the unit is preferred.

In the number “10-0001” listed in a tumor registry accession register, what does the prefix “10” represent?

A. The number of primary cancers reported for that patient
B. The year the case was entered into the database of the registry
C. The sequence number of the case
D. The stage of the tumor based upon the TNM system of staging

B Every case entered into the registry is assigned a unique accession number preceded by the accession year, or the year the case is entered into the database.

A risk manager needs to locate a full report of a patient’s fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the:

A. doctors’ progress notes.
B. integrated progress notes.
C. incident report.
D. nurses’ notes

C Factual summaries investigating unexpected facility events should not be treated as part of
the patient’s health information and therefore would not be recorded in the health record.

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

A. interdisciplinary patient care plan.
B. discharge summary.
C. transfer record.
D. problem list.

D (A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients.

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that:

A. it is too easy to delegate use of computer passwords.
B. evidence cannot be provided that the physician actually reviewed and approved each report.
C. electronic signatures are not acceptable in every state.
D. tampering too often occurs with this method of authentication.

B Auto authentication is a policy adopted by some facilities that allows physicians to state in advance that transcribed reports should automatically be considered approved and signed
(or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., “Consider it signed if I do not make changes within 7 days.”). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.

As part of a quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the:

A. prenatal record.
B. labor and delivery record.
C. postpartum record.
D. discharge summary.

A The antepartum record should include a comprehensive history and physical exam on each OB patient visit, with particular attention to menstrual and reproductive history.

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman:

A. a new H&P is required for every inpatient admission.
B. that you apologize for not noticing the H&P she provided.
C. the H&P copy is acceptable as long as she documents any interval changes.
D. Joint Commission standards do not allow copies of any kind in the original record.

C Joint Commission and COP allow a legible copy of a recent H&P done in a doctor’s office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the original H&P
is readily available.

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility’s:

A. disease index.
B. number control index.
C. physicians’ index.
D. patient index.

A The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments.

Joint Commission requires the attending physician to countersign health record documentation that is entered by:

A. interns or medical students.
B. business associates.
C. consulting physicians.
D. physician partners.

A Those who make entries in the medical record are given that privilege by the medical staff.
Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.

The minimum length of time for retaining original medical records is primarily governed by:

A. Joint Commission.
B. medical staff.
C. state law.
D. readmission rates.

C The statute of limitations for each state is information that is crucial in determining record retention schedules.

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of:

A. fingerprint signatures.
B. voice recognition systems.
C. expert systems.
D. electronic signatures

D Authentication by signature stamps requires a written agreement with the facility not to delegate the use of the stamps. Similarly, in a computer-based system, it is important to ensure that personal identification codes used to authenticate entries are used only by the persons to whom they are assigned. A. Fingerprint signatures are individualized automatically

Discharge summary documentation must include:

A. a detailed history of the patient.
B. a note from social services or discharge planning.
C. significant findings during hospitalization.
D. correct codes for significant procedures.

C A. Some reference to the patient’s history may be found in the discharge summary, but not a detailed history. B. The attending physician records the discharge summary. D. Codes are usually recorded on a different form in the record.

The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate:

A. quality of care through the use of pre-established criteria.
B. adverse effects and contraindications of drugs utilized during hospitalization.
C. potentially compensable events.
D. completeness, adequacy, and quality of documentation.

D A and B deal with issues directly linked to quality of care reviews. C deals with risk management. Only D points to a review aimed at evaluating the quality of documentation in the health record.

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the:

A. chief of staff.
B. attending physician.
C. HIM director.
D. risk manager.

B Although the nursing staff, hospital administration, and the health information management professional play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatric facility are generally in the form of:

A. retrospective deficiency analysis.
B. special study audits.
C. concurrent chart review.
D. occurrence screening.

C Periodic, concurrent chart review contributes to the timeliness and accuracy of documentation in a way that retrospective review and audits cannot. D. Occurrence screening is designed to identify documentation of adverse events for which the hospital would be liable.

The foundation for communicating all patient care goals in long-term care settings is the:

A. legal assessment.
B. medical history.
C. individualized patient care plan.
D. Uniform Hospital Discharge Data Set

C Unlike the acute care hospital, where most health care practitioners document separately, the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved.

Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?

A. Health Record Committee
B. Utilization Review Committee
C. Risk Management Committee
D. Joint Conference Committee

A B. Utilization review committees deal with the issues of the medical necessity of admissions and efficient utilization of facility resources. C. Risk management committees consider methods for reducing injury and financial loss. D. Joint conference committees act as a liaison between the governing body and the medical staff.

As part of Joint Commission’s National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient’s true identity, and to confirm that necessary documents such as x-rays or medical records are available They must also develop and use a process for:

A. including the primary caregiver in surgery consults.
B. including the surgeon in the preanesthesia assessment.
C. marking the surgical site.
D. apprising the patient of all complications that might occur.

C The Joint Commission requires hospitals to mark the correct surgical site and to involve the patient in the marking process to help eliminate wrong site surgeries.

In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended change is to:have more frequent committee meetings.
B. have the committee report to the Executive Committee.
C. have a physician perform all the reviews.
D. provide for record reviews to be performed by an interdisciplinary team of care providers
D Joint Commission suggests that HIM department, nursing, medical staff, administrative personnel, and other services participate in the record reviews.

According to the Joint Commission’s National Patient Safety Goals, which of the following abbreviations would most likely be prohibited?

A. 0.4 mg Lasix.
B. 4 mg Lasix.
C. 40 mg Lasix.
D. .4 mg Lasix.

D Among those abbreviations considered confusing or likely to be misinterpreted are those containing a leading decimal.

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates:

A. noncompliance with Joint Commission standards.
B. compliance with Joint Commission standards.
C. compliance with Medicare regulations.
D. compliance with Joint Commission standards for nonsurgical patients.

A Joint Commission specifies that H&Ps must be completed within 24 hours.

A different diagnosis may be recorded for which of the following progress note elements of a problem-oriented medical record?

A. Assessment
B. Plan
C. Subjective
D. Objective

A The assessment statement combines the objective and subjective into a diagnostic conclusion, sometimes in the form of a differential diagnosis, such as “peritonitis vs. appendicitis.”

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

A. Disease index
B. Physician index
C. Master patient index
D. Operation index

D A. The disease index is a listing in diagnostic code number order. B. The physician index is a listing of cases in order by physician name or number. C. The MPI cross-references the patient name and medical record number.

The best example of point-of-care service and documentation is :

A. using an automated tracking system to locate a record.
B. using occurrence screens to identify adverse events.
C. doctors using voice recognition systems to dictate radiology reports.
D. nurses using bedside terminals to record vital signs.

D A, B, and C all refer to a computer application of managing health information, but only answer D deals with the clinical application of data entry into the patient’s record at the time and location of service.

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to:

A. placement of hospital logo.
B. signature line for authentication.
C. use of box design.
D. bar code placement.

D Most facilities use bar-coded patient identification to ensure proper indexing into the imaging system.

Which of the following is a form or view that is typically seen in the health record of a long-term care patient, but is rarely seen in records of acute care patients?

A. Pharmacy consultation
B. Medical consultation
C. Physical exam
D. Emergency record

A Pharmacy consults are required for elderly patients who typically take multiple medications. These consults review for potential drug interactions and/or discrepancies in medications given and those ordered.

The health record states that the patient is a female, but the registration record has the patient listed as “male.” Which of the following characteristics of data quality has been compromised in this case?

A. Data comprehensiveness.
B. Data granularity.
C. Data precision.
D. Data accuracy.

D Data accuracy/validity denotes that data are correct values and are valid. A-data comprehensiveness denotes that all data items are included. B-data granularity denotes that the attributes and values of data should be defined at the correct level of detail. C-data precision denotes that data values should be just large enough to support the application of process.

The first cancer patient seen in your facility on January 1, 2010, was diagnosed with colon cancer, with no known history of previous malignancies. The accession number assigned to this patient is :

A. 10-0000/00.
B. 10-0000/01.
C. 10-0001/00.
D. 10-0001/01.

C In accession number 10-0001/00, “10” represents the year that the patient first entered the database; “0001” indicates that this was the first case entered that year; “00” indicates that this patient has only one known neoplasm.

Setting up an edit that checks to see that all patients with the diagnosis of ectopic pregnancy are listed as females in the database is one method of ensuring data:

A. reliability.
B. timeliness.
C. precision.
D. validity.

D Validity refers to the accuracy of data, while reliability refers to consistency of data.
Timeliness refers to data being available within a time frame helpful to the user, and precision refers to data values that are just large enough to support the application of the process.

In determining your acute care facility’s degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the:

A. CARF manual.
B. hospital bylaws.
C. Joint Commission accreditation manual.
D. Federal Register.

D CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.

In an acute care hospital, a complete history and physical may not be dictated for a new admission when:

A. the patient is readmitted for a similar problem within 1 year.
B. the patient’s stay is less than 24 hours.
C. the patient has an uneventful course in the hospital.
D. a legible copy of a recent H&P performed in the attending physician’s office is available.

D A. An interval H&P can be used when a patient is readmitted for the same or related problem within 30 days. B and C. No matter how long the patient stays or how minor the condition, an H&P is required.

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

A. Minimum Data Set
B. Uniform Hospital Discharge Data Set
C. Conditions of Participation
D. Federal Register

B A. The MDS is designed for use in long-term care facilities. C. The COP is the set of regulations that health care institutions must follow to receive Medicare reimbursement. D. The Federal Register is a daily government newspaper for publishing proposed and final rules of federal agencies.

Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should :

A. complete a new cancer abstract.
B. assign a new accession number.
C. update the follow-up file.
D. complete a new master index file.

C Readmission to the hospital requires documentation in the follow-up file. B and D. Only one accession number and one master index card are assigned for each patient entered into the registry. A. An abstract is prepared when the case is entered into the database.

When developing a data collection system, the most effective approach first considers:

A. the end user’s needs.
B. applicable accreditation standards.
C. hardware requirements.
D. facility preference.

A The needs of the end user are always the primary concern when designing systems.

A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the:

A. physical findings.
B. lab and diagnostic test results.
C. time and means of arrival.
D. instructions for follow-up care.

C Answers A, B, and D are required items in BOTH acute and ER records.

A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records would be:

A. chief complaint.
B. condition on discharge.
C. time and means of arrival.
D. growth and development record.

D Answers A and B are items that should be documented on any inpatient record. Answer C reflects a data item you would expect to find on ER records only.

For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and:

A. department.
B. discipline.
C. initials.
D. supervising physician

. B All health record signatures should be identified by a minimum of name and discipline,
e.g., “J. Smith, P.T.” Other types of authentication other than signature (such as written initials
or computer entry) must be uniquely identifiable.

In creating a new form or computer view, the designer should be most driven by:

A. QIO standards.
B. medical staff bylaws.
C. needs of the users.
D. flow of data on the page or screen

C The needs of the user are the primary concern in forms design.

Under which of the following conditions can an original patient health record be physically removed from the hospital?

A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital
B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court
C. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record
D. when the record is taken to a physician’s private office for a follow-up patient visit post discharge

B A and C. In these situations a transfer summary or pertinent copies from the inpatient health record may accompany the patient, but the original record stays on the premises.

According to the following table, the most serious record delinquency problem occurred in which of the following months?
April May June
Percentage incomplete records 70% 88% 79%
Percentage delinquent records 51 % 43% 61 %
Percentage delinquent due to missing H& P 3% 1 .4% 0.5%

A. April
B. May
C. June
D. cannot determine from this data

A A recommendation for improvement from Joint Commission is indicated if the number of delinquent records is greater than 50% or if the percentage of records with delinquent records due to missing H&Ps exceeds 2% of the average monthly discharges. In the month of April, both of these delinquency problems are reflected. The percentage of incomplete records is not relevant.

Using the SOAP style of documenting progress notes, choose the “subjective” statement from the following:

A. sciatica unimproved with hot pack therapy
B. patient moving about very cautiously, appears to be in pain
C. adjust pain medication; begin physical therapy tomorrow
D. patient states low back pain is as severe as it was on admission

D A represents the assessment statement, B the objective, and C the plan.

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the:

C. Uniform Clinical Data Set.
D. Uniform Ambulatory Core Data.

B OBRA mandates comprehensive functional assessments of long-term care residents using the Minimum Data Set for Long-Term Care.

As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the:

A. facility’s data dictionary.
C. Glossary of Health Care Terms.

A Answers B and D are types of data sets for collecting data in long-term (MDS) and acute care (UHDDS) facilities. A data dictionary should include security levels for each field as well as definitions for all entities.

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) will be added to his health record:.

A. interval summary
B. consultation report
C. advance directive
D. interdisciplinary care plan

B COP requires a consultation report on patients who are not a good surgical risk, as well as those with obscure diagnoses, patients whose physicians have doubts as to the best therapeutic measure to be taken, and patients for whom there is a question of criminal activity.

An example of objective entry in the health record supplied by a health care practitioner is the:
A. past medical history.
B. physical assessment.
C. chief complaint.
D. review of systems.
B The medical history, including a review of systems and chief complaint, is information supplied by the patient. A physical assessment adds objective data to the subjective data provided by the patient in the history.

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation.
The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at:

A. 12 hours after admission.
B. 24 hours after admission.
C. 12 hours after admission or prior to surgery.
D. 24 hours after admission or prior to surgery.

D This meets both Joint Commission and COP standards.

Based upon the following documentation in an acute care record, where would you expect this excerpt to appear? “With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation.”:

A. Physician progress notes
B. Operative record
C. Nursing progress notes
D. Physical examination

B This entry is typical of a surgical procedure.

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery; he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should:

A. provide the dictated tape to his staff.
B. request a “stat” report.
C. write a detailed operative note in the record.
D. request that administration hire more transcriptionists.

C Joint Commission requires that a detailed OP note be written in the health record when expeditious transcription of the dictated report is impossible to maintain continuity of care.

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

A. Yes, within 8 hours postsurgery
B. No as long as it is done ASAP
C. Yes, prior to surgery
D. Yes, within 24 hours postsurgery

C Joint Commission standards require the surgeon to document the history and physical examination prior to surgery.

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient’s record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing:

A. quantitative record review.
B. clinical pertinence review.
C. concurrent record analysis.
D. point-of-care documentation.

D AHIMA’s Position Statement supports that point-of-care documentation raises documentation standards and improves patient care. It is defined as data entry that occurs at the point and location of service

An example of a primary data source for health care statistics other than the patient health record is the:

A. disease index.
B. accession register.
D. hospital census.

D Answers A, B, and C are examples of secondary data sources.

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

A. objective survey of body systems.
B. chief complaint.
C. family history.
D. subjective review of systems.

A The medical history (including chief complaint, history of present illness, past medical history, personal history, family history, and a review of systems) is provided by the patient or the most knowledgeable available source. The physical examination adds objective data to the subjective data provided by the patient. The exam includes all body systems.

During a retrospective review of Rose Hunter’s inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

A. Utilization review
B. Quantitative review
C. Legal review
D. Qualitative review

D Quantitative analysis involves checking for the presence or absence of necessary reports and/or signatures, while qualitative analysis may involve checking documentation consistency, such as comparing a patient’s pharmacy drug profile with the medication administration record.

Which of the following is least likely to be identified by a deficiency analysis technician?

A. Missing discharge summary
B. Need for physician authentication of two verbal orders
C. Discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
D. X-ray report charted on the wrong record

C A, B, and D all represent common checks performed by a quantitative analysis clerk: missing reports, signatures, or patient identification. Answer C represents a more in-depth review dealing with the quality of the data documented.

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

A. Tissue examination done by the pathologist
B. Impressions of a cardiologist asked to determine whether patient is a good surgical risk
C. Interpretation of a radiologic study
D. Technical interpretation of electrocardiogram

B A, C, and D represent routine interpretations that are not normally considered to be consultations.

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding:

A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.
B. whether a postoperative infection occurred and how it was treated.
C. the quality of follow-up care.
D. whether the severity of illness and/or intensity of service warranted acute level care.

A B represents an appropriate job for the infection control officer. Answer C represents the clinical care evaluation process, rather than the review of quality documentation. Answer D is a function of the utilization review program.

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from:

A. generic screens used by record abstractors.
B. disease index.
C. R-ADT system.
D. indicator monitoring program.

C For tracking in-house patients who have been transferred to a specialty unit, the best source of information is the registration-admission, discharge, and transfer system.

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing:

A. integrated progress notes.
B. interdisciplinary treatment plans.
C. source-oriented records.
D. SOAP notes

A Progress notes may be integrated or they may be separated, with nurses, physicians, and other health care providers writing on designated forms for each discipline.

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

A. Chronic pain management
B. Palliative care
C. Brain injury management
D. Vocational evaluation

B The Commission on Accreditation of Rehabilitation Facilities is an independent accrediting agency for rehabilitation facilities. Palliative care (answer B) is most likely to be provided at a hospice.

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?

A. Written signature of the provider of care
B. Identifiable initials of a nurse writing a nursing note
C. A unique identification code entered by the person making the report
D. Delegated use of computer key by radiology secretary

D Written signatures, identifiable initials, unique computer codes, and rubber stamp signatures may all be allowed as legitimate means of authenticating an entry. However, the use of codes and stamped signatures MUST be confined to the owners and they are never to be used by anyone else.

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a:

A. data warehouse.
B. regional health information organization.
C. continuum of care.
D. data retrieval portal group.

B Regional health information organizations are intended to support health information exchange within a geographic region.

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?


A A. Data Elements for Emergency Departments—recommended data set for hospital-based emergency departments; B. Uniform Hospital Data Set—required data set for acute care hospitals; C. Minimum Data Set—required data set for long-term care facilities; D. ORYX—an initiative of Joint Commission whereby five core measures are implemented to improve safety and quality of health care.

As a new HIM manager of an acute care facility, you have been asked to update the facility’s policy for a physician’s verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult:

A. Consolidated Manual for Hospitals
B. Federal Register
C. Policy and Procedure Manual
D. Hospital Bylaws, Rules, and Regulations

D Although Joint Commission, CMS, and state laws may include standards for verbal orders, the specific information regarding which employees have been given authority to transcribe verbal orders in your facility should be located in your hospital’s bylaws, rules, and regulations.

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of:

A. peer review.
B. quantitative review.
C. qualitative review.
D. legal analysis.

C A. Peer review typically involves quality of care issues rather than quality of documentation issues. D. Legal analysis ensures that the record entries would be acceptable in a court of law.

Accreditation by Joint Commission is a voluntary activity for a facility and it is:

A. considered unnecessary by most health care facilities.
B. required for state licensure in all states.
C. conducted in each facility annually.
D. required for reimbursement of certain patient groups

D A. Advantages of accreditation are numerous and include financial and legal incentives. B. State licensure is required for accreditation, but not the reverse. C. Joint Commission conducts unannounced on-site surveys approximately every 3 years.

Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff?

A. Disease index
B. Procedure index
C. Master patient index
D. Physician index

D Because information contained in the physicians’ index is considered confidential, identification codes are often used rather than the physicians’ names.

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

A. Database
B. Problem list
C. Initial plan
D. Progress notes

B In a POMR, the database contains the history and physical; the problem list includes titles, numbers, and dates of problems and serves as a table of contents of the record; the initial plan describes diagnostic, therapeutic, and patient education plans; and the progress notes document the progress of the patient throughout the episode of care, summarized in a discharge summary or transfer note at the end of the stay.

As supervisor of the cancer registry, you report the registry’s annual caseload to administration.
The most efficient way to retrieve this information would be to use:

A. patient abstracts.
B. patient index.
C. accession register.
D. follow-up files.

C The accession register is a permanent log of all the cases entered into the database. Each number assigned is preceded by the accession year, making it easy to assess annual workloads.

An important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Both technical and procedural methods will be used with the CPR to control and manage confidential information. An example of a procedural method for protecting data is:

A. confidentiality statements signed by all staff.
B. limiting access of certain screens based on the staff’s need to know.
C. auditing capability of system to track data access.
D. computer backup systems

A Answers B, C, and D all represent technical methods of protecting computerized data. Additional procedural techniques include developing policies, procedures, and educational training, which address confidentiality.

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record:
A. patient admitted with COPD 1/4/2011 and discharged 1/7/2011
B. Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011
C. Baby Boy Hiltz’s mother admitted 1/5/2011, C-section delivery, and discharged 1/7/2011
D. Baby Boy Doe admitted 1/3/2011, died 1/4/2011
B A final progress note may substitute for a discharge summary in the following cases: patients who are hospitalized less than 48 hours with problems of a minor nature, normal newborns, and uncomplicated obstetrical deliveries. Answer A does not qualify because of the nature of the problem and the length of stay. Answer C describes a complicated delivery, and answer D cites a severely ill patient rather than one with a minor problem.

Based upon the following documentation in an acute care record, where would you expect this excerpt to appear? “Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient.”

A. Discharge summary
B. Physical exam
C. Admission note
D. Clinical laboratory report

A The excerpt clearly indicates an overall summary of the patient’s course in the hospital, which is a common element of the discharge summary.

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific accreditation standards and guidelines is the:

A. Conditions of Participation for Rehabilitation Facilities
B. Medical Staff Bylaws, Rules, and Regulations
C. Joint Commission manual
D. CARF manual

D The manual published by the Commission on Accreditation of Rehabilitation Facilities will have the most specific and comprehensive standards for a rehabilitation facility.

Which of the four distinct components of the problem-oriented record contains the medical and social history of the patient?

A. Database
B. Problem list
C. Initial plan
D. Progress notes

A In a POMR, the database contains the history and physical; the problem list includes titles, numbers, and dates of problems, and serves as a table of contents of the record; the initial plan describes diagnostic, therapeutic, and patient education plans; and the progress notes document the progress of a patient throughout the episode of care, summarized in a discharge summary or transfer note at the end of the stay.

Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

A. Disease index
B. Patient register
C. Pediatric census sheet
D. Procedure index

A The disease index is compiled as a result of abstracting patient code numbers into a computer database, allowing a variety of reports to be generated.

In a manual record tracking system, outguides replace a file that has been checked out of the system. A secondary function of outguides is to:

A. serve as a visual check for misfiled records.
B. expedite correct placement of refiled records.
C. enhance the use of file guides.
D.cross-reference a file that has been moved forward to a new number

B An outguide is a plastic folder used in place of the record when the record has been removed from the files. When refiling the record, the outguide often speeds up the process of visually identifying the empty place in the file.

Key reports in a health record, such as history and physicals, discharge summaries, and operative reports, are generally dictated and transcribed. This recommended standard contributes most to data:

A. timeliness.
B. accuracy.
C. legibility.
D. security.

C Answers A and B. The processes of dictation and transcribing reports may actually delay its appearance on the chart, and transcription errors may be more frequent than errors in handwritten reports. D. These processes should not affect record security.

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show:

A. Missing signatures on progress notes
B. Missing discharge summaries
C. Absence of SOAP format in progress notes
D. Missing operative reports

. D Answers A and B. Both signature omissions and discharge summary reports can be captured after discharge, but history and physicals should be on the chart within 24 hours of the patient’s admission. Answer C. the SOAP format is not a requirement of Joint Commission. Answer D. Institutions are given a Type I recommendation when 2% of delinquent records are due to missing history and physicals or operative reports.

A primary focus of screen format design in a health record computer application should be to ensure that:

A. programmers develop standard screen formats for all hospitals.
B. the user is capturing essential data elements.
C. paper forms are easily converted to computer forms.
D. data fields can be randomly accessed.

B Both paper-based and computer-based records share similar forms and view design considerations. Among these are the selection and sequencing of essential data items.

A quality improvement team is focusing on the unacceptable number of unsigned doctors’ orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be:

A. performing a retrospective review where all orders can be flagged at one time.
B. holding a printed order sheet on the medical care unit at least 24 hours post discharge to give the physician time to sign.
C. developing an open-record review process.
D. devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient’s care

C A and B. Signing orders after discharge does not affect the patient’s care process. D. Although this process would speed up the signature process, it is not a legally sound method of obtaining signatures on orders.

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

A. peer review organization.
B. National Practitioner Data Bank.
C. risk manager.
D. Health Plan Employer Data and Information Set.

B With the passage of the Health Care Quality Improvement Act of 1986, the NPDB was established. Hospitals are required to query the data bank before granting clinical privileges to physicians.

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:

A. reliability.
B. accessibility.
C. legibility.
D. completeness.

A Data reliability implies that data are consistent no matter how many times the same data are collected and entered into the system. Accessibility implies that data are available to authorized people when and where needed. Legibility implies data that are readable. Completeness implies
that all required data are present in the information system.

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:

A. written within 24 hours of the patient’s admission.
B. accepted by a charge nurses only.
C. co-signed by the attending physician within 12 hours of giving the order.
D. accepted by persons authorized by hospital regulations and procedures.

. D Only persons designated by hospital policies and procedures and state and federal law are to accept verbal orders.

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:

A. documented in an incident report and filed in the patient’s health record.
B. reported as a potentially compensable event.
C. reported to the Executive Committee.
D. documented in both the progress notes and the discharge summary


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, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every:

A. week.
B. month.
C. 60 days.
D. 90 days.


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:

A. medical staff bylaws.
B. quality management plan.
C. Joint Commission accreditation manual.
D. medical staff rules and regulations


A quarterly review reveals the following data for Springfield Hospital:
Springfield Hospital Quarterly Statistics
Average monthly discharges 1 ,820
Average monthly operative procedures 458
Number incomplete records 1 ,002
Number delinquent records 590

88. What is the percentage of incomplete records during this quarter?

A. 55%
B. 54%
C. 33%
D. 32%

A Using the basic rate formula, calculate as follows:
Incomplete records × 100 divided by average monthly discharges, or
1,002 × 100 = 55.1%

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

A. 55%
B. 32%
C. 33%
D. 54%

B Using the basic rate formula, calculate as follows:
Delinquent records × 100 divided by average monthly discharges, or
590 × 100 = 32.4%

Still referring to the information in the table in question number 88 and the delinquent record rate shown in the answer for question 89, would the facility be out of compliance with Joint Commission standards?

A. Yes
B. No


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

A. information security manager.
B. clinical data specialist.
C. health information manager.
D. risk manager.


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

A. principal diagnosis.
B. expected payer.
C. admitting diagnosis.
D. review of systems.


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

A. beta blocker at discharge.
B. blood culture before first antibiotic received.
C. early administration of aspirin.
D. discharged on antithrombotic.


. One record documentation requirement shared by BOTH acute care and emergency departments is:

A. patient’s condition on discharge.
B. time and means of arrival.
C. advance directive.
D. problem list.


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

A. standing orders.
B. telephone orders.
C. stop orders.
D. discharge order.


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:

A. objective symptoms observed by the physician.
B. past and current activities, such as smoking and drinking habits.
C. a chronological description of patient’s present condition from time of onset to present.
D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.


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

A. Joint Commission standards.
B. NHIN standards.
C. HL-7 standards.
D. CMS standards.


Based upon the following documentation in an acute care record, where would you expect this excerpt to appear? “The patient is alert and in no acute distress. Initial vital signs: T98, P 102 and regular, R 20 and BP 120/69…”

A. Physical exam
B. Past medical history
C. Social history
D. Chief complaint


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