How can the healthcare facility determine which physician has the best patient outcomes?
Which of the following HIM tasks is eliminated by the electronic health record system?
In which department or unit does the health record typically begin?
Which one of the following is an example of virtual HIM?
|Information systems that store back-up data off site|
|Employees who code from home|
|Information systems employees access remotely from the hospital|
|Documentation physicians add from their office|
The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review?
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
|Vital signs record|
Which of the following is an example of a long-term care setting?
|Assisted living facility|
|Ambulatory surgery center|
|Community mental health center|
|Acute care hospital|
Which of the following elements is typically found in the paper health record?
|MRI imaging films|
The ambulatory surgery record contains information most similar to which records?
|Physician’s office records|
|Emergency care records|
|Hospital operative records|
|Hospital obstetric records|
Which of the following assists in locating misfiles in the paper-based filing systems?
|Weight of folder|
|Number of files on shelf|
|Thickness of folder|
Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?
|Master patient index|
Which of the following should be taken into consideration when designing a health record form?
|Choosing the field type such as radio buttons|
|Number of clicks to access data|
|Including original and revised dates|
|Difference between paper and screen|
True or false? Auto-authentication is not in compliance with the CMS Interpretive Guidelines for Hospitals.
Which of the following represents the attending physician’s assessment of the patient’s current health status?
What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?
Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip?
When correcting erroneous information in a paper health record, which of the following is appropriate?
|Print “addendum” above the entry|
|Backdate to the date that the addendum covers|
|Add the reason for the change|
|Use a black pen to obliterate the entry|
Why should the copy and paste function should not be used in the electronic health record?
|The content may contain outdated information|
|Joint Commission standards prevent this practice|
|This feature is never found in the electronic health record|
|Medicare has a regulation against this practice.|
The overall goal of documentation standards is to _____________.
|Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient|
|Ensure that the healthcare provider organization is reimbursed appropriately by payers|
|Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization|
|Ensure physicians have access to the health record information they need to care for the patient|
Which of the terms below represents fixed rules that must be followed?
|Forms control program|
What is the software that is used for voice recognition known as?
|Electronic health record|
|Natural language processing|
True or false? The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance.
Which of the following filing methods is considered the most efficient?
|Straight numeric filing|
|Terminal digit filing|
Patient history questionnaires are most often used in what setting?
Which of the following is a secondary purpose of the health record?
|Support for provider reimbursement|
|Support for patient self-management activities|
|Support for research|
|Support for patient care delivery|
Which system is best suited for a small healthcare facility such as a one-physician practice?
|Alphabetic filing system|
|Serial unit numbering system|
|Serial numbering system|
|Unit numbering system|
Which of the following indexes is key to locating a health record?
|Master patient index|
Which of the following represents documentation of the patient’s current and past health status?
When defining the legal health record, what must the healthcare provider do?
|Assess the legal environment|
|Determine what the other healthcare providers are doing|
|Decide if the legal health record is needed|
|Include only the paper components of the health record|
True or false? The term ambulatory is the same as the term outpatient.
An RAI/MDS and care plan are found in records of patients in what setting?
True or false? An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance.
Critique this statement: Version control is not an issue in the EHR.
|This is a true statement.|
|There are issues related to versions of documents, such as there must be a flag to indicate a previous version.|
|There are issues related to versions of documents, such as each version should be visible to all users.|
|There are issues related to versions of documents which include the need to delete the old version when a new one is added.|
What is the function of a consultation report?
|Provides a chronological summary of the patient’s medical history and illness|
|Documents opinions about the patient’s condition from the perspective of a physician not previously involved in the patient’s care|
|Concisely summarizes the patient’s treatment and stay in the hospital from the time of admission to the time of discharge|
|Documents the physician’s instructions to other parties involved in providing care to a patient|
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
Which of the following contains the physician’s findings based on an examination of the patient?
True or false? CMS does not require healthcare providers to inform their patients about general patient rights afforded to them.
The annual volume statistics for General Hospital are noted below. How many shelving units will be required to store this year’s inpatient discharge records?
Average inpatient discharges = 12,000
Average inpatient record thickness = ¾ inch
Shelving units shelf width = 36 inches
Number of shelves per unit = 6
The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:
Which of the following is a request from a clinical area to charge out a health record?