How can the healthcare facility determine which physician has the best patient outcomes?

Qualitative analysis
Data mining
Quantitative analysis
Version control

2 points   

QUESTION 157

Which of the following HIM tasks is eliminated by the electronic health record system?

Document imaging
Analysis
Assembly
Indexing

2 points   

QUESTION 158

In which department or unit does the health record typically begin?

HIM department
Patient registration
Nursing unit
Billing department

2 points   

QUESTION 159

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

2 points   

QUESTION 160

The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review?

Proactive
Prospective
Concurrent
Retrospective

2 points   

QUESTION 161

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

Flow record
Vital signs record
Care plan
Surgical note

2 points   

QUESTION 162

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

2 points   

QUESTION 163

Which of the following elements is typically found in the paper health record?

Patient identification
Radiology imaging
MRI imaging films
Financial information

2 points   

QUESTION 164

The ambulatory surgery record contains information most similar to which records?

Physician’s office records
Emergency care records
Hospital operative records
Hospital obstetric records

2 points   

QUESTION 165

Which of the following assists in locating misfiles in the paper-based filing systems?

Color coding
Weight of folder
Number of files on shelf
Thickness of folder

2 points   

QUESTION 166

Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?

Deficiency slips
Master patient index
Outguides
Requisition slip

2 points   

QUESTION 167

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

2 points   

QUESTION 168

True or false? Auto-authentication is not in compliance with the CMS Interpretive Guidelines for Hospitals.

True

False

2 points   

QUESTION 169

Which of the following represents the attending physician’s assessment of the patient’s current health status?

Physical examination
Medical history
Progress notes
Discharge summary

2 points   

QUESTION 170

What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?

42 inches
3,600 inches
252 inches
216 inches

2 points   

QUESTION 171

Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip?

Document image
Microfilm roll
Microfilm jacket
Microfiche

2 points   

QUESTION 172

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

2 points   

QUESTION 173

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.

2 points   

QUESTION 174

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

2 points   

QUESTION 175

Which of the terms below represents fixed rules that must be followed?

Standard
Guidelines
Forms control program
Policy

2 points   

QUESTION 176

What is the software that is used for voice recognition known as?

Data mining
Voice mail
Electronic health record
Natural language processing

2 points   

QUESTION 177

True or false? The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance.

True

False

2 points   

QUESTION 178

Which of the following filing methods is considered the most efficient?

Alphabetical filing
Alphanumeric filing
Straight numeric filing
Terminal digit filing

2 points   

QUESTION 179

Patient history questionnaires are most often used in what setting?

Ambulatory care
Rehabilitative care
Home healthcare
Long-term care

2 points   

QUESTION 180

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

2 points   

QUESTION 181

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

2 points   

QUESTION 182

Which of the following indexes is key to locating a health record?

Disease index
Master patient index
Operation index
Physician index

2 points   

QUESTION 183

Which of the following represents documentation of the patient’s current and past health status?

Medical history
Physical exam
Physician orders
Patient consent

2 points   

QUESTION 184

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

2 points   

QUESTION 185

True or false? The term ambulatory is the same as the term outpatient.

True

False

2 points   

QUESTION 186

An RAI/MDS and care plan are found in records of patients in what setting?

Home healthcare
Long-term care
Behavioral healthcare
Rehabilitative care

2 points   

QUESTION 187

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.

True

False

2 points   

QUESTION 188

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.

2 points   

QUESTION 189

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

2 points   

QUESTION 190

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?
36-45-99
37-45-99
38-45-99

Straight numerical
Terminal digit
Middle digit
Unit

2 points   

QUESTION 191

Which of the following contains the physician’s findings based on an examination of the patient?

Patient instructions
Discharge summary
Medical history
Physical exam

2 points   

QUESTION 192

True or false? CMS does not require healthcare providers to inform their patients about general patient rights afforded to them.

True

False

2 points   

QUESTION 193

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

41
41.67
42
74

2 points   

QUESTION 194

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:

Inactivated
Purged
Clearing
Removal

2 points   

QUESTION 195

Which of the following is a request from a clinical area to charge out a health record?

Outguide folder
Requisition
MPI
Patient registry

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