front 1 A critical early step in designing an EHR is to develop a(n)___ in which the characteristics of each data element are defined. A. Accreditation manual | back 1 D |
front 2 Once a hospital discharge abstract system were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: A. Data sets | back 2 A |
front 3 In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: A. Provide uniform data definitions | back 3 A |
front 4 A health information technician is responsible for designing a data collection form to collect data on patients in an acute care hospital. The first resource that he or she should us is: A. UHDDS | back 4 A |
front 5 Which of the following is not a characteristic of the common healthcare data set such as UHDDS and UACDS? A. They define minimum data elements to be collected | back 5 B |
front 6 A corporation is evaluating several health plans for its benefits package. The data set that provides the comparison information about health plan performance is: A. ORYX | back 6 B |
front 7 The name of the government advisory group that makes proposals for improvement of basic data sets for health records and computer database is: A. Centers for Medicare and Medicaid Services | back 7 D |
front 8 The primary purpose of a minimum data set in healthcare is to: A. Recommend common data elements to collected in health
records | back 8 A |
front 9 The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the: A. Ambulatory Care Data Set | back 9 B |
front 10 Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: A. Performance improvement programs | back 10 A |
front 11 The focus of out patient data collection in the UACDS is on: A. Reason for admission | back 11 B |
front 12 In long-term care, the resident's care plan is based on data collected in the: A. UHDDS | back 12 C |
front 13 Reimbursement for home health services is dependent on data collection from: A. HEDIS | back 13 C |
front 14 Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for: A. Government regulations | back 14 B |
front 15 A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is: A. Continuity of Care Record | back 15 A |
front 16 The home health prospective payment system uses the _____ data set for patient assessments A. HEDIS | back 16 B |
front 17 The government agency most closely involved in the development of healthcare data sets and information standards is: A. Centers for Medicare and Medicaid Services | back 17 D |
front 18 The data set designed to organize data for public release about the outcomes of care is: A. UHDDS | back 18 D |
front 19 OASIS data are used to assess the _____ of home health service. A. Outcome | back 19 A |
front 20 Which of the following includes patient-identifiable information? A. MEDLINE | back 20 C |
front 21 A notation for a diabetic patient in a physicians progress notes reads; "Occasionally gets hungry. No insulin reactions. Says she follows her diabetic diet." In which part of a POMR progress note would this be written? A. Subjective | back 21 A |
front 22 A notation for a diabetic patient in a physicians progress note reads: "FBS 110 mg%, urine sugar, no acetone," In which part of POMR progress note would this be written? A. Subjective | back 22 B |
front 23 A notation for hypersensitive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mg once daily. Return visit in 2 week." In which part of a POMR progress note would this be written? A. Subjective | back 23 D |
front 24 A notation for a hypersensitive patient in ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this be written? A. Subjective | back 24 C |
front 25 A specific set of terms that may be used in an EHR is referred to as a: A. Classification | back 25 D |
front 26 Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services? A. Current Procedural Terminology | back 26 B |
front 27 Which of the following is a classification system specifically for coding histology, topography, and behavior of neoplasms? A. Current Procedural Terminology | back 27 C |
front 28 Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records? A Current Procedural Terminology | back 28 D |
front 29 Which of the following is a system for classifying morbidity and mortality information for statistical purposes? A. Current Procedural Terminology | back 29 D |
front 30 Which of the following is not a knowledge source for users of the Unified Medical Language System? A. Concept table | back 30 A |
front 31 Nosology can be defined as the branch of medical science that deals with: A. Cosmetic surgery | back 31 D |
front 32 Which of the following classifications is used exclusively for classifying cases of malignant disease? A. CPT | back 32 D |
front 33 Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record? A. CPT | back 33 D |
front 34 WHich of the following provides a set of codes used for collecting data about substance abuse and the mental health disorders? A. CPT | back 34 B |
front 35 Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? A. Data compliance | back 35 C |
front 36 Mrs. Smith's admitting data indicates that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? A. Data compliance | back 36 B |
front 37 The term used to describe expected data value is: A. Data definition | back 37 C |
front 38 The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as a carcinoma on the discharge summary. This is an example of a problem with: A. Data granularity | back 38 B |
front 39 Which of the following is a primary weakness of the paper-based health record? A. Difficulty to provide availability to a number of providers at
the same time | back 39 A |
front 40 Which of the following elements is not a component of most patient records? A. Patient Identification | back 40 C |
front 41 Which of the following is not a characteristic of high-quality healthcare data? A. Data relevancy | back 41 D |
front 42 Which of the following represents an example of data granularity? A. A progress note recorded at or near the time of the
observation | back 42 C |
front 43 Which of the following is a primary purpose of the health record? A. Document patient care delivery | back 43 A |
front 44 Which of the following best describes data accuracy? A. Data are correct | back 44 A |
front 45 Which of the following best describes data comprehensiveness? A. Data are correct | back 45 C |
front 46 Which of the following best describes data accessibility? A. Data are correct | back 46 B |
front 47 In which department or unit is the health record number typically assigned? A. HIM | back 47 B |
front 48 Identify where the following information would be found in the acute-care record; "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion." A. Anesthesia report | back 48 C |
front 49 Identify where the following information would be found in the acute-care record: "CBC, WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MVC 93." A. Medical laboratory report | back 49 A |
front 50 Identify where the following information would be found in the acute-care record; "PA and Lateral Chest: The lungs are clear. the heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine." A. Medical Laboratory report | back 50 D |
front 51 The attending physician is responsible for which of the following types of acute-care documentation? A. Consultation report | back 51 B |
front 52 A nurse is responsible for which of the following types of acute-care documentation? A. Operative report | back 52 B |
front 53 Which of the following is an example of clinical data? A. Admitting diagnosis | back 53 A |
front 54 Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of speciality record? A. Home health | back 54 A |
front 55 The following is documented in a acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear? A. History | back 55 C |
front 56 The following is documented in acute-care record; "Microscopice: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear? A. History | back 56 B |
front 57 The following is documented in an acute-care record: "Admit ti 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear? A. Physician order | back 57 A |
front 58 The following is documented in an acute-care record: "The patient was places in the supine position and prepped and draped in the usual manner. Following induction of anesthesia, an incision was made." In which of the following would this documentation appear? A. Anesthesia record | back 58 C |
front 59 The following is documented in an acute-care record: "Gluc 97, BUN 12, K 40, and PHOS 3.0." In which of the following would this documentation appear? A. Anesthesia report | back 59 B |
front 60 The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear? A. Admission note | back 60 C |
front 61 The following is documented in an acute-care record; "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear? A. Admission order | back 61 C |
front 62 The following is documented in an acute-care record; "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following documentation would this appear? A. Admission note | back 62 B |
front 63 The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral, Case manager to meet with patient and family." In which of the following documentation would this appear? A. Admission note | back 63 D |
front 64 Which of the following is not usually a part of quantitative analysis review? A. Checking that all forms contain the patient's name and health
record number | back 64 C |
front 65 Which of the following materials is not documented in an emergency care record? A. Patient's instructions at discharge | back 65 C |
front 66 Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? A. Anesthesia report | back 66 D |
front 67 Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in which of the following records? A. Emergency | back 67 B |
front 68 In a problem-oriented medical record, problems are organized: A. In alphabetical order | back 68 B |
front 69 Which of the following best describes an integrated health record format? A. Each section of the record is maintained by the patient care
department that provided the care | back 69 D |
front 70 Which of the following represents documentation of the patient's current and past health status? A. Physical exam | back 70 B |
front 71 Which of the following contains the physician's findings based on an examination of the patient? A. Physical exam | back 71 A |
front 72 What is the function of a consultation report? A. Provides a chronological summary of the patient's medical
history and illness | back 72 B |
front 73 What is the function of physician's orders? A. Provide a chronological summary of the patient's illness and
treatment | back 73 C |
front 74 Which type of patient care record includes documentation of a family bereavement period? A. Hospice record | back 74 A |
front 75 Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ___ review? A. Quantitative | back 75 A |
front 76 Which of the following is a secondary purpose of the health record? A. Support for provider reimbursement | back 76 C |
front 77 Use of health record by a clinician to facilitate quality patient care is considered: A. A primary purpose of the health record | back 77 A |
front 78 Use of the health record to monitor bioterrorism activity is considered a: A. Primary purpose of the health record | back 78 B |
front 79 In designing an electronic health record, one of the best resources to use to define the structure and content and standardize data definitions are standards promulgated by the: A. Centers for Medicare and Medicaid Services | back 79 B |
front 80 The ____ mandated the development of standards for electronic medical records. A. Medicare and Medicaid legislation of 1965 | back 80 C |
front 81 Messaging standards for electronic data interchange in healthcare have been developed by: A. HL7 | back 81 A |
front 82 A statement or guideline that directs decision making or behavior is called a: A. Directive | back 82 C |
front 83 Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2? A. Current Procedural Terminology (CPT) | back 83 D |
front 84 Which organization originally publishes ICD and it's revisions? A. American Medical Association | back 84 D |
front 85 Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? A. Centers for Disease Control | back 85 B |
front 86 At which level of the classification systems are the most specific ICD-9-CM codes found? A. Category level | back 86 D |
front 87 What are five digit ICD-9-CM diagnosis codes referred to as? A. Category codes | back 87 D |
front 88 What are four-digit ICD-9-CM diagnosis codes referred to as? A. Category codes | back 88 C |
front 89 Which of the following ICD-9-CM codes are always alphanumeric? A. Category codes | back 89 D |
front 90 Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect? A. Category codes | back 90 B |
front 91 Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures? A. Volume 1 | back 91 C |
front 92 Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals? A. Current Procedural Terminology | back 92 A |
front 93 Which of the following is used to report healthcare supplies, products, and services provided to patients by healthcare professionals? A. CPT | back 93 B |
front 94 Which of the following is a standard terminology used to code medical procedures and services? A. CPT | back 94 A |
front 95 Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures? A. Reliability | back 95 C |
front 96 A patient is admitted to the hospital with acute lower abdominal pain. The principal dx is acute appendicitis. The patient also has a dx of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a co-morbid condition? A. Acute appendicitis | back 96 C |
front 97 A Medicare patient had two physician office visits, underwent hospital radiology examinations, clinical lab tests, and received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system? A. Clinical Lab tests | back 97 C |
front 98 Which payer does the hospital proportionately receive the least
amount of payment A. Medicare | back 98 B |
front 99 What term is used for retrospective cash payments paid by the patient for services rendered by a provider? A. Fee-for-service | back 99 A |
front 100 Which of the following is the condition established after the study to be the reason for hospitalization? A. Case mix | back 100 D |
front 101 In which of the following payment systems is the amount of payment determined before the service is delivered? A. Fee-for-service | back 101 C |
front 102 Which of the following is a prospective payment system implementation for payment of inpatient services? A. APC | back 102 B |
front 103 In the Inpatient Prospective Payment System, assignment to a DRG begins with the: A. Principal Diagnosis | back 103 A |
front 104 Which of the following types of hospitals are excluded from Medicare inpatient perspective payment systems? A. Children's | back 104 A |
front 105 Diagnosis-related group are organized into: A. Case-mix classifications | back 105 C |
front 106 MS-DRG may be split into a maximum of ____ payment tiers based on severity as determined by the prescence of a major complication/comorbidity, a CC; or no CC. A. Two | back 106 B |
front 107 The purpose of the present on admission (POA) indicator is to: A. Differentiate between conditions present on admission and
conditions that develop during an inpatient admission | back 107 A |
front 108 The present on admission (POA) indicator is a requirement for A. Inpatient Medicare claims submitted by all hospitals | back 108 A |
front 109 Which of the following is associated with the Medicare fee schedule A. APC's | back 109 C |
front 110 SNFs complete MDS assessments: A. On admission and once every 14 days | back 110 C |