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89 Cards in this Set

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1. The services provided by HIM departments in acute care hospitals usually include all the following except:




a) Medical transcription


b) Medical billing


c) Clinical coding


d) Release of information

b) Medical billing

2. The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the:



a) Patient registration department


b) Patient care unit


c) Billing department


d) HIM department

a) Patient registration department

3. As an HIM professional, you would be directly responsible for tracking the compliance(順守) with the Joint Commission's standard for the:



a) Physical plant safety report


b) Average quarterly(年4回の) medical record delinquency(過失) rate


c) Allowable outstanding account receivables(債務)


d) Medication errors

b) Average quarterly medical record delinquency rate

4. Which of the following tasks would the HIM department NOT perform in an electronic health record system?



a) Document imaging


b) Analysis


c) Assembly(組み立て)


d) Indexing(指標付け)

c) Assembly

5. The master patient index:



a) Is the most important index maintained by the HIM department


b) Contains basic demographic(人口統計(学)の/層) information about the patient


c) Is commonly part of the admission, discharge, and transfer computer system


d) All of the above

d) All of the above

8. 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(量の)


b) Qualitative(質的な)


c) Statistical(統計上の)


d) Outcomes

a) Quantitative

9. The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is _____ review.



a) Proactive(先を見越した)


b) Prospective(予想される)


c) Concurrent(同時に起こる)


d) Retroactive(遡って効力がある)

d) Retroactive

10. The release of information function requires the HIM professional to have knowledge of:



a) Clinical coding principals


b) Database development


c) Federal and state confidentiality laws


d) Human resource management

c) Federal and state confidentiality laws

11. In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility?



a) Alphabetic filing system


b) Serial numbering system


c) Terminal digit filing system


d) Unit numbering system

b) Serial numbering system

12. In which of the following system does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters?



a) Alphabetic filing system


b) Serial numbering system


c) Unit numbering system


d) None of the above

c) Unit numbering system

13. A record not completed within the time frame specified in the medical staff rules and regulation is called a:



a) Suspended(停止した) record


b) Completed record


c) Delinquent(延滞の) record


d) Purged(除かれる) record

c) Delinquent record

14. Which of the following should be taken into consideration when designing a health record form?




a) Assigning a unique identifying number to the form


b) Using a concise(簡潔な) title that identifies the form's purpose


c) Including original and revised dates for tracking purposes


d) All of the above

d) All of the above

15. Which of the following statements describes alphabetical filing?




a) By the first name, followed by the middle initial, and then the last name


b) By the last name, followed by the first name, and then the middle initial


c) By the middle initial and then the first name


d) By the last name only

b) By the last name. followed by the first name, and then the middle initial

17. Which of the following is a micrographic(顕微鏡写真の) method of storing health records in which each document page is placed sequentially(連続して) on a long roll?




a) Document scanning system


b) Microfilm roll


c) Microfilm jacket


d) Microfiche(多数枚の小さな写真を一枚のシートに収めた写真)

b) Microfilm roll

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




a) Deficiency(不備) slips


b) Master patient indexes


c) Outguides


d) Requisition(要求) slips

c) Outguides

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




a) Alphabetical filing


b) Alphanumeric filing


c) Straight numeric filing


d) Terminal digit filing

d) Terminal digit filing

20. Which of the following indexes is considered to be the authoritative(信頼できる) key to locating a health record?




a) Disease index


b) Master patient index


c) Operation index


d) Physician index

b) Master patient index

21. Healthcare organizations are considered to be in compliance with the Medicare Conditions of Participation. This is called:




a) Joint(共同の) accreditation(認証評価)


b) Deemed(見なす) status


c) Condition of accreditation


d) Compliance status

b) Deemed status

22. A statement or guideline that directs decision making behavior is called a:




a) Directive(命令)


b) Procedure(医療手当)


c) Policy(方針)


d) Process(一連の行為)

c) Policy

23. If the vice president of marketing requested information regarding the number of cardiac catheterizations performed in 2010, what index would you consult?




a) Master patient index


b) Physician index


c) Disease index


d) Operations/procedures index

d) Operations/procedures index

24. What committee oversees the development and approval of new forms for the health record?




a) Quality review committee


b) Medical staff committee


c) Executive committee


d) Forms committee

d) Forms committee

329-1. The system in which a health record number is assigned at the first encounter and then used for all subsequent(後続の) healthcare encounter is the:




a) Serial numbering system


b) Unit numbering system


c) Serial-unit numbering system


d) Terminal-digit filing system

b) Unit numbering system

329-2. The primary guide to locating a record in a numerical filing system is the:




a) Master patient index


b) Admission register


c) Discharge register


d) Physician index

a) Master patient index

329-3. What type of algorithm(s) may be used to identify duplicate medical record numbers?




a) Deterministic(決定性の)


b) Probabilistic(確率的な)


c) Rules-based


d) All of the above

d) All of the above

330-4. The health record number is typically assigned by:




a) Patient registration


b) Nursing


c) Billing


d) HIM staff

a) Patient registration

330-5. Which of the following is used to locate an electronic health record?




a) Health record number


b) Barcode


c) Color code


d) Terminal digit

a) Health record number

330-6. John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record number is:




a) Duplicates


b) Overlay


c) Overlap


d) Integrity(完全)

a) Duplicates

330-7. Which of the following should be part of a comprehensive(総合的な) MPI maintenance program?




a) Advanced person search


b) Issuing medical record numbers


c) Deletion(削除) capabilities


d) Employee training

a) Advanced person search

330-8. Which of the following is true about the Social Security number?




a) AHIMA supports using the SSN as the health record identifier.


b) The Social Security Administration supports using the SSN as the health record identifier.


c) Both AHIMA and the SS Administration oppose using the SSN as the health record identifier.


d) Both AHIMA and the SSA support using the SSN as the health record identifier.

c) Both AHIMA and the SS Administration oppose using the SSN as the health record identifier.

330-9. Describes the electronic sharing of Information among two or more entities.




a) Enterprise group


b) Health information exchange


c) Work queues


d) Overlay organization

b) Health information exchange

330-10. Which identification system is at a disadvantage when there are two patients with the same name?




a) Serial numbering


b) Unit numbering


c) Serial-unit numbering


d) Alphabetic

d) Alphabetic

335-1. Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-55. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?




a) Straight numerical filing


b) Terminal-digit filing


c) Middle-digit filing


d) Family digit filing

b) Terminal-digit filing

335-2. The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except:




a) Straight numerical


b) Terminal-digit filing


c) Middle-digit filing


d) Alphabetical filing

d) Alphabetical filing

335-3. The term used to describe a combination of paper-based and electronic health record is:




a) Flexible


b) Joint


c) Mixed


d) Hybrid

d) Hybrid

335-4. Which of the following is an advantage of a centralized unit filing system?




a) Having the records close to the specialized patient care area


b) One location in which to look for records


c) Different file folders for each area of specialty


d) Having different rules for each area

b) One location in which to look for records

335-5. Which filing system is considered to be the most efficient?




a) Straight numeric


b) Terminal-digit


c) Middle-digit


d) Alphabetic

b) Terminal-digit

342-1. What type of paper-based storage system conserves floor space by eliminating all but one or two aisles?




a) Open-shelf units


b) Carousel system


c) Mobile filing units


d) Filing cabinets

c) Mobile filing units

342-2. What feature of the filing folder helps locate misfiles within the paper-based filing system?




a) Fasteners


b) Folder weight


c) Color coding


d) Barcodes

c) Color coding

342-3. In a paper-based system, the HIM department routinely delivers health records to:




a) Patient registration


b) Nursing units


c) Billing department


d) Administration

b) Nursing units

342-4. Which of the following paper weights would be the most durable for the medical record folder?




a) 11


b) 14


c) 20


d) 8

c) 20

342-5. What microfilm format is inefficient when patients have multiple admissions on microfilm?




a) Roll


b) Jacket


c) Microfiche


d) Both roll and jacket

a) Roll

348-1. Under the False Claims Act, claims may be brought up to how many years?




a) 10 years


b) No more than 7 years


c) Generally 7 years, but could go as high as 10


d) Depends but is generally 5 t0 7 years

c) Generally 7 years, but could go as high as 10

349-2. Record retention(保存) should be based on:




a) Desire of the medical staff only


b) HIPAA standards


c) State regulations only


d) State regulations and AHIMA recommendations

d) State regulations and AHIMA recommendations

349-3. Which of the following is the appropriate method for destroying microfilm?




a) Burning


b) Shredding


c) Pulverizing(微粉砕)


d) Degaussing(消磁)



c) Pulverizing

349-4. Which of the following is the appropriate method for destroying electronic data?




a) Burning


b) Shredding


c) Pulverizing


d) Degaussing

d) Degaussing

349-5. The tool used to track paper-based health records is:




a) Compliance documentation


b) Outguide


c) Requisition


d) MPI

b) Outguide

359-1. What should be done when the HIM department's error or accuracy rate is deemed unacceptable?




a) A corrective action should be taken.


b) The problem should be treated as an isolated incident.


c) The formula for determining the rate may need to be adjusted.


d) Re-audit the problem area.

a) A corrective action should be taken.

359-2. The forms design committee:




a) Provides oversight for the development, review, and control of forms and computer screens


b) Is responsible for the EHR implementation and maintenance


c) Is always a subcommittee of the quality improvement committee


d) Is an optional function for the HIM department

a) Provides oversight for the development, review, and control of forms and computer screens

359-3. Statement that define the performance expectations and/or structures or processes that must be in place are:




a) Rules


b) Policies


c) Outcomes


d) Standards

d) Standards

359-4. In a paper-based system, individual health records are organized in a pre-established order. This process is called:




a) Retrieval(修正)


b) Assembly


c) Analysis


d) Reordering

b) Assembly

359-5. Reviewing a health record for missing signatures and missing medical reports is called:




a) Assembly


b) Indexing


c) Analysis


d) Coding

c) Analysis

359-6. Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?




a) Concurrent


b) Retrospective


c) Real-time


d) Qualitative

b) Retrospective

360-7. Incomplete record that are not completed by the physician within the time frame specified in the healthcare facility's policies are called:




a) Suspended records


b) Delinquent records


c) Loose records


d) Default records

b) Delinquent records

360-8. T or F


In a paper-based record, errors should be completely obliterated(消す).

F

360-9. T or F


Addendums(付録) should document the date the event actually happened - not the date it was documented.

T

360-10. T or F


The best practice for forms design is to use white paper with black ink.

T

371-1. Which of the following chart-processing activities is eliminated with an EDMS(Electronic documents management system) that uses scanned images of barcoded forms?




a) Chart preparation


b) Scanning


c) Assembly


d) Quality review

c) Assembly

372-2. One of the advantages of and EDMS is that it can:




a) Help manage work tasks


b) Decrease the time records should be retained


c) Improve communications with physicians


d) Eliminate all of the problems encountered with the paper record

a) Help manage work tasks

372-3. Which term indicates that a document has been removed from standard view?




a) Correction


b) Resequencing


c) Reassignment(配置転換)


d) Retraction(撤回)

d) Retraction

372-4. Which term is the process of checking individual data elements, reports or files against each other to resolve discrepancies?




a) Nonrepudiation(否認防止)


b) Reconciliation(調整)


c) Reassignment(配置転換)


d) Resequencing



b) Reconciliation

372-5. Which of the following could be used to determine if someone has the right to view a health record?




a) Photo identification


b) Signature


c) Verbal request for record


d) Phone call prior to arrival

a) Photo identification

387-1. Version control of documents in the EHR requires:



a) The deletion of old versions and the retention(保存) of the most recent


b) Policies and procedures to control which version(s) is displayed


c) Signed and unsigned documents not to be considered two versions


d) Previous versions to be accessible to administration only


b) Policies and procedures to control which version(s) is displayed

387-2. Which of the following is a risk of copying and pasting?




a) Reductions in the time required to document


b) System may not save data


c) Copying the note in the wrong patient's record


d) System thinking that the information belongs to the patient from whom the content is being copied.

c) Copying the note in the wrong patient's record

387-3. How are materials from other facilities documented in the EHR?




a) They are still filed in the paper medical record.


b) They are scanned and filed in the EHR.


c) They are destroyed - not documented in the EHR.


d) They are returned to the originating organization.

b) They are scanned and filed in the EHR.

387-4. Which term verifies claim of identity?




a) Identification


b) Authentication(認証)


c) Authorization


d) Nonrepudiation(否認防止)

b) Authentication

387-5. How are amendments(米国憲法の修正条項) handled in the EHR?




a) Automatically appended(添付の) to the original note. No additional signature is required.


b) Amendments must be entered by the same person as the original note.


c) Amendments cannot be entered if after 24 hours of the event.


d) The amendment must have a separate signature, date, and time.

d) The amendment must have a separate signature, date, and time.

387-6. T or F


EHR data are captured by scanning and direct entry.

T

387-7. T or F


Data validation includes an undo button.

F

387-8. T or F


Policies should address how the patient information will be removed from computers at the end of their useful life.

T

387-9. T or F


Data quality begins at the point of creation.

T

387-10. T or F


Authorization is identifying a patient through the use of a use name.

F

416-1. If one needed to know the number of C-sections performed by a specific obstetrician, which of the following indices would be used to identify the cases?




a) Operation index


b) Disease index


c) Physician index


d) Master patient index

a) Operation index

417-2. The computer system that may serve as the MPI function is the:




a) Patient registration system


b) Abstract system


c) Encoder


d) Chart-tracking system

a) Patient registration system

417-3. A chronological(年代順の) listing of data is called a/an:




a) Index


b) Registry


c) Abstract


d) Record

b) Registry

417-4. What department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?




a) Patient registration


b) Nursing unit


c) Billing department


d) Administration

c) Billing department

417-5. The function within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called:




a) Clinical coding


b) Medical transcription


c) Clerical(書記の) services


d) Release of information

b) Medical transcription

417-6. Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM department?




a) Analysis function


b) Clinical coding


c) Storage and retrieval function


d) Release of information function

d) Release of information function

417-7. Where does the health record begin?




a) Patient registration


b) Nursing unit


c) Billing department


d) HIM department

a) Patient registration

417-8. One of the most sought(捜索する) after accreditation(認証評価) distinction by healthcare facilities is offered by the:




a) American Medical Association


b) American Hospital Association


c) The Joint Commission


d) American Health Information Management Association

c) The Joint Commission

418-9. Statements that describe general guidelines that direct behavior or direct or constrain(強要する) decision making are called:




a) Policies


b) Procedures


c) Standards


d) Criteria(基準)

a) Policies

418-10. Step-by-step instructions on how to complete a specific task are called:




a) Policies


b) Procedures


c) Standards


d) Criteria

b) Procedures

418-11. Assigning ICD-9-CM and CPT codes to the diagnoses and procedures documented in the medical record is called:




a) Clinical coding


b) Release of information


c) Billing


d) Medical transcription

a) Clinical coding

418-12. Which of the following is an example of how the HIM professional interacts with the medical staff?




a) Serve on medical staff committees


b) Provide security for information systems


c) Retain the health record


d) Support reserch

a) Serve on medical staff committees

25. Which entity(ies) have established documentation standards?




a) Medicare


b) Joint Commission


c) American Osteopathic Association


d) All of the above

d) All of the above

26. What is the term used to describe the process of checking individual data elements, reports, or files against each other to resolve discrepancies in accuracy of data and information?




a) Repudiation(否定)


b) Reconciliation(調整)


c) Legal health record


d) Analysis

b) Reconciliation

27. Critique this statement: Version control is not an issue in the EHR.




a) This is a true statement.


b) There are issues related to versions of documents such as there must be a flag indicating a previous version.


c) There are issues related to versions of documents such as each version should be visible to all users.


d) There are issues related to versions of documents which includes the need to delete the old version when a new one is added.

b) There are issues related to versions of documents such as there must be a flag indicating a previous version.

28. Dr. Smith wants to use a lot of free text in his EHR. What should be your response?




a) Good idea Dr. Smith. This allows you to customize the documentation for each patient.


b) Dr. Smith, we recommend that you do not use any free text in the EHR.


c) Dr. Smith, we recommend that you should use only a little free text in the EHR.


d) Dr. Smith, we recommend that you use little, if any, free text in the EHR.

d) Dr. Smith, we recommend that you use little, if any, free text in the EHR.

29. I am arguing against the use of the copy/paste function in the EHR. Which of the following would be my argument?




a) I am unable to identify the author.


b) I am unable to print the data out.


c) I am concerned about the time that it takes to copy/paste the documentation.


d) I am concerned that the users will not know how to perform the copy/paste function.

a) I am unable to identify the author.

30. An HIM student has asked you, the HIM director, why the hybrid record is so challenging, What is your response?




a) It is because we are focusing on the EHR.


b) It is because we have to maintain all of the traditional HIM functions.


c) It is because HIM professions do not have the skills to manage the EHR.


d) It is because we have to manage both the electronic media as well as the paper.

d) It is because we have to manage both the electronic media as well as the paper.