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Finding easier/better ways to perform work, is called work? simplification The HIM director is concerned about backlogs occurring in the technical area. What management tool would the director utilize to determine the amount of time employees currently spend on various activities? Work distribution chart Predetermined elements against which aspects of quality of care may be measured are called? criteria What is the sequence for performing a health information department QM study? select topic, review charts, identify problems, evaluate. The QM coordinator's role in medical care evaluation is to? obtain and review medical records A court ordered subpoena duces tecum issued to a hospital is signed by the? judge A 17-year-old patient requests her patient record be sent to her insurance company; the R.H.I.T. would? return the request for authorization by parent/guardian. The release of information from records at an alcohol-drug abuse center is strictly? governed by federal regulations. Procedures that alert systems managers that unauthorized access to a computer is being attempted? Surveillance procedures Written authorization for release of information from a deceased patient's record could be signed by the? executor The R.H.I.T. receives a subpoena duces tecum on a current inpatient. There are no previous hospitalizations for this patient. The R.H.I.T. would? tell the judge that the record is a current inpatient record and suggest a copy be sent Malpractice is a form of? Malpractice is a form of negligence. In the litigation process, the summons advises the defendant that? action is being taken against him During the trial, a jury decides questions of? fact Willful disregard of a subpoena is punishable as? contempt of court A person whom an action is brought against in a lawsuit, is the? defendant A patient comes to the physician's office complaining of a wart on his foot. The physician recommends removal. The patient sits on the examining table and raises his foot. This is an example of? consent implied by actions A court assigns a person to "stand in the place of parents and possess their legal rights toward a child." This is called? in loco parentis Authority delegated to a subordinate should be commensurate with? the nature of work being supervised When a QM study is performed to reassess the effectiveness of corrective action and to determine whether the problem has been eliminated, we are? controlling A job description should undergo revision? when the job function changes What is the usual first step in applying discipline for the first inappropriate behavior or conduct by an employee? oral reprimand The essential items that should be recorded by all data systems to provide a complete picture of the inpatient's stay are referred to as the? Uniform Hospital Discharge Data Set "UHDDS" What computer system network uses a series of computers which directly communicate with one other without passing through a central host CPU? ring In order to be useful, data must be? interpreted A computer program which uses clinical information to assign inpatients to DRGs is called a(n)? grouper What systems is utilized when a patient is readmitted to the hospital, is assigned a new medical record number, and has old medical records merged with the new medical record? The serial-unit numbering system. What is the part of the computer that contains instructions for storing, manipulating, and retrieving data? program What lists all patients admitted to the facility in chronological order? patient register Name the comprehensive medical information system for ambulatory care which allows for the capture and storage of narrative medical information? COSTAR In what system would downtime be a major disadvantage? large system with one CPU What device converts digital computer signals to analog signals and transmits them over telephone lines? modem Who has final responsibility for the completion/accuracy of the record? attending physician In long term care facilities, restraints may be used? by order of the doctor The nurse should document the reason for administration of? antibiotics Concurrent occurrences screening provides for the identification of? unusual events that occur during the patient's care Tina is the health information technician who performed analysis on charts of patients discharged the previous day. To be sure she had all of the discharged patient charts, she needs to? obtain the admission/discharge list JCAHO standards require that if a complete H&P has been obtained within ____ prior to admission, a durable, legible copy may be used on the inpatient medical record provided there is no significant change(s) recorded at the time of admission. 30 days In ICD-9-CM, what is a mandatory cross-referencing direction to look somewhere else for further information? See or see also What diagnosis is based upon symptoms and physical signs of two or more contrasting diseases? differential All tissue specimens removed during an operation must be examined thoroughly? macroscopically and, when necessary, microscopically by a qualified pathologist. Each week Dr. Blue brings a rubber signature stamp to the medical record department. He gives it to his secretary and tells her to use it to stamp all of his dictated reports. This means of authentication is? not allowed because the doctor is the only one who can use it In the unit filing system, the file drawers or shelves should not be filled to more than? 75% capacity. A deficiency slip is completed in the health information management department and attached to the patient's record. It is considered? a temporary part of the medical record Monitoring the accuracy of quantitative analysis of health records is illustrated by? initially flagging chart deficiencies A patient expired October 12. The pathologist submitted the completed protocol of the autopsy two months later on December 12. This is? in accordance with JCAHO standards An automated incomplete record control system is most useful in situations where? multiple providers have deficiencies on the same medical record A record with the discharge date of August 9 is lacking a report and two signatures on September 15. This record is considered? delinquent What numbering system makes it easiest to purge inactive medical records for microfilming? serial-unit The combining of information from independently derived sources for individuals, groups, or institutions using a common number is called? serial-unit numbering A list of all abstracted cases in a cancer registry, using a consecutive numbering system prefixed by the year of the abstract is housed in the? accession register What is the most important consideration in the retention of records? statute of limitations Which form of microfilm has the greatest storage density? roll film In computing the infection rate. The ratio is that of infections rates to the? total discharges All accredited cancer registries must have an annual follow-up rate of at least? 90% Fetal death rate is determined by dividing total number of fetal deaths for the period by total number of? obstetrical discharges A fetal death at 28 weeks' gestation is classified as? premature What would best illustrate the number of times changes occur over a period of time? frequency distribution When coding neoplasms, if the primary site was previously excised or eradicated on a previous admission with no evidence of recurrence of the original primary site and the patient is admitted with a secondary lesion, code the? secondary site as principal diagnosis In the diagnostic statement, "carcinoma of the lung with metastasis to the brain," brain is considered? secondary In ICD-9-CM, the primary arrangement of the Alphabetic Index of Procedures is according to? procedure The inpatient discharge diagnosis "rule out diabetes mellitus" should be coded as? diabetes mellitus In ICD-9-CM, the term "and" in a code title is interpreted as: and/or Relevant findings from quality management "QM" activities must be considering during? reappraisal/reappointment of medical staff members Quality managment findings, conclusions, recommendations, actions taken, and results of action must be? documented in all pertinent committee minutes and reported through established channels to the board of directors The nuclear medicine department is going to begin review of the appropriate use of various diagnostic modalities. What is the first step they must take in initiating this topic-specific study? develop justification criteria for each modality to be studied In ICD-9-CM, this encloses modifiers that may be present or absent in the diagnostic or procedural statement for code assignment? parentheses The path taken in a DRG decision tree is influenced by? OR procedures Identify the basic tool or control mechanism in risk management? incident report Under PPS, cases with very high costs are called? outliers When CPT coding, if the index entry reads "Hallus valgus 28290-28299," this indicates that the coder will? choose a code from the range of codes between 28290-28299 The annual budgeted amount for office supplies is $7,000. As of September the department spent $5,400. Calculate the variance for office supplies $150.03 $7,000 divided by 12 equals $583.33, which is the amount/month that is to be spent on office supplies. $583.33 x 9 = $5,249.97, which is the total amount that should have spent thus far for office supplies (January throuogh September). $5,400 - $5,249.97 = $150.03. The HIM manager performed a one-day work sampling of a file clerk's activity. Of 300 tasks observed, the employee speaks on the telephone 76 times. How much of the employee's time is spent on the phone if the employee works seven (7) hours per day? 1.77 hours 7 hours x 60 minutes in an hour equals 420 minutes. 420 minutes divided by 300 tasks equals 1.4 minutes/task (average). 76 telephone calls x 1.4 minutes/call equals 106.4 minutes. 106.4 divided by 60 minutes in an hour equals 1.77 hours. The hospital needs to expand the current filing space of 18,225 filing inches to allow for an additional 3,250 filing inches. They are buying all new shelving for their records. Each new shelving unit has 8 shelves, each measuring 36 inches. The total number of shelving units needed is 75 18,225 + 3,250 = 21,475 8 x 36 = 288 21,475 divided by 288 = 74.56, which you round to 75 because you can't purchase .56 of a shelving unit (and 74 units won't be enough to house the records). transcription unit supervisor decides that an error rate of 2% or less is acceptable (no more than 2% of the lines transcribed may contain errors). After proofreading a sample of work, it was determined that 2,586 lines of dictation contained 156 lines with errors. This unit has: This unit has done worse than its standard because 156 lines with errors divided by 2,586 lines of dictation is calculated as a 6.03% error rate. The mode of 17, 23, 94, 46, 94, 52, and 25 is _________? The mode is 94 because it the number that appears most frequently. "The mean is 50.14. The median is 46 because you resequence the numbers in order as 17, 23, 25, 46, 62, 94, 94." a total of 57,325 service days to adult inpatients during the past year. It maintained a bed capacity of 250, except during January through March when a 125-bed wing was closed for alterations. Rounding off to a whole number, calculate the inpatient bed occupancy rate. 72% To calculate the formula, first multiply the bed count for each month by the number of days in each month. Second, total the number of days for the year. Third, divide the number of days into the total service days. Thus 57,325 / 80,000 = 71.65625 = 72% The census taken at midnight August 21 indicated that there were 186 patients remaining in the hospital. On August 22, 13 adults and children were admitted and ten patients were discharged. Calculate the daily inpatient census for August 22. 189 The Medical Center reported discharging 8,300 patients during 1990. The hospital has a bed capacity of 290 and an occupancy rate of 78%. Calculate the bed turn-over rate. 28.6% The Medical Center discharged 1,300 adult and child patients and 40 newborns during September. Total discharge days for these discharged patients was 11,500 for the adults and children, and 270 for the newborns. The formula for the average duration of inpatient hospitalization for adult and child patients discharged in September is: The formula is 11,500. 1300 The hospital had three deaths on the OB delivered service and one death on the OB aborted service during 1987 when 575 obstetrical patients were discharged or died; the formula for the maternal death rate is: The formula is 4 x 100. 575 A patient was admitted to the hospital on April 24 and discharged on May 2. The total length of stay for this patient is: The total length of stay for this patient is 8. "The month of April has just 30 days in it. Also, count the day of admission but not count the day of discharge when calculating total length of stay." Gastrointestinal hemorrhage from esophageal varices; cirrhosis of liver. 571.5 456.20 Assign 571.5 and 456.20, in that order, per the instructional note in the ICD tabular list that states "Code first underlying disease as: cirrhosis of liver (571.5-571.9) Patient admitted for follow-up course of IV chemotherapy for ovarian cancer, resected six months ago. V58.1 183.0 99.25 A liveborn infant was delivered spontaneously with mild erythroblastosis fetalis due to Rh incompatibility. Exchange transfusion was completed via umbilical vein catheterization. V30.00 773.0 99.01 38.92 Gangrene due to diabetes mellitus (IDDM); postoperative dehiscence of stump; previous amputation of four toes on the same limb (1986). Below-knee amputation of leg. Resuture of BK stump. 250.71 785.4 998.3 84.15 86.59 Baby Boy Baker was delivered at term by cesarean section because of a breech presentation. On the day after birth he had an umbilical hemorrhage. The principal diagnosis on the baby's record would be? V30.01, Single liveborn, in hospital by cesarean section