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Data sets serve two purposes in healthcare. One purpose is to identify data elements that are to be collected about each patient. The second purpose is to _______________.
provide uniform data definitions
guide efforts toward computerization
determine statistical formulas
provide a research database

Provide uniform data definitions

In creating a new form or computer view, the designer should be most driven by?
QIO standards
Medical staff bylaws
Needs of the users
Flow of data on the page or screen

Needs of the users

A HIM director finds during an audit of health records that transcribed reports are being changed by the author up to a week after the initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To correct the problem, the HIM director should recommend which of the following?
Immediately stop the practice of changing transcribed reports
Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form
Conduct a verification audit
Alert hospital legal counsel of the practice

Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form.

An electronic health system defines the expected values of the data element "gender" as female, male, and unknown. This type of specificity is known as _________.
data comprehensiveness
data consistency
Data granularity
Data precision

Data Precision

As the privacy officer, you have been asked to develop policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. First, you judge the value of information processed by your system and classify it. Another step you would need to take is:
Authorize access to information collected based on level of data sensitivity
Prevent all nonclinicaians access to any confidential information in the system
Establish firewalls to protect aggregate data collected within your facility
Establish passwords for all customers, both internal and external, who request access to the information in your system.

Authorize access to information collected based on level of data sensitivity

OBRA helped change the focus in long-term care to patient outcomes, which resulted in the core assessment data elements to be collected on each resident as defined in:
MDS
UHDDS
Uniform Ambulatory Core Data
Uniform Clinical Data Set

MDS (minimum Data Set)

In a quantitative analysis review, it was found that a doctor dictated a discharge summary on 02/15/10. The patient, however, was discharged two days later. What is the best course of action to take?
Request that the physician dictate another discharge summary
Have the record analyst note the date discrepancy
Request the physician dictate an addendum to the discharge summary.
File the record as complete since the discharge summary includes all of the pertinent patient information.

Request the physician dictate an addendum to the discharge summary

Which one of the following type of record contains information about sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores?
Emergency
Newborn
Obstetric
Surgical

Newborn

Which of the following would NOT require the healthcare provider to obtain a written consent before the procedure performed on an inpatient?
Appendectomy
Hernia Repair
Chest x-ray
Cholecystectomy

Chest X-ray

In home health care services what is OASIS data used to assess?
Financial performance
Utilization
Outcome
Core measure

Outcome

Which of the following would be the best resource for revising policies at a rehabilitation facility for checking out specific accreditation standards and guidelines?
Conditions of Participation for Rehabilitation Facilities
Medical Staff Bylaws, Rules, and Regulations
Joint Commission manual
CARF manual

CARF manual

l

Documentation of a patient's current and past health status is represented by which of the following?
Physical exam
Medical history
Physician orders
Patient consent

Medical History

Which of the following is a statement or guideline that directs decision making or behavior?
Directive
Procedure
Policy
Process

Policy

The following would be documented in which part of an acute care record:
HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma.
CHEST: Good bilateral breath sounds.
History
Pathology Report
Physical examination
Operation report

Physical examination

) In which part of the POMR progress note would this notation be written?
"Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks."
Subjective
Objective
Assessment
Plan

Plan

) ICD-9 was originally published by?
American Medical Associations (AMA)
Centers for Disease Control (CDC)
United States federal; government
World Health Organization (WHO)

World Health Organization (WHO)

What will a facility be paid should they perform a procedure that has a status indicator of "T"? (Points : 5)
0 %
50%
75%
100%

100%

What type of closure includes retention sutures according to CPT?
Complex
Intermediate
Not specified
Simple

Complex

A 50 yo female is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnosis are treated equally. The correct coding and sequencing of the case would be:
Sequence either the pancreatitis or the noncalculus cholecystitis as the principal diagnosis
Pancreatitis; noncalculus cholecystitis; abdominal pain
Noncalculus cholecystitis; pancreatitis; abdominal pain
Abdominal pain; pancreatitis; noncalculus cholecystitis

Sequence either the pancreatitis or the noncalculus cholecystitis as the principal diagnosis

) An 85-yo woman was admitted for repair of a hiatal hernia, which was performed on the first day of admission. On the second day, the patient attempted to get out of bed to go to the bathroom unassisted and fell sustaining a fractured femur, which was surgically reduced. Additional complications included severe angina for which a PTCA and cardiac catheterization were done. The principal procedure is:
Femur reduction
Herniorrhaphy
Catherization
PTCA

Catherization

A health information technician is hired as the chief compliance officer for a large group practice. The program has written standards of conduct and policies and procedures that address specific areas of potential fraud, as well as, audits in place to monitor compliance. What else should be in place?
Compliance program education and training programs for all employees in the organization.
Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation
Adopt procedures to adequately identify individuals who make complaints so that the appropriate follow-up action can be conducted

Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation

Diagnosis-related groups (DRGs) are organized into _______________.
Case-mix classifications
Geographic practice cost indices
Major diagnostic categories
Resource-based relative values

MAjor Diagnostic Catagories

Third-party payers update fee schedules how often?
Annually
Monthly
Semiannually
Weekly

Annually

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