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In preparation for an EHR, you are working with a team conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is
a. operative report.
b. recovery room record.
c. pathology report.
d. discharge summary
Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be
a. procedures and dates.
b. personal identification.
c. cognitive patterns.
d. principal diagnosis.
In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the
a. use of prohibited or "dangerous" abbreviations.
b. prohibited use of any abbreviations.
c. flagrant use of specialty-specific abbreviations.
d. use of abbreviations used in the final diagnosis.
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the
a. incident report.
b. doctors' progress notes.
c. integrated progress notes.
d. nurses' notes.
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
a. transfer record.
b. interdisciplinary patient care plan.
c. discharge summary.
d. problem list.
Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that
a. transfer record.
b. interdisciplinary patient care plan.
c. discharge summary.
d. problem list.
As part of a quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the
a. postpartum record.
b. prenatal record.
c. labor and delivery record.
d. discharge summary.
As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman
a. the H&P copy is acceptable as long as she documents any interval changes.
b. a new H&P is required for every inpatient admission.
c. that you apologize for not noticing the H&P she provided.
d. Joint Commission standards do not allow copies of any kind in the original record.
You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's
a. physicians' index.
b. disease index.
c. number control index.
d. patient index
Discharge summary documentation must include
a. significant findings during hospitalization.
b. a detailed history of the patient.
c. a note from social services or discharge planning.
d. correct codes for significant procedures.
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
a. potentially compensable events.
b. quality of care through the use of preestablished criteria.
c. adverse effects and contraindications of drugs utilized during hospitalization.
d. the overall quality of documentation
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
a. HIM director.
b. chief of staff.
c. attending physician.
d. risk manager.
The foundation for communicating all patient care goals in long-term care settings is the
a. interdisciplinary plan of care.
b. legal assessment.
c. medical history.
d. Uniform Hospital Discharge Data Set.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for
a. marking the surgical site.
b. including the primary caregiver in surgery consults.
c. including the surgeon in the preanesthesia assessment.
d. apprising the patient of all complications that might occur.
According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited?
a. 40 mg Lasix
b. 0.04 mg Lasix
c. 4 mg Lasix
d. 0.4 mg Lasix
Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis?
You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?
a. master patient index
b. disease index
c. physician index
d. operation index
The best example of point-of-care service and documentation is
a. doctors using voice recognition systems to dictate radiology reports.
b. using an automated tracking system to locate a record.
c. using occurrence screens to identify adverse events.
d. nurses using bedside terminals to record vital signs
Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?
a. physical exam
b. pharmacy consultation
c. medical consultation
d. emergency record
In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the
a. Joint Commission accreditation manual.
b. CARF manual.
c. hospital bylaws.
d. Federal Register.
In an acute care hospital, a complete history and physical may not be required for a new admission when
a. the patient has an uneventful course in the hospital.
b. the patient is readmitted for a similar problem within 1 year.
c. the patient's stay is less than 24 hours.
d. a legible copy of a recent H&P performed in the attending physician's office is available.
When developing a data collection system, the most effective approach first considers
a. hardware requirements.
b. the end user's needs.
c. applicable accreditation standards.
d. facility preference
A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the
a. time and means of arrival.
b. physical findings.
c. lab and diagnostic test results.
d. instructions for follow-up care
Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?
a. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record
b. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital
c. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court
d. when the record is taken to a physician's private office for a follow-up patient visit postdischarge
Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.
a. adjust pain medication; begin physical therapy tomorrow
b. sciatica unimproved with hot pack therapy
c. patient moving about very cautiously, appears to be in pain
d. patient states low back pain is as severe as it was on admission
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the
a. Uniform Clinical Data Set.
d. Uniform Ambulatory Core Data
Before you submit a new form to the Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the
a. Glossary of Health Care Terms.
b. facility's data dictionary.
You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) ________ will be added to his health record.
a. advance directive
b. interval summary
c. consultation report
d. interdisciplinary care plan
An example of objective entry in the health record supplied by a health care practitioner is the
a. chief complaint.
b. past medical history.
c. physical assessment.
d. review of systems
You have been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules, and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at
a. 12 hours after admission or prior to surgery.
b. 12 hours after admission.
c. 24 hours after admission.
d. 24 hours after admission or prior to surgery.
Based on the following documentation in an acute care record, where would you expect this excerpt to appear?
"With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation."
a. nursing progress notes
b. physician progress notes
c. operative record
d. physical examination
One essential item to be captured on the physical exam is the
a. family history as related by the patient.
b. general appearance as assessed by the physician.
c. chief complaint.
d. subjective review of systems.
A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2011. Which of the following indices would be the best source in locating the needed records?
a. disease index
b. master patient index
c. physicians' index
d. operation index
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?
a. legal review
b. utilization review
c. quantitative review
d. qualitative review
Which of the following is least likely to be identified by a deficiency analysis technician?
a. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
b. missing discharge summary
c. need for physician authentication of two verbal orders
d. x-ray report charted on the wrong record
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