QUESTION 156How can the healthcare facility determine which physician has the best patient outcomes? Qualitative analysis Data mining Quantitative analysis Version control2 points QUESTION 157Which of the following HIM tasks is eliminated by the electronic health record system? Document imaging Analysis Assembly Indexing2 points QUESTION 158In which department or unit does the health record typically begin? HIM department Patient registration Nursing unit Billing department2 points QUESTION 159Which one of the following is an example of virtual HIM? Information systems that store back-up data off site Employees who code from home Information systems employees access remotely from the hospital Documentation physicians add from their office2 points QUESTION 160The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review? Proactive Prospective Concurrent Retrospective2 points QUESTION 161Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? Flow record Vital signs record Care plan Surgical note2 points QUESTION 162Which of the following is an example of a long-term care setting? Assisted living facility Ambulatory surgery center Community mental health center Acute care hospital2 points QUESTION 163Which of the following elements is typically found in the paper health record? Patient identification Radiology imaging MRI imaging films Financial information2 points QUESTION 164The ambulatory surgery record contains information most similar to which records? Physician’s office records Emergency care records Hospital operative records Hospital obstetric records2 points QUESTION 165Which of the following assists in locating misfiles in the paper-based filing systems? Color coding Weight of folder Number of files on shelf Thickness of folder2 points QUESTION 166Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations? Deficiency slips Master patient index Outguides Requisition slip2 points QUESTION 167Which of the following should be taken into consideration when designing a health record form? Choosing the field type such as radio buttons Number of clicks to access data Including original and revised dates Difference between paper and screen2 points QUESTION 168True or false? Auto-authentication is not in compliance with the CMS Interpretive Guidelines for Hospitals.TrueFalse2 points QUESTION 169Which of the following represents the attending physician’s assessment of the patient’s current health status? Physical examination Medical history Progress notes Discharge summary2 points QUESTION 170What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches? 42 inches 3,600 inches 252 inches 216 inches2 points QUESTION 171Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip? Document image Microfilm roll Microfilm jacket Microfiche2 points QUESTION 172When correcting erroneous information in a paper health record, which of the following is appropriate? Print “addendum” above the entry Backdate to the date that the addendum covers Add the reason for the change Use a black pen to obliterate the entry2 points QUESTION 173Why should the copy and paste function should not be used in the electronic health record? The content may contain outdated information Joint Commission standards prevent this practice This feature is never found in the electronic health record Medicare has a regulation against this practice.2 points QUESTION 174The overall goal of documentation standards is to _____________. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient Ensure that the healthcare provider organization is reimbursed appropriately by payers Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization Ensure physicians have access to the health record information they need to care for the patient2 points QUESTION 175Which of the terms below represents fixed rules that must be followed? Standard Guidelines Forms control program Policy2 points QUESTION 176What is the software that is used for voice recognition known as? Data mining Voice mail Electronic health record Natural language processing2 points QUESTION 177True or false? The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance.TrueFalse2 points QUESTION 178Which of the following filing methods is considered the most efficient? Alphabetical filing Alphanumeric filing Straight numeric filing Terminal digit filing2 points QUESTION 179Patient history questionnaires are most often used in what setting? Ambulatory care Rehabilitative care Home healthcare Long-term care2 points QUESTION 180Which of the following is a secondary purpose of the health record? Support for provider reimbursement Support for patient self-management activities Support for research Support for patient care delivery2 points QUESTION 181Which system is best suited for a small healthcare facility such as a one-physician practice? Alphabetic filing system Serial unit numbering system Serial numbering system Unit numbering system2 points QUESTION 182Which of the following indexes is key to locating a health record? Disease index Master patient index Operation index Physician index2 points QUESTION 183Which of the following represents documentation of the patient’s current and past health status? Medical history Physical exam Physician orders Patient consent2 points QUESTION 184When defining the legal health record, what must the healthcare provider do? Assess the legal environment Determine what the other healthcare providers are doing Decide if the legal health record is needed Include only the paper components of the health record2 points QUESTION 185True or false? The term ambulatory is the same as the term outpatient.TrueFalse2 points QUESTION 186An RAI/MDS and care plan are found in records of patients in what setting? Home healthcare Long-term care Behavioral healthcare Rehabilitative care2 points QUESTION 187True or false? An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance.TrueFalse2 points QUESTION 188Critique this statement: Version control is not an issue in the EHR. This is a true statement. There are issues related to versions of documents, such as there must be a flag to indicate a previous version. There are issues related to versions of documents, such as each version should be visible to all users. There are issues related to versions of documents which include the need to delete the old version when a new one is added.2 points QUESTION 189What is the function of a consultation report? Provides a chronological summary of the patient’s medical history and illness Documents opinions about the patient’s condition from the perspective of a physician not previously involved in the patient’s care Concisely summarizes the patient’s treatment and stay in the hospital from the time of admission to the time of discharge Documents the physician’s instructions to other parties involved in providing care to a patient2 points QUESTION 190Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?36-45-9937-45-9938-45-99 Straight numerical Terminal digit Middle digit Unit2 points QUESTION 191Which of the following contains the physician’s findings based on an examination of the patient? Patient instructions Discharge summary Medical history Physical exam2 points QUESTION 192True or false? CMS does not require healthcare providers to inform their patients about general patient rights afforded to them.TrueFalse2 points QUESTION 193The annual volume statistics for General Hospital are noted below. How many shelving units will be required to store this year’s inpatient discharge records?Average inpatient discharges = 12,000Average inpatient record thickness = ¾ inchShelving units shelf width = 36 inchesNumber of shelves per unit = 6 41 41.67 42 742 points QUESTION 194The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is: Inactivated Purged Clearing Removal2 points QUESTION 195Which of the following is a request from a clinical area to charge out a health record? Outguide folder Requisition MPI Patient registry