Question 1

A major distinction between DRGs and APCs is that

Accepted Answer

A)  APCs are used for the reimbursement of outpatient and ancillary procedures. 
B)  DRGs are used exclusively for outpatient studies. 
C)  DRGs reference the ICD-10 revision and APCs reference the ICD-9 version. 
D)  APCs are generally at a lower reimbursement amount and are used only by the federal government because of this lower cost. 
A)  APCs are used for the reimbursement of outpatient and ancillary procedures. 
B)  DRGs are used exclusively for outpatient studies. 
C)  DRGs reference the ICD-10 revision and APCs reference the ICD-9 version. 
D)  APCs are generally at a lower reimbursement amount and are used only by the federal government because of this lower cost. A

Question 2

A key function performed by a patient's health information record is to

Accepted Answer

A)  ensure the patient is discharged in a timely fashion. 
B)  communicate to the patient's physician all care rendered by all persons. 
C)  document the patient's chief complaint to see if it was treated and explain the outcome. 
D)  ensure all patient's requests were met during the stay as a measure of quality assurance. 
A)  ensure the patient is discharged in a timely fashion. 
B)  communicate to the patient's physician all care rendered by all persons. 
C)  document the patient's chief complaint to see if it was treated and explain the outcome. 
D)  ensure all patient's requests were met during the stay as a measure of quality assurance. B

Question 3

With regard to patient medical information

Accepted Answer

A)  patient health records are considered legal documents. 
B)  original patient health records must be submitted to courts upon subpoena. 
C)  a spouse has a legal right to the medical information of their partner. 
D)  when a patient's attorney requests medical records,the patient must be present to sign off on the release. 
A)  patient health records are considered legal documents. 
B)  original patient health records must be submitted to courts upon subpoena. 
C)  a spouse has a legal right to the medical information of their partner. 
D)  when a patient's attorney requests medical records,the patient must be present to sign off on the release. A

Question 4

As you and a colleague transport a patient back to the emergency department,the patient's fingers get caught in the wheels of the wheelchair,but there is no apparent injury to the patient.This event does require that an incident report be completed.The incident report must be part of the

Accepted Answer

A)  patient's health record. 
B)  patient's medical history on discharge. 
C)  hospital's risk management documentation. 
D)  nurses' notes in the patient's chart. 
A)  patient's health record. 
B)  patient's medical history on discharge. 
C)  hospital's risk management documentation. 
D)  nurses' notes in the patient's chart.

Question 5

To maximize the full reimbursement for a diagnostic study performed in medical imaging,

Accepted Answer

A)  the correct DRG must be attached to inpatient studies performed. 
B)  any changes to radiology's examinations must be communicated with the hospital chargemaster so that the correct CPT-4 code is assigned. 
C)  the correct CPT code must be assigned using the ICD-10-CM nomenclature. 
D)  All of the above are correct. 
A)  the correct DRG must be attached to inpatient studies performed. 
B)  any changes to radiology's examinations must be communicated with the hospital chargemaster so that the correct CPT-4 code is assigned. 
C)  the correct CPT code must be assigned using the ICD-10-CM nomenclature. 
D)  All of the above are correct.

Question 6

When entering information into a patient health record,it is important to remember that

Accepted Answer

A)  entries can be made in ink or with an indelible pencil. 
B)  abbreviations that are common with cell phone texting are acceptable. 
C)  any data entered must be legible and in ink when the entry is written. 
D)  information can be entered electronically by anyone with a hospital-provided computer. 
A)  entries can be made in ink or with an indelible pencil. 
B)  abbreviations that are common with cell phone texting are acceptable. 
C)  any data entered must be legible and in ink when the entry is written. 
D)  information can be entered electronically by anyone with a hospital-provided computer.

Question 7

As a radiographer working in a busy department,you have received an examination request for an interventional venous line placement for an inpatient.The referring physician is very upset about any delay with his patient.In reviewing the request,you notice that there is no indication as to why this examination is being done.How would you proceed with this situation?

Accepted Answer

A)  Complete the examination and get the missing information later. 
B)  Ask the patient if he knows why the examination is being done. 
C)  Because this patient is an inpatient,the missing information is unnecessary. 
D)  Delay the examination until the needed information is provided by the referring physician. 
A)  Complete the examination and get the missing information later. 
B)  Ask the patient if he knows why the examination is being done. 
C)  Because this patient is an inpatient,the missing information is unnecessary. 
D)  Delay the examination until the needed information is provided by the referring physician.

Question 8

It is important for the professional imaging technologist to thoroughly understand his or her responsibilities with regard to health information confidentiality.Particularly important considerations include

Accepted Answer

A)  a testimonial statement must be signed,indicating your awareness and responsibility in maintaining the privacy of patient records. 
B)  all examination results are released to patients by physicians only. 
C)  all health care personnel have the same responsibilities for maintaining confidentiality,including students. 
D)  All of the above 
A)  a testimonial statement must be signed,indicating your awareness and responsibility in maintaining the privacy of patient records. 
B)  all examination results are released to patients by physicians only. 
C)  all health care personnel have the same responsibilities for maintaining confidentiality,including students. 
D)  All of the above

Question 9

The shift to a prospective payment system (PPS)and diagnostic related groups (DRGs)has made the health information process of _____ critically important to the complete and timely reimbursement of medical costs provided by the government (Medicare/Medicaid)and third-party payers.

Accepted Answer

A)  digitization 
B)  archiving 
C)  transcription 
D)  coding 
A)  digitization 
B)  archiving 
C)  transcription 
D)  coding

Question 10

Standards have been established for the maintenance of complete medical records by

Accepted Answer

A)  The Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations). 
B)  the American Registry of Medical Records (ARMR). 
C)  the American Medical Association (AM
A) . 
D)  the World Trade Organization (WTO). 
A)  The Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations). 
B)  the American Registry of Medical Records (ARMR). 
C)  the American Medical Association (AM
A) . 
D)  the World Trade Organization (WTO).

Question 11

Medical history,including the chief complaint

Accepted Answer

A)  1,2,4,6,and 7 only 
B)  1,3,4,6,and 7 only 
C)  2,3,4,5,and 7 only 
D)  1,4,and 6 only 
A)  1,2,4,6,and 7 only 
B)  1,3,4,6,and 7 only 
C)  2,3,4,5,and 7 only 
D)  1,4,and 6 only

Question 12

In the event a correction is needed in a paper document in a patient health record,

Accepted Answer

A)  the correction can be made by erasing the original entry,writing over it,and initialing the correction. 
B)  the incorrect entry can be covered using whiteout and the record can be recopied with the correction along with the person's initials. 
C)  the original entry needs to be crossed out by the author with a line and highlighted as an ERROR followed by authentication and dating. 
D)  the person discovering the error can make the correction by writing ERROR and recording their name,date,and time. 
A)  the correction can be made by erasing the original entry,writing over it,and initialing the correction. 
B)  the incorrect entry can be covered using whiteout and the record can be recopied with the correction along with the person's initials. 
C)  the original entry needs to be crossed out by the author with a line and highlighted as an ERROR followed by authentication and dating. 
D)  the person discovering the error can make the correction by writing ERROR and recording their name,date,and time.

Question 13

An effective hospital quality improvement program

Accepted Answer

A)  includes the operations and effectiveness of the hospital's medical staff. 
B)  includes only departments that are historically problematic. 
C)  deals exclusively with the financial strength of the hospital. 
D)  publishes all of its findings to local media outlets. 
A)  includes the operations and effectiveness of the hospital's medical staff. 
B)  includes only departments that are historically problematic. 
C)  deals exclusively with the financial strength of the hospital. 
D)  publishes all of its findings to local media outlets.

Question 14

With regard to HIPAA regulations,

Accepted Answer

A)  patients cannot access their medical information without their physician's consent and attendance. 
B)  patients have a legal write to their medical information and to have copies made at no cost to the patient. 
C)  copying and faxing medical information is strictly forbidden. 
D)  None of the above is true. 
A)  patients cannot access their medical information without their physician's consent and attendance. 
B)  patients have a legal write to their medical information and to have copies made at no cost to the patient. 
C)  copying and faxing medical information is strictly forbidden. 
D)  None of the above is true.

Question 15

In 2007,the government upgraded the DRG system of reimbursement and introduced the MS-DRG system.This upgrade is designed to take into account

Accepted Answer

A)  the patient's severity of illness and the amount of medical resources utilized. 
B)  the amount of medical resources used to care for the patient. 
C)  whether or not the patient had a positive outcome. 
D)  patients who are ultimately placed into extended care facilities such as rehabilitation centers or nursing homes. 
A)  the patient's severity of illness and the amount of medical resources utilized. 
B)  the amount of medical resources used to care for the patient. 
C)  whether or not the patient had a positive outcome. 
D)  patients who are ultimately placed into extended care facilities such as rehabilitation centers or nursing homes.

Question 16

According to the Mammography Quality Standards Act,

Accepted Answer

A)  a patient can request that her images be sent to another mammography service. 
B)  original mammographic images must be converted to a paper media and stored in medical records. 
C)  mammographic images must be kept for 24 months or until her next mammographic examination date,whichever is sooner. 
D)  All of the above are correct. 
A)  a patient can request that her images be sent to another mammography service. 
B)  original mammographic images must be converted to a paper media and stored in medical records. 
C)  mammographic images must be kept for 24 months or until her next mammographic examination date,whichever is sooner. 
D)  All of the above are correct.

Question 17

You have been asked to participate in the radiology department's quality assurance committee.The purpose of this committee would most likely be to

Accepted Answer

A)  determine the qualifications of radiographers used in the department. 
B)  review personnel monitoring data to determine staff exposures. 
C)  evaluate various radiology services to seek improvement. 
D)  calculate the cost of X-ray equipment service contracts between companies. 
A)  determine the qualifications of radiographers used in the department. 
B)  review personnel monitoring data to determine staff exposures. 
C)  evaluate various radiology services to seek improvement. 
D)  calculate the cost of X-ray equipment service contracts between companies.

Question 18

Before a diagnostic study can be initiated,

Accepted Answer

A)  a formal,documented examination request is entered into the institution's information system. 
B)  the requesting physician must be identified on the request. 
C)  reasons for the examination must be on the request. 
D)  all of the above should be done. 
A)  a formal,documented examination request is entered into the institution's information system. 
B)  the requesting physician must be identified on the request. 
C)  reasons for the examination must be on the request. 
D)  all of the above should be done.

Question 19

A typical health information management department

Accepted Answer

A)  charges patients and doctors for its services and is a major revenue center for a hospital. 
B)  is responsible for the maintenance,retrieval,and storage of health information. 
C)  is considered an essential department and staffed by physicians only. 
D)  provides health records to physicians only. 
A)  charges patients and doctors for its services and is a major revenue center for a hospital. 
B)  is responsible for the maintenance,retrieval,and storage of health information. 
C)  is considered an essential department and staffed by physicians only. 
D)  provides health records to physicians only.

Question 20

Entering health information into a patient's medical record (charting)is completed by

Accepted Answer

A)  any department personnel who provide care to a patient. 
B)  physicians and practitioners only. 
C)  physicians and charge nurses only. 
D)  health information managers only. 
A)  any department personnel who provide care to a patient. 
B)  physicians and practitioners only. 
C)  physicians and charge nurses only. 
D)  health information managers only.

Exam 25: Health Records and Health Information Management

A major distinction between DRGs and APCs is that

A key function performed by a patient's health information record is to

With regard to patient medical information

As you and a colleague transport a patient back to the emergency department,the patient's fingers get caught in the wheels of the wheelchair,but there is no apparent injury to the patient.This event does require that an incident report be completed.The incident report must be part of the

To maximize the full reimbursement for a diagnostic study performed in medical imaging,

When entering information into a patient health record,it is important to remember that

It is important for the professional imaging technologist to thoroughly understand his or her responsibilities with regard to health information confidentiality.Particularly important considerations include

The shift to a prospective payment system (PPS)and diagnostic related groups (DRGs)has made the health information process of _____ critically important to the complete and timely reimbursement of medical costs provided by the government (Medicare/Medicaid)and third-party payers.

Standards have been established for the maintenance of complete medical records by

Medical history,including the chief complaint

In the event a correction is needed in a paper document in a patient health record,

An effective hospital quality improvement program

With regard to HIPAA regulations,

In 2007,the government upgraded the DRG system of reimbursement and introduced the MS-DRG system.This upgrade is designed to take into account

According to the Mammography Quality Standards Act,

You have been asked to participate in the radiology department's quality assurance committee.The purpose of this committee would most likely be to

Before a diagnostic study can be initiated,

A typical health information management department

Entering health information into a patient's medical record (charting)is completed by

Introduction to Imaging and Radiologic Sciences

Professional Organizations

Educational Survival Skills

Critical-Thinking and Problem-Solving Strategies

Introduction to Clinical Education

Radiology Administration

Radiographic Imaging

Radiographic and Fluoroscopic Equipment

Basic Radiation Protection and Radiobiology

Human Diversity

Patient Interactions

History Taking

Safe Patient Movement and Handling Techniques

Immobilization Techniques

Vital Signs, oxygen, chest Tubes, and Lines

Basic Cardiac Monitoring: the Electrocardiogram

Infection Control

Aseptic Techniques

Nonaseptic Techniques

Medical Emergencies

Pharmacology

Principles of Drug Administration

Contrast Media and Introduction to Radiopharmaceuticals

Professional Ethics

Medical Law

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