Deck 25: Health Records and Health Information Management

Question 1

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

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

Answer 1

D

Question 2

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

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.

Answer 2

A

Question 3

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

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.

Answer 3

C

Question 4

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?

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 5

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

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 6

The ICD-10-CM codes for radiologic procedures using CPT coding nomenclature range from

A) 10000 to 59999.
B) 70010 to 79999.
C) 80000 to 89999.
D) 90010 to 99999.

Question 7

Before a diagnostic study can be initiated,

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 8

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

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.

Question 9

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

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 (AMA).
D) the World Trade Organization (WTO).

Question 10

A typical health information management department

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 11

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

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 12

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

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

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

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 14

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

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.

Question 15

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.

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

Question 16

You are asked to testify in a court case involving a mammographic biopsy with which you were involved as a mammographer.During testimony,a question is raised regarding whether the biopsy was done successfully.You remember clearly that it was,and state so.In the patient's health record,there is no written documentation of the biopsy being done.As far as the court is concerned,

A) the biopsy did not occur.
B) your testimony is all that is needed to straighten out the mistake.
C) the examination was completed if the patient paid her bill.
D) the radiologist who performed the procedure must be subpoenaed.

Question 17

A major distinction between DRGs and APCs is that

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.

Question 18

An effective hospital quality improvement program

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 19

All of the following would be characteristics of a patient health record except it

A) is a single record on a single patient only.
B) may be maintained in paper or electronic media (or both).
C) is required for hospitals and emergency department visits only.
D) promotes communication among providers and continuity of care.

Question 20

Medical history,including the chief complaint

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 21

According to the Mammography Quality Standards Act,

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 22

With regard to patient medical information

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.

Question 23

With regard to HIPAA regulations,

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.