Deck 25: Health Records and Health Information Management

Question 1

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.

Answer 1

D
For documentation of medical necessity,a diagnosis or sign or symptom for which the test is being performed must accompany radiology examination requests.Failure of the attending physician to report such a diagnosis or sign or symptom will result in a delay in performance of the procedure.Hospital and billing requirements under medical necessity require that the medical necessity be justified before a procedure is performed.

Question 2

You have been asked to participate on 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)assess the amount of linen used for specific x-ray examinations.
C)evaluate various radiology services to seek improvement.
D)calculate the cost of x-ray equipment service among companies.

Answer 2

C
Performance improvement is a process by which the quality of the care and services provided to patients within a health care facility are monitored and evaluated.The terms quality assurance,quality assessment,and performance improvement are all used to encompass activities related to performance improvement.

Question 3

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 are used to calculate the APC multiplier.
D)APCs are generally at a lower reimbursement amount and are used only by the federal government because of this lower cost.

Answer 3

A
Health record data serve as the basis for hospital reimbursement in the Prospective Payment System (PPS)using the DRG system in the inpatient setting and ambulatory patient classifications (APCs)in the outpatient setting.

Question 4

Health records for inpatients should contain what information?
1)Patient identification data
2)Number of patient visitors during the stay
3)Reports of any diagnostic or therapeutic studies
4)Physical examination data
5)Number of times the nurse call light is activated for nursing care
6)All informed consent documents
7)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 5

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 6

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.
B)the amount of medical resources used to care for the patient.
C)whether the patient is cured or not on discharge.
D)both a and b.

Question 7

As part of a medical imaging quality assurance program,items to be considered would include

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

Question 8

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 only.
C)nurses only.
D)health information managers only.

Question 9

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.
D)make sure all the patient's requests were met during the stay.

Question 10

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,preferably a #1.
B)abbreviations that are common with cell phone texting are acceptable.
C)any date entered must be legible.
D)information can be entered electronically by anyone with a computer.

Question 11

An effective hospital quality improvement program

A)presents its findings and recommendations to the hospital medical staff and board of trustees.
B)includes only departments that are perennially problematic.
C)deals exclusively with the financial strength of the hospital.
D)publishes all of its findings in the local newspaper and on television and radio.

Question 12

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-9-CM nomenclature.
D)all of the above are correct.

Question 13

The health information department performs which of the following supportive functions?

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

Question 14

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 15

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 needed only in hospitals.
D)provides health records to physicians only.

Question 16

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 17

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 18

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 Osteopathic Association (AOA).
D)both a and c.

Question 19

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 that.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 because it is not in the health record.
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 examination was completed because the insurance company paid the bill.

Question 20

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)and third-party payers.

A)duplication and copying
B)archiving
C)transcription
D)coding

Question 21

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 and writing over it.
B)the incorrect entry can be covered using whiteout and the record can be recopied with the correction.
C)the original entry needs to be crossed out with a line and highlighted as an ERROR;the correction can then be entered,authenticated,and dated by the person making the correction.
D)any of the above is acceptable for making corrections.

Question 22

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 need to be destroyed after 24 months and a copy of the report kept on file.
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 23

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.

Question 24

As a professional imaging team member,it is important to remember that

A)patient health records are considered legal documents.
B)incorrect coding of patient data has little effect on the day-to-day operations of a health care provider.
C)only the radiologist will be asked to provide legal testimony regarding a patient's examination in which you participated.
D)HIPAA rules are voluntary and followed only by outpatient imaging centers.

Question 25

With regard to HIPAA regulations,

A)patients cannot access their medical information without their physician's consent and attendance.
B)patients can access the health information of other patients who have had a similar medical experience during their stay.
C)copying and faxing medical information is strictly forbidden.
D)none of the above is true.