Question 1

TThe representation of diagnoses and procedures as alphanumerical values in order to capture them in the database is called ___________.

Accepted Answer

coding

Question 2

A patient's record was not completed as of the 26th day after the patient's discharge from the hospital. This record is considered:

Accepted Answer

A)   Deficient
B)   Delinquent
C)   In process
D)   Invalid A

Question 3

Which of the following is a detective control?

Accepted Answer

A)   A nurse alerts a physician that a patient is allergic to an ordered medication.
B)   The nursing supervisor reviews a chart to ensure that medication administration notes were properly entered.
C)   The HIM department sends a physician a list of the physician's incomplete charts.
D)   A coder reviews a record in order to assign a clinical code. B

Question 4

What is the most common problem associated with paper records that is not found when managing electronic health records?

Accepted Answer

A)   Loose sheets management
B)   Disorganized patient records
C)   Missing documentation
D)   Lack of documentation

Question 5

TJC requires that acute care records be completed:

Accepted Answer

A)   Within 15 days of discharge
B)   In whatever time period the facility requires
C)   Within 30 days of discharge
D)   In whatever time period the state requires

Question 6

An original signature on a report that is then scanned into an electronic document is a __________.

Accepted Answer

The answer of An original signature on a report that...

Question 7

What is the most efficient way to track changes to a patient's electronic health record?

Accepted Answer

A)   Keeping a paper log of changes
B)   Detective control review
C)   Reviewing the error report
D)   Reviewing the audit trail

Question 8

Given your knowledge of rehabilitation and long-term care, how do you think documentation issues and HIM processing issues differ in these facilities from those in acute care?

Accepted Answer

The answer of Given your knowledge of rehabilitation and long-term...

Question 9

When the HIM department obtains control of the records, a process must be in place to determine whether all records have been received. Describe this process.

Accepted Answer

The answer of When the HIM department obtains control of...

Question 10

The health information management department can verify which patient records are available for processing by referring to the:

Accepted Answer

A)   Admission register
B)   Audit trail
C)   Discharge register
D)   Exception list

Question 11

A written document, like a living will, that specifies a patient's wishes for his/her care and dictates power of attorney, for the purpose of providing clear instructions in the event the patient is unable to do so is an _________.

Accepted Answer

The answer of A written document, like a living will,...

Question 12

The process of recording data into an information system is called:

Accepted Answer

A)   Data entry
B)   Utilization review
C)   Detective control
D)   Collection

Question 13

Quantitative analysis is usually performed by:

Accepted Answer

A)   An allied health professional
B)   A nurse case manager
C)   An HIM professional
D)   A unit care nurse

Question 14

Which of the following is a benefit of concurrent coding?

Accepted Answer

A)   Allows the facility to bill the insurance company prior to discharge
B)   Ensures that all clinical personnel are aware of the admitting diagnosis
C)   Gives the physician the correct principal diagnosis
D)   Helps determine the estimated length of the patient's hospital stay

Question 15

List and define the three fundamental types of internal control. Give a postdischarge processing example of each.

Accepted Answer

The answer of List and define the three fundamental types...

Question 16

What is the difference between concurrent and retrospective analysis? What are the benefits to either?

Accepted Answer

The answer of What is the difference between concurrent and...

Question 17

List the forms that are present, in one way or another, in every acute care health record. What is the most useful way to organize those forms in a record while it is on the nursing unit? Postdischarge? Why do some organizations want the record to be organized differently predischarge and postdischarge?

Accepted Answer

The answer of List the forms that are present, in...

Question 18

What is the correct way to modify a medical record?

Accepted Answer

A)   Use white out
B)   Scratch out the error and have the physician initial it
C)   Put one line through the error and write the correct data near it
D)   Black out the error and indicate the time

Question 19

You have just checked in all of the records received from the nursing unit. One record that was received is not on your discharge register. What could have happened? How do you determine what to do with the extra record?

Accepted Answer

The answer of You have just checked in all of...

Question 20

All of the following are steps in postdischarge processing EXCEPT:

Accepted Answer

A)   Coding
B)   Abstracting
C)   Chart retrieval
D)   Concurrent analysis

Exam 5: Health Information Management Processing