TEST BANK for Foundations of Health Information Management 5th Edition by Nadinia Davis

Foundations of Health Information Management 5th Edition Davis Test Bank Chapter 1: The Health Care Industry Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. Which physician focuses on patient care in acute settings? a. hospitalist b. histologist c. radiologist d. obstetrician ANS: A REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

2. What set of standards allow a physician to care for patients at a hospital? a. standards of professional practice b. privileges c. orders to admit d. deemed status ANS: B REF: p. 4 | p. 5 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

3. A synonym for “licensed vocational nurse” is: a. registered nurse. b. licensed practical nurse. c. nurse practitioner. d. advanced practice nurse.

ANS: B REF: p. 6 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

4. Which type of nurse can prescribe medicine? a. licensed vocational nurse (LVN). b. registered nurse (RN). c. licensed practical nurse (LPN). d. advanced practice registered nurse (APRN).

ANS: D REF: p. 6 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

5. Which is an example of a diagnosis? a. Tonsillitis b. Appendectomy c. Chest x-ray d. Physical therapy ANS: A REF: p. 3 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

6. Which is an example of a procedure? a. bed sore b. pneumonia c. amputation d. appendicitis ANS: C REF: p. 3 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

7. Which health care professionals are responsible for orders that create the treatment plan? a. Nurses b. Physicians c. Physical therapists d. Medical assistants ANS: B REF: p. 3 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

8. A primary care provider (PCP) is responsible for: a. providing specialty medical care. b. surgical procedures. c. patient care in an acute care facility. d. routine care and referrals.

ANS: D REF: p. 5 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

9. A nurse is responsible for: a. delivering and managing patient care. b. ordering prescriptions. c. ordering the patient to be admitted or discharged. d. developing a patient care plan.

ANS: A REF: p. 5 | p. 6 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

10. Which individual is not an allied health professional? a. Respiratory therapist b. Surgical technologist c. Radiologist d. Dietician ANS: C REF: p. 6 | p. 7 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

11. Which health care professional is responsible for educating patients about medication regimens from the patient care plan? a. health information technologist b. physician c. psychologist d. nurse ANS: D REF: p. 6 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

12. Which health care professional works to restore the patient’s functioning in activities of daily living? a. clinical document improvement professional b. gastroenterologist c. neonatologist d. occupational therapist ANS: D REF: p. 7 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

13. Which task would be performed by a primary care provider? a. remove breast tumor b. take a chest x-ray c. analyze routine blood test results d. a colonoscopy ANS: C REF: p. 4 | p. 5 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

14. The additional training required to maintain a credential is called: a. continuing education (CE) b. accreditation c. behavioral health d. Conditions of Participation (CoP) ANS: A REF: p. 8 | p. 9 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

15. HIM professionals do all of the following, EXCEPT: a. secure health information. b. report health information. c. develop and implement EHRs. d. document patient care in health records.

ANS: D REF: p. 6 | p. 7 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

16. Which type of HIM professional specializes in privacy and security aspects of HIM practice? a. medical coder b. data analyst c. patient registrar d. release of information specialist ANS: D REF: p. 8 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

17. Which credential requires an associate degree? a. Registered Health Information Technician (RHIT) b. Certified Coding Specialist (CCS) c. Certified Health Unit Coordinator (CHUC) d. Certified in Healthcare Privacy and Security (CHPS) ANS: A REF: p. 8 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

18. The American Health Information Management Association (AHIMA) and the American Medical Association (AMA) are examples of: a. accrediting bodies b. allied health professionals c. professional associations d. payers ANS: C REF: p. 9 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

19. How is the support from the American Health Information Management Association (AHIMA) different from the American Academy of Professional Coders (AAPC)? a. The AAPC only supports coders. b. AHIMA supports health information management professionals whereas AAPC supports coding professionals. c. AAPC supports health information management professionals whereas AHIMA supports billing professionals. d. AHIMA offers credentials while the AAPC does not.

ANS: B REF: p. 9 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

20. Evidence of competence (by passing an examination) entitles an individual to professional: a. credentials. b. accreditation. c. associations. d. privileges.

ANS: A REF: p. 7 | p. 8 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

21. All the information about the illness or health problem, the treatments provided, and the directions for self-care are documented in the patient’s: a. health record. b. continuum of care. c. bill. d. program.

ANS: A REF: p. 10 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

22. Community Care Center has 200 beds. It has an average length of stay of years. Most of the patients are elderly, but there are some younger patients with serious chronic illnesses. Community Care Center is most likely a(n) facility. a. acute care b. behavioral health c. long-term care (LTC) d. rehabilitation ANS: C REF: p. 12 | p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

23. A(n) offers exclusively palliative care services in an inpatient residential setting or in the home. a. ambulatory care facility b. hospice c. skilled nursing facility d. managed care facility ANS: B REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

24. Chapone Health Care is an organization that owns a number of different health care facilities: three acute care hospitals, two long-term care facilities, and a number of physician offices. Chapone also owns a rehabilitation hospital and an assisted living facility, which also delivers home care. The organization delivers care to patients at every point along the continuum of care.

Chapone Health Care can be described as a(n): a. hospital. b. Medical Home. c. accountable care organization (ACO). d. integrated delivery system (IDS).

ANS: D REF: p. 17 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

25. A patient will most likely receive physical therapy in which type of health care facility? a. acute care b. long-term care c. rehabilitation d. hospice ANS: C REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

26. The patient was admitted to the hospital on Tuesday morning and died Tuesday evening. This patient is classified as a(n): a. inpatient. b. outpatient. c. observation status d. visit ANS: A REF: p. 11 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

27. The number of beds that the state has approved for the facility is the: a. licensed beds. b. bed count. c. registered beds. d. certified count.

ANS: A REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

28. Care from multiple medical specialties over the course of a patient’s lifetime is called the: a. patient care plan. b. integrated delivery system (IDS). c. continuum of care. d. entitlement program.

ANS: C REF: p. 15 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

29. Which patient is considered an inpatient for an acute care facility? a. A patient who died prior to arriving at the acute care facility b. A patient who spent 10 hours in the emergency room c. A patient who had her hand operated on in outpatient surgery, and then returned home d. A patient who was admitted for pneumonia ANS: D REF: p. 11 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

30. Which patient is not counted as a discharge? a. a patient who was treated in the emergency department and sent home b. an inpatient patient who died in the operating room c. an inpatient who was transferred to another health care facility d. an inpatient who left an acute care facility against medical advice (AMA) ANS: A REF: p. 11 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

31. Daisy Community Center is an acute care facility with 350 beds. On May 1, there were 305 inpatients. What is the percent occupancy? a. 32% b. 87% c. 100% d. 85% ANS: B REF: p. 13 | p. 14 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

32. Rehabilitation facilities are LEAST likely to have: a. inpatients. b. outpatients. c. laboratories. d. operating rooms.

ANS: D REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

33. Counting the 12 discharges on the maternity ward this week, you see women have stayed 2 days, 2 days, 2 days, 3 days, 3 days, 3 days, 3 days, 3 days, 3 days, 4 days, 4 days, and 7 days. What is the average length of stay (ALOS) on the maternity ward this week? a. 39 days b. 12 days c. 0.308 days d. 3.25 days ANS: D REF: p. 14 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

34. Which is true of an acute care facility? a. Patients receive care for severe conditions and are expected to recover. b. Treatment episodes are referred to as visits or encounters. c. Patients are not allowed to stay longer than 30 days. d. It offers primary care.

ANS: A REF: p. 12 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

35. Most community hospitals are: a. not-for-profit b. for-profit c. children’s hospitals d. accountable care organizations (ACOs) ANS: A REF: p. 16 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

36. Which is characteristic of not-for-profit health care facilities? a. they don’t make a profit b. the employees are volunteers c. they don’t charge patients as much as other facilities d. they receive tax breaks.

ANS: D REF: p. 16 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

37. Which is true of an accountable care organization (ACO)? a. providers bill separately from the hospital b. patients receive low-cost or free care c. payment for inpatient services flows through the hospital and out to other providers d. the primary care provider acts as the gatekeeper to specialists and services ANS: C REF: p. 17 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

38. What is the fixed amount a health insurance policyholder pays each month? a. Deductible b. Capitation c. Copay d. Premium ANS: D REF: p. 18 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

39. Why is health insurance referred to as a “third-party payer”? a. Because a third party, the payer, pays a provider (second party) for the patient (first party). b. Because it was originally required only when a husband and wife have a child, the third party. c. Because it only pays for one-third of the expenses. d. Because it is the third option for payment, following the patient and the government.

ANS: A REF: p. 18 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

40. Medicare was enacted through which legislation? a. Title IX of the Health and Human Services Act b. Patient Protection and Affordable Care Act c. Family and Medical Leave Act d. Title XVIII of the Social Security Act ANS: D REF: p. 18 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

41. What U.S. federal agency is responsible for the oversight of Medicare and Medicaid? a. The Department of Health and Human Services (DHHS) b. National Institutes of Health (NIH) c. Centers for Disease Control and Prevention (CDC) d. Department of Homeland Security (DHS) ANS: A REF: p. 19 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

42. How is patient satisfaction with the health care provider and its services measured? a. surveys b. blogs c. social media posts d. Healthy People 2020 indicators ANS: A REF: p. 18 | p. 19 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

43. In which program do policymakers monitor health indicators and create objectives to promote wellbeing? a. managed care b. The Agency for Healthcare Research and Quality (AHRQ) c. The Patient Centered Outcomes Research Institute (PCORI) d. Healthy People 2020 ANS: D REF: p. 18 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

44. What do pharmaceutical manufacturers cite as the main reason for high drug costs? a. outsourcing b. research and development c. health insurance premiums d. marketing expenses ANS: B REF: p. 19 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

45. Unlike Medicare, eligibility for Medicaid is primarily based on: a. age b. disability status c. economic circumstances d. prior military service ANS: C REF: p. 18 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

46. What is a benefit of health care facility obtaining accreditation through The Joint Commission in lieu of a Conditions of Participation review? a. Accreditation b. Unconditional status c. Certification d. Deemed status ANS: D REF: p. 22 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

47. Medicare is administered by: a. Food and Drug Administration (FDA). b. Centers for Medicare and Medicaid (CMS). c. individual states. d. National Committee for Quality Assurance (NCQA).

ANS: B REF: p. 19 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

48. A facility is reviewing its policies and procedures to ensure that it complies with The Joint Commission (TJC) standards. This facility is concerned about its: a. accreditation. b. certification. c. licensure. d. registration.

ANS: A REF: p. 21 | p. 22 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

49. A state agency develops and administers regulations that must be followed in order for a facility to maintain its: a. licensure. b. accreditation. c. registration. d. certification.

ANS: A REF: p. 20 | p. 21 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

50. Which federal agency protects patients from discrimination? a. Health Resources and Services Administration (HRSA) b. The Agency for Healthcare Research and Quality (AHRQ) c. Office for Civil Rights (OCR) d. Occupational Health and Safety Administration (OSHA) ANS: C REF: p. 20 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

51. How often does the Joint Commission (TJC) conduct onsite surveys? a. At least once a year b. At least once every 2 years c. At least once every 3 years d. At least once every 5 years ANS: C REF: p. 21 | p. 22 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

52. Medical professions have a code of a. conduct b. professionalism c. honor d. ethics

that govern the conduct of their members.

ANS: D REF: p. 23 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, VI.7. Assess ethical standards of practice.

53. Which independent organization, formerly the Institute of Medicine, published the report, To Err is Human: Building a Safer Healthcare System? a. The National Academy of Medicine (NAM) b. The Leapfrog Group c. Institute for Healthcare Improvement (IHI) d. The Patient Centered Outcomes Research Institute (PCORI) ANS: A REF: p. 23 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

COMPLETION 1. A nurse delivery.

focuses on the care of women during the period surrounding childbirth: pregnancy, labor, delivery, and after

ANS: midwife REF: p. 6 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

2. A profession is characterized by specific training in a body of knowledge that is supported by an explicit code of continuing education.

and

ANS: ethics REF: p. 2 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, VI.7. Assess ethical standards of practice.

3. When one physician asks another physician for an opinion regarding the care of a patient, the first physician is asking for a(n) .

ANS: consultation REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

4. A long-term care (LTC) facility has an average length of stay (ALOS) greater than numeric value)

days. (Input your answer in

ANS: 30 REF: p. 12 | p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

5. The actual number of beds that a hospital has available for inpatients is called the

.

ANS: bed count REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

6. A health care organization that has permanent facilities, 24-hour nursing care for inpatients, and an organized medical staff is a type of .

ANS: hospital REF: p. 11 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

7. The payment to a health care provider is called

.

ANS: reimbursement REF: p. 17 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

8. A facility that routinely perform eye surgeries, colonoscopies, excisions, and many types of orthopedic surgeries on an outpatient basis, wherein the patient returns home after the procedure is performed is called a(n) surgery center.

ANS: ambulatory REF: p. 12 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

9.

health care focuses on treating patients where they reside.

ANS: Home REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

10. Palliative care for the terminally ill is the focus of

care.

ANS: hospice REF: p. 13 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

11. A seamless continuity of care with services from many different providers across a patient’s lifespan is called which has yet to be fully realized in practice.

care,

ANS: integrated REF: p. 16 OBJ: 2. Summarize the structure of the health care system, including types of providers and their patients, third-party payers and the role of the employer, pharmaceutical companies and device manufacturers, and the interrelationships working to provide continuity of care.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

12. The Centers for Medicare and Medicaid Services waives routine Conditions of Participation compliance audits for appropriately accredited facilities by granting them .

ANS: deemed status REF: p. 22 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

13. Voluntary compliance with a set of standards developed by an independent agency is part of the

process.

ANS: accreditation REF: p. 21 OBJ: 3. Discuss the external forces that guide policy-making and health care delivery, including the impact of various levels of government, accreditation agencies, and professional organizations.

MSC: CAHIIM, V.4. Identify the impact of policy on health care.

14. A(n)

administers substances that cause loss of sensation.

ANS: anesthesiologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

15. A(n)

specializes in treating patients with cancer.

ANS: oncologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

16. The type of physician who provides care related to the female reproductive system is a(n)

.

ANS: gynecologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

17. A(n)

for women before, during, and after delivery.

ANS: obstetrician REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

18. A(n)

delivers primary care to children.

ANS: pediatrician REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

19. A(n)

treats diseases of the digestive system.

ANS: gastroenterologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

20. A(n)

is a medical doctor who treats diseases of the mind.

ANS: psychiatrist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

21. A(n)

specializes in diseases and disorders of the heart and blood vessels.

ANS: cardiologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

22. The physician specializing in skin disorders is the

.

ANS: dermatologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

23. A(n)

treats diseases and disorders of the eyes.

ANS: ophthalmologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

24. A(n)

studies changes in human tissues, cells, and organs.

ANS: histologist REF: p. 4 OBJ: 1. Describe the roles of clinicians and allied health professionals, including health information management professionals, and their interrelationships across the health care delivery system. MSC: CAHIIM, V.4. Identify the impact of policy on health care.

Chapter 2: Collecting and Storing Health Care Data Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. Organized data that have been collected about a patient or a group of patients is called: a. the health record. b. epidemiology. c. health data. d. health information.

ANS: D REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

2. Data that have been processed into a useful frame of reference are called: a. observation. b. information. c. schedule. d. assessment.

ANS: B REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

3. Data is a plural term. What is the singular form of the word data? a. datum b. datus c. dato d. datae ANS: A REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

4. You create a list of all the cases of the flu seen at the clinic in the past month. What is this list an example of? a. primary data b. data analytics c. aggregate data d. vital statistics ANS: C REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

5.

is the process of examining the data and exploring them to create information. a. b. c. d.

data analytics epidemiology aggregate data vital statistics

ANS: A REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

6. Electronic data are collected and organized into a: a. database. b. system. c. data map. d. data set.

ANS: A REF: p. 33 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

7. What is the first step in collecting quality data? a. determining the needs of the users b. creating the request for proposal (RFP) c. looking at the data that have already been collected d. designing a data collection form or screen ANS: A REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

1

8.

What is the meaning of the expression, “garbage in, garbage out?” a. all data must be collected in to discover what must be ignored b. collecting incorrect data will result in having data that is not useful c. quality data can only be collected by quality people d. even bad data is useful to some users of data ANS: B REF: p. 33 | p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

9. Which of the following is NOT an example of the possible contents of a two-character state field? a. F b. FL c. DC d. NM ANS: A REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

10. A(n) field may contain both letters and numbers. a. numeric b. character c. alphanumeric d. valid ANS: C REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

11. Where would an HIM professional find a list of field names, their sizes, who collects them, and where the data is stored? a. data repository b. data warehouse c. data dictionary d. electronic health record (EHR) ANS: C REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

12. Which organizational policy would prohibit creation of EHR fields for physician-specific data collection? a. All patient data be archived electronically. b. All forms must be approved by the Health Records Committee. c. All EHR data elements must comply with UHDDS d. All EHR data elements must satisfy an organizational purpose ANS: D REF: p. 34 | p. 35 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

13. What is the problem with a patient’s Social Security number that is ten digits long? a. It is not organized. b. It is not valid. c. It is illegal. d. It is undefined.

ANS: B REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

14. A group of fields is called a: a. record. b. file. c. data dictionary. d. character.

ANS: A REF: p. 35 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

15. A group of characters is called a: a. record. b. file. c. field. d. character.

ANS: C REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

2

16. A group of related records is called a: a. record. b. file. c. field. d. data set.

ANS: B REF: p. 35 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

17. With what language does an HIM professional retrieve data in a relational database? a. Structured Query Language (SQL) b. Codasyl c. meaningful use d. syntactic interoperability ANS: A REF: p. 36 OBJ: 3. Describe the structure of a relational database.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

18. How is a relational database arranged? a. different tables linked by a common field b. separate screens for each field c. a summary of data dictionaries in a file d. alphabetical strings of text in rows assigned numerically ANS: A REF: p. 36 OBJ: 3. Describe the structure of a relational database.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

19. What is the name for the unique identifier assigned to the patient at each visit? a. master patient index (MPI) b. patient account number c. medical record number (MRN) d. Uniform Hospital Discharge Data Set (UHDDS) ANS: B REF: p. 36 OBJ: 3. Describe the structure of a relational database.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

20. Where is the demographic data collected by patient registration stored? a. the master patient index (MPI) b. the data dictionary c. the medical record number (MRN) d. the Uniform Hospital Discharge Data Set (UHDDS) ANS: A REF: p. 36 OBJ: 3. Describe the structure of a relational database.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

21. A standardized data set allows users of the data to: a. compare facilities and track trends b. identify patients who do not pay bills c. identify physicians who charge too much d. monitor the effects of treatments ANS: A REF: p. 37 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

22. Which data set pertains to acute care facilities? a. Minimum Data Set (MDS 3.0) b. Outcome and Assessment Information Set (OASIS) c. ICD-10-CM d. Uniform Hospital Discharge Data Set (UHDDS) ANS: D REF: p. 38 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

23. How do providers know what data to report in the Uniform Hospital Discharge Data Set (UHDDS)? a. HIM professionals check a website quarterly for changes. b. It is published in the Code of Federal Regulations (C.F.R.) each year. c. The data elements are required fields on the Uniform Bill (UB-04). d. Instructions are published by the entity to which the provider submits the data.

ANS: D REF: p. 38 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

3

24. Which data element is a required component of the UHDDS? a. patient’s eye color b. patient’s primary care provider (PCP) c. citizenship status of patient d. principal diagnosis ANS: D REF: p. 38 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

25. Which data set is used in long-term care facilities? a. Minimum Data Set (MDS 3.0) b. Outcome and Assessment Information Set (OASIS) c. Uniform Ambulatory Care Data Set (UACDS) d. Uniform Hospital Discharge Data Set (UHDDS) ANS: A REF: p. 38 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

26. All of the data that have been collected about an individual patient are called a: a. data set. b. file. c. health record. d. data repository.

ANS: C REF: p. 39 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

27. In creating a data collection device, which of the following is the most important consideration? a. Purpose of the form b. The size of the paper or the computer screen c. The number of fields on the page d. The Joint Commission (TJC) rules regarding forms creation ANS: A REF: p. 39 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

28. Which comparison is true of the data collected in the physician’s office versus the acute care setting? a. More people are recording patient data in the physician’s office. b. The physician’s office is more likely to use electronic data collection devices. c. More data is collected in the acute care setting. d. The physician’s office records patient progress while the acute care facility does not.

ANS: C REF: p. 39 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

29. Who develops a form? a. the Chief Medical Officer (CMO) b. a committee of users c. the HIM department d. the physician ANS: B REF: p. 40 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

30. Which is included on every page of a form or screen? a. patient ID b. vital signs c. current medications d. provider ID ANS: A REF: p. 40 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

4

31. Authentication shows: a. the person responsible for the data on a form. b. the name of the facility and its logo. c. the patient’s name or barcode. d. the title and number of the form.

ANS: A REF: p. 43 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

32. Which is a consideration in developing a computer data collection screen that is less important in a paper form? a. the needs of the users b. the order in which the data is collected c. the purpose of the data collection d. simplicity ANS: B REF: p. 44 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

33. Which is a benefit of electronic data collection? a. more easily tailored to user needs b. menus to select valid choices c. simpler interface and design d. automatic data transfer to accrediting bodies ANS: B REF: p. 42 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

34. Which feature reduces the chance that a physician orders a non-approved drug? a. electronic authentication b. drop-down menus c. connection to pharmacy computers d. character limits for fields ANS: B REF: p. 42 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

35. Which is a benefit of using forms to collect data? a. they are easy to duplicate b. they remind the user of what data must be collected c. they are easy to fill out d. they can be tailored to the needs of the patient and provider ANS: B REF: p. 40 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

36. Where are blank original copies of forms kept? a. in the electronic health record (EHR) b. in the master forms file c. at patient registration d. in the master patient index (MPI) ANS: B REF: p. 44 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

37. Which system do providers use to send orders? a. the systems development life cycle (SDLC) b. the electronic health record (EHR) c. computerized physician order entry (CPOE) d. the health information exchange (HIE) ANS: C REF: p. 46 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

5

38. Which is characteristic of the electronic health record (EHR)? a. the records follows the patient b. low upfront costs c. more secure than paper files d. data collection at the point-of care ANS: D REF: p. 46 | p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

39. Which is recommended by the clinical decision-making system (CDS)? a. discounted medicines b. referrals to other physicians c. possible side effects and allergies d. possible treatment plans ANS: D REF: p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

40. A facility that collects some data electronically and some data on paper forms uses a(n): a. hybrid record. b. electronic health record (EHR). c. electronic medical record (EMR). d. patient portal.

ANS: A REF: p. 45 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

41. What system stores paper forms for electronic review and retrieval? a. clinical decision-making system (CDS) b. computerized physician order entry (CPOE) system c. picture archiving and communication system (PACS) d. document imaging system ANS: D REF: p. 45 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

42. What term describes the patient’s access to the electronic health record (EHR)? a. point-of-care b. patient portal c. meaningful use d. hybrid record ANS: B REF: p. 53 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

43. How did the federal government encourage adoption of the electronic health record (EHR)? a. Congress passed legislation requiring its use b. Financial incentives in the form of increased payments c. Zero-interest loans for community hospitals d. Free computer systems for qualified providers ANS: B REF: p. 48 | p. 49 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

44. Which activity is facilitated in an EHR as opposed to a hybrid record? a. Documentation by individual providers b. Authentication of entries at point of care c. Concurrent review by multiple users d. Medication administration records ANS: C REF: p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

6

45. A network of various health care providers with access to each other’s patient records from approved points of care is a: a. computerized physician order entry (CPOE). b. health information exchange (HIE). c. electronic document management system (EDMS). d. master patient index (MPI).

ANS: B REF: p. 50 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

46. Interoperability means: a. the ability to share data among different computer systems. b. incentives for electronic health record (EHR) adoption. c. efforts to use the same computers nation-wide. d. surgery performed remotely using robots.

ANS: A REF: p. 49 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

47. Health Level Seven (HL7) is a: a. committee working on EHRs for hospitals within the Veteran’s Administration (VA). b. committee established by the President of the United States to investigate the use of EHRs. c. health clinic for seven boroughs in New York City. d. standards development organization whose domain is clinical and administrative data.

ANS: D REF: p. 52 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

48. The Office of the National Coordinator for Health Information Technology (ONC) supports the development of the Nationwide Health Information Network (NHIN), which is a: a. set of standards and policies. b. series of networked computers. c. centrally located data repository. d. cloud-based EHR software suite.

ANS: A REF: p. 52 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

49. What is a benefit to an interoperable nationwide health information network (NHIN)? a. continuity of care b. more secure records c. less training for health care professionals d. physicians spend less time entering orders.

ANS: A REF: p. 52 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

50. Which entity fostered collaboration between the public sector and private sector to develop standards for the exchange of electronic medical information? a. Institute of Medicine b. National Committee on Vital and Health Statistics c. Markle Foundation d. Consolidated Health Informatics ANS: C REF: p. 52 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

51. Which standard supports the storage and transmission of diagnostic images? a. picture archiving and communication system (PACS) b. Health-Level 7 (HL7) c. 837I d. Digital Imaging and Communication in Medicine (DICOM) ANS: A REF: p. 50 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

7

52. A(n) can store the data from these different systems and make them usable through an interface without the need to run reports from each system. a. data repository b. data warehouse c. health information exchange (HIE) d. data mapper ANS: A REF: p. 54 OBJ: 8. Explain the use of the data repository, data warehouse, and data mapping in the storage of health data.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

53. A(n) collects information from different databases and organizes it for use in creating reports and for analytical research. a. electronic data interchange (EDI) b. health information exchange (HIE) c. electronic document management system (EDMS) d. secure messaging system (SMS) ANS: B REF: p. 50 | p. 51 OBJ: 8. Explain the use of the data repository, data warehouse, and data mapping in the storage of health data.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

54. The EHR software is chosen after considering the needs of the a. employees b. selection committee c. HIM department d. stakeholders

, or those who will use and maintain the system.

ANS: D REF: p. 56 OBJ: 9. Explain the system acquisition and evaluation process.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

55. The standard operating nomenclature, specifications, or protocols of a system is called the: a. electronic data interchange (EDI). b. interface. c. infrastructure. d. relational database.

ANS: C REF: p. 57 OBJ: 9. Explain the system acquisition and evaluation process.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

56. Which is another term for data quality? a. data integrity b. data authentication c. data definition d. data imaging ANS: A REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

COMPLETION 1. The smallest elements or units of facts or observations is

.

ANS: data REF: p. 30 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

2. Public health data collected through birth certificates, death certificates, and other data-gathering tools are called _ statistics.

ANS: vital REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

3. The study of morbidity trends and occurrences is

.

ANS: epidemiology REF: p. 32 OBJ: 1. Distinguish health data and health information.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

8

4. A single letter, number, or symbol is a(n)

.

ANS: character REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

5. A collection or series of related characters is a(n)

.

ANS: field REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

6. In a database, a list of details about each field is a data

.

ANS: dictionary REF: p. 34 OBJ: 2. Explain the purpose and contents of a data dictionary.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

7. The abbreviation for the data set used in home health settings is

.

ANS: OASIS REF: p. 38 OBJ: 4. Define the data sets used in health care and compare their applications and purposes.

MSC: CAHIIM, I.3. Identify policies and strategies to achieve data integrity.

8. The development, implementation, and enforcement of policies and procedures that ensure that standards are met is

.

ANS: compliance REF: p. 43 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

9. A

is a mark indicating that a subordinate’s work has been supervised.

ANS: countersignature REF: p. 43 OBJ: 5. Describe the importance of forms and their application to data collection.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

10. The clinical decision-making system (CDS) in an EHR is based on -based medicine, a methodology for patient care that makes conscientious, explicit, and judicious use of current best research.

ANS: evidence REF: p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

11. A health care record consisting of both paper and electronic data collection is a

record.

ANS: hybrid REF: p. 45 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

12. A formula or set of steps for solving a particular problem is called a(n)

.

ANS: algorithm REF: p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

9

13. The interface which grants patients web-based access to their medical record is known as a patient

.

ANS: portal REF: p. 47 OBJ: 6. Compare and contrast an electronic health record with a hybrid electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

14. When two or more systems can exchange information and interpret the meaning of the information exchanged without any ambiguity, it is called interoperability.

ANS: semantic REF: p. 50 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

15. The individual’s separate health record containing information owned and managed by the patient is called the health record.

_

ANS: personal REF: p. 53 | p. 54 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

16. The electronic use of information that can flow electronically from one type of provider to another along the continuum of care and over time is called .

ANS: longitudinal REF: p. 49 OBJ: 7. Discuss the importance of interoperability and the longitudinal use of the electronic health record.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

17. Data database.

is the matching of a data element in one system or database to the same element in another system or

ANS: mapping REF: p. 54 OBJ: 8. Explain the use of the data repository, data warehouse, and data mapping in the storage of health data.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

18. An open database that stores data from various independent sources that can be integrated to enable viewers to see documents from several sources is a(n) .

ANS: data repository REF: p. 54 OBJ: 8. Explain the use of the data repository, data warehouse, and data mapping in the storage of health data.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

19. A collection of information from different databases, organized to be used for ad hoc reports and analytical research that may not include patient identifying information, is called the data .

ANS: warehouse REF: p. 54 OBJ: 8. Explain the use of the data repository, data warehouse, and data mapping in the storage of health data.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

20. The process used to plan, design, develop, implement, and maintain an information system is called the system development cycle.

ANS: life REF: p. 56 OBJ: 9. Explain the system acquisition and evaluation process.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

10

21. The an EHR product.

is used to explain to EHR vendors what the health care organization intends to accomplish and requires of

ANS: request for proposal REF: p. 56 OBJ: 9. Explain the system acquisition and evaluation process.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

22. An individual trained in all aspects of a computer system who can offer on-site support to others is called a

.

ANS: superuser REF: p. 58 OBJ: 9. Explain the system acquisition and evaluation process.

MSC: CAHIIM, III.7. Summarize standards for the exchange of health information; III.9. Identify standards for exchange of health information (DM).

11

Chapter 3: Sources of Data Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. All of the data that have been collected about an individual patient are called a a. health record b. SOAP note c. history & physical (H&P) d. discharge summary ANS: A REF: p. 65 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

2. A compilation of patient data that have been collected over time from different settings are called a a. progress note b. longitudinal record c. plan of care d. discharge summary ANS: B REF: p. 65 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

3. The individual or organization that is ultimately responsible for paying a hospital bill is called the a. employer b. guarantor c. patient d. spouse ANS: B REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

4. Which is NOT an example of socioeconomic data? a. marital status b. religion c. gender d. sexual orientation ANS: C REF: p. 65 | p. 66 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

5. Which is an example of demographic data? a. patient name b. marital status c. primary care provider (PCP) d. employer ANS: A REF: p. 65 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

6. Which of the following is NOT an example of clinical data? a. appendectomy 3 years ago b. primary care provider (PCP) c. blood pressure reading d. family history of chronic depression ANS: B REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

7. Which individual or entity is billed first for health services? a. the patient b. the guarantor c. the primary payer d. the guardian ANS: C REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

1

8. A patient presented in the emergency department with unusual lesions on the skin, a fever, and dehydration. Which type of data is the most helpful to the physician developing a diagnosis? a. demographic data b. administrative data c. socioeconomic data d. financial data ANS: C REF: p. 65 | p. 66 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

9. The physician’s conclusion about the patient’s condition is the a. outcome b. symptom c. assessment d. diagnosis ANS: D REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

10. Patient status such as inpatient, outpatient, or observation are examples of a. demographic b. administrative c. socioeconomic d. financial

data.

ANS: B REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

11. Which is a distinguishing factor between emergent and urgent care? a. risk to the patient’s health b. social status c. health insurance coverage d. patient has appointment ANS: A REF: p. 70 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

12. The Centers for Medicare and Medicaid (CMS) allows some patients to stay in the hospital up to 48 hours for monitoring without being admitted. This is called status. a. elective b. observation c. emergency d. urgent ANS: B REF: p. 70 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

13. Which would NOT be found on an admission record? a. admitting diagnosis b. patient name c. nursing progress notes d. attending physician ANS: C REF: p. 73 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

14. The result of a plan of treatment is called the: a. assessment b. outcome c. diagnosis d. health record ANS: B REF: p. 76 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

2

15. “Patient complains of dizziness and shortness of breath” is an example of which of the following components of medical decision making? a. subjective b. objective c. assessment d. plan ANS: A REF: p. 74 | p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

16. “Pupils equal, round, and reactive to light and accommodation” is an example of which of the following components of medical decision making? a. subjective b. objective c. assessment d. plan ANS: B REF: p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

17. “Rule out congestive heart failure versus cerebrovascular accident” is an example of which of the following components of medical decision making? a. subjective b. objective c. assessment d. plan ANS: C REF: p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

18. “Chest x-ray to rule out congestive heart failure” is an example of which of the following components of medical decision making? a. subjective b. objective c. assessment d. plan ANS: D REF: p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

19. In which step of the medical decision-making process can the following statement be found?

“Patient’s blood pressure is 120/75, hypertension ruled out.” a. subjective b. objective c. assessment d. plan ANS: C REF: p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

20. SOAP notes are examples of a. demographic b. socioeconomic c. financial d. clinical

data.

ANS: D REF: p. 74 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

21. If there is one physical location within the hospital for all patient registration activities, the registration function is said to be a. centralized b. uniform c. authenticated d. departmental ANS: A REF: p. 71 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

3

22. What is the name for the personnel who coordinate the patient’s care and activities? a. patient access b. registrar c. case management d. health records services ANS: C REF: p. 71 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

23. Which patient would be most likely to draw the attention of a Centers for Medicare and Medicaid Services auditor? a. a patient who stays the night in the emergency department b. a patient who is admitted, then discharged the next day c. a patient on observation status for 28 hours d. a patient who is treated without first obtaining demographic data ANS: B REF: p. 71 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

24. If a hospital wanted to correspond with a patient after discharge, the appropriate source of the patient’s current address would be the a. discharge summary b. attending physician’s office records c. history and physical d. latest admission record ANS: D REF: p. 73 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

25. Which of the following should be collected during the patient registration process? a. A plan of care, the measures to treat the patient’s condition or disease b. An advance directive, to specify the patient’s wishes for his or her care c. A discharge summary, to recap the patient’s stay d. A history, to document the patient’s previous treatments ANS: B REF: p. 73 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

26. a. b. c. d.

is the term for the physician’s process of eliminating a potential diagnosis.

Plan of care Precertification Rule out Outcome

ANS: C REF: p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

27. The clerk enters code 43, meaning the patient was sent to a Veteran’s Administration hospital, as part of the data element. a. progress note b. SOAP note c. discharge disposition d. outcome and assessment ANS: C REF: p. 76 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

28. Which of the following is an element of an acute care admission record? a. patient’s previous operations b. type of dwelling in which the patient lives c. name of patient’s employer d. patient’s height and weight ANS: C REF: p. 73 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

4

29. Which is NOT one of the typical elements of an inpatient admission record? a. home telephone number b. religion c. primary payer d. vital signs ANS: D REF: p. 73 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

30. The extent and complexity of a history and physical are dictated by: a. Joint Commission guidelines. b. facility policy c. what the provider deems pertinent to the patient’s problem d. managed care guidelines ANS: C REF: p. 80 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

31. Which is NOT a necessary part of a medication record? a. The physician’s signature b. The dosage of the medication c. The name of the nurse who administered the medication d. The date and time of administration ANS: A REF: p. 86 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

32. What is/are the area(s) of focus for the provider performing a problem-focused physical examination? a. All body areas and organ systems. b. The head, neck, chest, and abdomen c. The patient’s general appearance and his or her vital signs d. The body area(s) or organ system(s) affected ANS: D REF: p. 80 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

33. In acute care, how often are physician’s progress notes documented? a. at least hourly b. at least daily c. at least every 48 hours d. at least every 72 hours ANS: B REF: p. 83 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

34. Obstetrical records differ from other types of acute care records because: a. prenatal care data is collected earlier and transferred to the hospital. b. obstetricians are not required by The Joint Commission (TJC) to collect a patient history and physical. c. the newborn is considered an admission. d. childbirth is not considered a disease.

ANS: A REF: p. 87 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

35. All of the following are always required elements of a physician’s order, EXCEPT: a. Date of the order. b. physician’s signature. c. Time of the order. d. reason/rationale for the order.

ANS: D REF: p. 83 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

5

36. Which must the recorder read back to the provider for confirmation? a. order to admit b. telephone order (TO) c. order for Schedule I drugs d. order for discharge ANS: B REF: p. 81 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

37. The best place to look to determine what medications a patient has received is the a. physician’s orders b. physician’s progress notes c. nursing medication administration record d. discharge summary ANS: C REF: p. 86 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

38. According to TJC standards, when must the physician’s operative report be completed? a. prior to the procedure b. during the procedure c. immediately after the procedure d. within 30 days of the patient’s discharge ANS: C REF: p. 87 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

39. Which documentation records the patient’s status during a surgical procedure? a. physician’s order b. operative report c. nursing progress note d. anesthesia report ANS: D REF: p. 87 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

40. Which data element is NOT needed for a physician’s verbal order? a. the nurse’s authentication b. the name of the patient c. the time of the physician’s authentication d. the name of the payer or guarantor ANS: D REF: p. 83 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

41. A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called: a. plan of care. b. protocol. c. utilization review. d. verbal orders.

ANS: B REF: p. 81 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

42. Which department reviews admissions to see if they are appropriate for the patient? a. utilization review (UR) b. risk management (RM) c. health information management (HIM) d. institutional review board (IRB) ANS: A REF: p. 90 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

6

43. The patient was admitted to the hospital in congestive heart failure with the approval of the patient’s insurer. After 3 days, utilization review, in conjunction with the patient’s insurer, informed the physician that there was insufficient documentation in the patient’s record to justify further hospitalization and that no additional charges would be reimbursed. Utilization review’s action in this case is called: a. discharge planning. b. admission denial. c. continued stay denial. d. managed care.

ANS: C REF: p. 90 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

44. A case manager is usually a a. nurse b. physician c. medical assistant d. health information technician ANS: A REF: p. 89 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

45. Utilization review staff work with the physicians to make sure documentation supports the length of an inpatient stay. a. clinical pathway b. working DRG c. chief complaint d. discharge disposition

, which estimates the

ANS: B REF: p. 90 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

46. All of the following are elements of the Uniform Hospital Discharge Data Set (UHDDS), EXCEPT: a. principal diagnosis. b. race. c. marital status. d. disposition.

ANS: C REF: p. 92 OBJ: 4. Examine the elements of the Uniform Hospital Discharge Data Set. MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

47. All of the following are elements of the UHDDS, EXCEPT: a. date of birth. b. gender. c. religion. d. discharge date.

ANS: C REF: p. 92 OBJ: 4. Examine the elements of the Uniform Hospital Discharge Data Set. MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

48. The extracorporeal elimination of waste products from blood is most likely to be performed at a: a. dialysis center. b. laboratory. c. radiology center. d. rehabilitation center.

ANS: A REF: p. 108 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

49. The prioritization of patients presenting for treatment in an emergency department (ED) is determined by: a. patient’s condition upon arrival. b. encounter. c. arrival time. d. appointment time.

ANS: A REF: p. 99 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

7

50. Triage is generally performed by a(n): a. health information management professional. b. registration clerk. c. nurse. d. physician.

ANS: C REF: p. 99 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

51. An example of a stand-alone facility with an average length of stay of over 30 days is a(n) a. ambulatory surgery center (ASC) b. acute care hospital c. long-term care (LTC) facility d. medical mall ANS: C REF: p. 102 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

52. The Minimum Data Set (MDS) is one component of a series of data collections called the Resident Assessment Instrument (RAI), which is used in: a. rehabilitation. b. long-term care (LTC) c. hospice. d. home health.

ANS: B REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

53. The minimum data set used in emergency departments is the a. Uniform Hospital Discharge Data Set (UHDDS) b. Uniform Ambulatory Care Data Set (UACDS) c. Data Elements for Emergency Department Systems (DEEDS) d. Resident Assessment Instrument (RAI) ANS: C REF: p. 99 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

54. All of the following are common ambulatory surgery procedures, EXCEPT: a. carpal tunnel release. b. colectomy. c. colonoscopy. d. cataract removal.

ANS: B REF: p. 101 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

55. The minimum data set used for ambulatory care settings is the a. Uniform Hospital Discharge Data Set (UHDDS) b. Uniform Ambulatory Care Data Set (UACDS) c. Data Elements for Emergency Department Systems (DEEDS) d. Resident Assessment Instrument (RAI) ANS: B REF: p. 102 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

56. The Case Mix Assessment Tool (CMAT) is a tool used by CMS for the prospective payment system in: a. behavioral health. b. rehabilitation. c. long-term care (LTC) d. home health.

ANS: A REF: p. 105 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

8

57. Using technology, images or video of a patient is recorded to be viewed by a specialist later. a. industrial rehabilitation b. synchronous videoconferencing c. store-and-forward d. remote patient monitoring ANS: C REF: p. 111 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

58. Rehabilitation physical therapy occurs under the direction of a: a. phlebotomist. b. physiatrist. c. psychiatrist. d. psychologist.

ANS: B REF: p. 106 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

59. Self-care, driving, and shopping are types of a. activities of daily living (ADLs) b. palliative care c. maximum functions d. hospice ANS: A REF: p. 106 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

60. Which term describes a unit of health care in an ambulatory setting? a. discharge b. treatment c. admission d. encounter ANS: D REF: p. 91 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

61. Which is an ambulatory care service? a. lab work performed on an inpatient b. vaginal delivery of a newborn c. MRI performed at an imaging center d. Group therapy session for residents at a state psychiatric facility ANS: C REF: p. 91 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

62. A patient went to a clinic. He saw a physician, had an x-ray, then got a blood test. This patient can be said to have had visit(s) and encounter(s). a. two; two b. three; one c. one; four d. one; three ANS: D REF: p. 91 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

63. In an open access physician practice, patients do not need: a. a co-pay. b. a referral. c. an appointment. d. insurance.

ANS: C REF: p. 93 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

9

64. Ambulatory care accreditation is offered by The Joint Commission (TJC) and: a. Accreditation Association for Ambulatory Health Care (AAAHC). b. The Centers for Medicare and Medicaid (CMS). c. Community Health Accreditation Program (CHAP). d. National Center for Injury Prevention and Control (NCIPC).

ANS: A REF: p. 97 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

65. The following are types of physician specialties that can be found in a primary care group practice, EXCEPT: a. dermatologist. b. pediatrician. c. gynecologist. d. anesthesiologist.

ANS: D REF: p. 93 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

66. Patients requiring care who are unable to make an appointment with their primary care provider (PCP) should visit the a. emergency department b. urgent care center c. skilled nursing facility d. respite care center ANS: B REF: p. 93 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

67. Which is a data element of the Uniform Ambulatory Care Data Set (UACDS)? a. time of the encounter b. phone number c. triage level d. total charges ANS: D REF: p. 97 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

68. Which is a data element of the Uniform Ambulatory Care Data Set (UACDS)? a. gender identity b. referring professional c. current medications d. disposition ANS: D REF: p. 97 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

69. A patient with no significant medical history other than alcohol dependence was admitted to the detoxification unit of an acute care facility. After 3 days of successful treatment for alcohol withdrawal, what is the likely next phase of treatment? a. Place patient in restraints so they cannot continue to be harmful to themselves. b. Transfer patient to an alcohol rehabilitation facility. c. Transfer patient from the detoxification unit to a medical unit within the same facility. d. Arranging respite care for the patient’s family.

ANS: B REF: p. 104 | p. 105 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

70. Reimbursement for patients in hospice care is typically based on: a. the time and date of the order for hospice care to the time and date of death. b. a 71-day average length of stay c. the 6-month rule as certified by the physician. d. a 24-day median length of stay ANS: C REF: p. 107 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

10

71. What type of facility provides cognitive remediation? a. behavioral health b. dialysis center c. physical therapy d. rehabilitation ANS: D REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

72. The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 to a. prevent hospitals from refusing to treat indigent patients and transferring them to charity care hospitals. b. enable the hospital to apply for reimbursement from CMS for services rendered to indigent patients. c. require hospitals to provide community services during nonpeak, routine daytime hours. d. ensure that indigent patients are not billed for EMTALA authorized services.

ANS: A REF: p. 99 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

73. Which is true of inpatient surgery? a. it costs less than ambulatory surgical services b. services are performed by physician assistants rather than surgeons c. the Centers for Medicare and Medicaid Services require it for certain procedures d. it is becoming more frequently utilized ANS: C REF: p. 101 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

74. Which setting lags behind others in the adoption of the electronic health record? a. behavioral health b. dialysis center c. long-term care d. ambulatory surgery ANS: C REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

75. Which setting utilizes the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)? a. behavioral health b. hospice c. long-term care d. telehealth ANS: A REF: p. 105 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

76. What is the purpose of respite care? a. to offer relief to caregivers of the chronically ill b. to provide comfort measure to those with a terminal illness c. to offer relief to patient s with chronic renal failure d. to return patients to maximum functioning in activities of daily living ANS: A REF: p. 108 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

77. Which technology simplifies home health care documentation? a. the electronic health record (EHR) b. document imaging c. remote patient monitoring (RPM) d. picture archiving and communication system (PACS) ANS: A REF: p. 109 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

11

COMPLETION 1. Data collected for the purpose of patient identification is

data.

ANS: demographic REF: p. 65 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

2. The provider’s evaluation of the patient is the

.

ANS: assessment REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

3. The medical record number (MRN) is part of the

data.

ANS: administrative REF: p. 67 OBJ: 1. Define the health record and understand the types of data it contains.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

4. In urgent situations, a physician’s office may call a facility in advance to order an admission. This is called a(n)

.

ANS: direct admission REF: p. 70 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

5. The attending physician provides a(n)

to explain the reason for admission.

ANS: admitting diagnosis REF: p. 71 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

6. There may be a(n) her health record.

code on the patient’s wristband, readable by machine, which connects the patient to his or

ANS: bar REF: p. 73 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

7. The following statement will be found in the “Patient states dizziness and shortness of breath.”

step of medical decision making.

ANS: subjective REF: p. 74 | p. 75 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

8. During the process, the hospital staff check whether the patient has insurance and whether it will pay for the services requested by the physician.

ANS: precertification REF: p. 71 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

9. During registration, the patient signs an admission form to grant the hospital permission to provide general diagnostic and therapeutic care, as well as to release information to a third-party payer.

ANS: consent REF: p. 73 | p. 74 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

12

10. If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be by the supervisor.

ANS: countersigned REF: p. 83 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

11. In a patient’s history, the reason the patient presented for evaluation and treatment is called the

complaint.

ANS: chief REF: p. 78 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

12. Routine documentation of the nurse’s interaction with a patient is recorded in the

.

ANS: nursing progress notes REF: p. 85 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

13. The physician who is primarily responsible for coordinating the care of the patient in the hospital is the

.

ANS: attending physician REF: p. 70 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

14. When a patient is first seen by a physician in any health care setting, the physician generally records the patient’s chief complaint, pertinent family and social data, and a review of the patient’s body systems. This record is called the (three words) .

ANS: history and physical REF: p. 80 OBJ: 2. Describe the flow of clinical data through an acute care facility.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

15. An infection identified after

hours of hospitalization is called nosocomial or hospital acquired infections (HAI).

ANS: 48 REF: p. 86 OBJ: 5. Assess patient records to ensure compliance with organizational policy and procedures as well as regulatory and accreditation requirements.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

16. In caring for a patient, an attending physician may request a(n) who specializes in the patient’s problem.

from another physician or health care professional

ANS: consultation REF: p. 83 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

17. A

is called when an attending physician would like a specialist to review a patient case.

ANS: consultant REF: p. 83 | p. 84 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

18. The process of evaluating medical interventions against established criteria, based on the patient’s known or tentative diagnosis, is called .

ANS: utilization review REF: p. 90 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

13

19. The coordination of the patient’s care and services, including reimbursement considerations, is characteristic of

.

ANS: case management REF: p. 88 | p. 89 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

20. An operation performed on an outpatient basis is called same-day surgery or

surgery.

ANS: ambulatory REF: p. 91 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

21. Medicare requires a plan of care for patients admitted to hospice within

hours of admission.

ANS: 48 REF: p. 108 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

22. A woman who went to the wholesale club and got a flu shot receives services in the treatment for minor illnesses offered in stores, supermarkets, and pharmacies.

care setting, which offers

ANS: retail REF: p. 108 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

23. The abbreviation for the mandated minimum data set for home health care patients is the

.

ANS: OASIS REF: p. 108 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

24. The , abbreviated RAP, is a large volume of data used to continually develop the patient plan of care in the long-term care setting, in which the patient's condition is regularly reevaluated.

ANS: Resident Assessment Protocol REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

25. The accrediting agency for rehabilitation is known by the abbreviation

.

ANS: CARF REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

26. The accrediting agencies for home health care are The Joint Commission (TJC) and CHAP, which stands for the

.

ANS: Community Health Accreditation Program REF: p. 109 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

14

27. A community health center is a type of that provides primary or secondary care in a specific geographic area. accessible to populations that have challenges with accessing health care.

ANS: clinic REF: p. 93 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

28. In a physician’s office, the receptionist or medical secretary usually collects demographic and

data.

ANS: financial REF: p. 96 | p. 97 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

29. The Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal agency that provides key resources on health issues.

ANS: behavioral REF: p. 105 | p. 106 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

30. The system of prioritizing patients by severity of illness is called

.

ANS: triage REF: p. 99 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

31. A

has knowledge of office procedures, scheduling, and filing, as well as some basic clinical knowledge.

ANS: medical assistant REF: p. 96 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

32. Multiple physicians who share facilities and resources and may also cooperate in rendering patient care are engaged in a(n) practice.

ANS: group REF: p. 91 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

33. The insurance company often makes the patient select a(n) the need for a specialist’s care.

care provider, who delivers routine care and evaluates

ANS: primary REF: p. 96 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

34. The setting in which palliative health care services are rendered to the terminally ill, their families, and their friends is .

ANS: hospice REF: p. 107 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

15

35. The physical location of the specialists who analyze body fluids is the

.

ANS: laboratory REF: p. 67 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

36. Radiology and laboratory tests require a physician

and diagnosis to support the purpose of the test.

ANS: order REF: p. 100 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

37. Health care service that is intended to soothe, comfort, or reduce symptoms but is not intended to cure is called

care.

ANS: palliative REF: p. 107 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

MATCHING Match the following data with their source or recorder. a. test showing a nosocomial infection b. vital signs c. CT scan d. autopsy report e. primary and secondary payer f. physician identification database g. order to admit h. progress of pregnancy 1.

2.

3.

4.

5.

6.

7.

8.

Physician Nursing staff Pathologist Patient registration Medical Staff Office Obstetrician’s office Laboratory Radiology

1. ANS: G REF: p. 70 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

2. ANS: B REF: p. 85 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

3. ANS: D REF: p. 88 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

4. ANS: E REF: p. 93 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

5. ANS: F REF: p. 68 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

6. ANS: H REF: p. 87 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

7. ANS: A REF: p. 86 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

8. ANS: C REF: p. 86 OBJ: 3. Differentiate the various providers and disciplines who contribute to clinical documentation.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

16

Match the clinical personnel with their responsibility. a. advance practice registered nurse (APRN) b. medical assistant c. medical secretary d. phlebotomist e. registered nurse 9.

10.

11.

12.

13.

Administers injections, performs wound care and patient education Answers telephone and records appointments Specializes in venipuncture for diagnostic testing May deliver primary care in the retail clinic Takes vital signs, changes dressings

9. ANS: E REF: p. 110 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

10. ANS: C REF: p. 96 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

11. ANS: D REF: p. 100 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

12. ANS: A REF: p. 75 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

13. ANS: B REF: p. 96 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

Match the health care setting with the corresponding patient. a. dialysis center b. long-term care (LTC) facility c. behavioral health center d. hospice e. rehabilitation facility f. skilled nursing facility (SNF) g. ambulatory surgery center (ASC) h. physician’s office i. urgent care center j. emergency department 14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

Patient who suffered from a stroke 3 days ago requires 24-hour nursing assistance, speech therapy, and physical therapy Patient visits three times a week for therapy to treat end-stage renal disease Patient was diagnosed with terminal disease that requires palliative care Patient is recovering from hip replacement therapy Patient was admitted after attempting suicide related to severe depression Patient visits the PCP for a well-baby checkup Patient visited a surgery center for a bunionectomy and returned home the same day Patient needs 24-hour nursing care and monitoring for more than 30 days Patient needs to visit his or her PCP, but no appointments are available, so the patient visits this center Patient presents with a gunshot wound to the arm

14. ANS: F REF: p. 103 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

15. ANS: A REF: p. 108 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

16. ANS: D REF: p. 107 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

17. ANS: E REF: p. 76 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

18. ANS: C REF: p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

17

19. ANS: H REF: p. 89 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

20. ANS: G REF: p. 101 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

21. ANS: B REF: p. 103 | p. 104 OBJ: 7. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of long-term care (LTC), behavioral health, rehabilitation, hospice care, home health, and other settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

22. ANS: I REF: p. 93 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

23. ANS: J REF: p. 99 OBJ: 6. Discuss the services, care providers, data collection, data sets, licensure, and accreditation of ambulatory care settings.

MSC: CAHIIM, I.1. Describe health care organizations from the perspective of key stakeholders.

18

Chapter 4: Data Quality and Management Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. The process of documentation into an electronic record is called: a. data entry. b. postdischarge processing. c. abstracting. d. collection.

ANS: A REF: p. 117 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

2. Access to a patient’s health record is tracked using a(n) a. audit trail b. exception file c. concurrent analysis d. error report ANS: A REF: p. 119 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

3. The data quality characteristic associated with the capture of data concurrently with its observation is: a. completeness. b. reliability. c. timeliness. d. validity.

ANS: C REF: p. 120 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

4. The data quality characteristic associated with the collection of data in its entirety is: a. completeness. b. reliability. c. timeliness. d. validity.

ANS: A REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

5. A pharmacy collects information on new customers, including whether the customer owns or rents a home. The pharmacy does not require this data and never uses it to make decisions. Based on data quality characteristics, this data: a. should be collected, because it is accurate b. should not be collected because it is not relevant c. should be collected, because it contributes to completeness d. should not be collected because it is not consistent ANS: B REF: p. 122 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

6. Which reflects data timeliness? a. Laboratory results are waiting to be scanned into the patient’s record at nursing station 3. b. Laboratory results were entered into the patient’s electronic health record a few hours after they arrived. c. Dr. Johnson had to call the medical clinic out of state to get the patient’s previous laboratory results. d. A laboratory report was just scanned into the record of a patient who was discharged 42 days ago.

ANS: B REF: p. 120 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

7. Ensuring that data is collected the same way each time it is collected is a. data precision. b. data consistency. c. data currency. d. data timeliness.

ANS: B REF: p. 120 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

1

8. The nurse took the patient’s temperature and found it to be 97.6°F. She entered “96.7°F” in the record. This entry fails the data quality characteristic of: a. timeliness. b. accuracy. c. validity. d. completeness.

ANS: B REF: p. 118 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

9. The nurse took the patient’s temperature and found it to be 97.6°F. She entered “197.6°F” in the computer. The computer program displayed an error message. What was the computer program checking? a. timeliness b. accuracy c. validity d. completeness ANS: C REF: p. 118 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

10. The medical assistant logs into the health record, but she cannot update the patient’s tobacco use because she is not assigned the proper user role. Which data quality characteristic is lacking? a. accessibility b. precision c. granularity d. relevancy ANS: A REF: p. 119 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

11. The medical assistant wrote that the patient had “pain in the arm,” which left the provider wondering whether it was the left arm or right arm, as well as where on the arm the patient felt pain. The problem with the medical assistant’s note is that it lacks a. accessibility b. precision c. granularity d. relevancy ANS: B REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

12. A certain medication dosage is determined by the patient’s weight, but it has been two months since the last time the patient was weighed at the office. The provider will not use the old data because it is not a. accessible b. relevant c. granular d. current ANS: D REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

13. The HIM professional offers a data dictionary to all the collectors and users of the database, so that everyone knows what a given field represents and how to collect and record those data. The data quality characteristic being illustrated is data a. relevancy b. definition c. granularity d. currency ANS: B REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

14. Which is a detective control? a. A nurse alerts a provider that a patient is allergic to an ordered medication. b. The nursing supervisor reviews a record to ensure that medication administration notes were properly entered. c. The health information management (HIM) department sends a physician a list of the incomplete records. d. A coder reviews a record in order to assign a clinical code.

ANS: B REF: p. 123 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

2

15. Which is a corrective control? a. A nurse alerts a provider that a patient is allergic to an ordered medication. b. The nursing supervisor reviews a record to ensure that medications were administered on a timely basis. c. The HIM department sends a physician a list of the physician’s incomplete records. d. A coder reviews a record in order to assign a clinical code.

ANS: C REF: p. 123 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

16. When recording the patient’s use of oxygen, the nurse can only select from a list of four choices. Which type of control is this? a. detective b. corrective c. ancillary d. preventive ANS: D REF: p. 122 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

17. While the patients are sleeping, nurses on the night shift review the charts of current inpatients to make sure certain elements are properly recorded. This is a internal control. a. preventive b. retrospective c. corrective d. detective ANS: D REF: p. 123 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

18. Which is a preventive control? a. The CPOE alerts the provider about a contraindication for a medication she is ordering. b. The nursing supervisor reviews charts to ensure that progress notes are being recorded. c. The deficiency system sends email reminders to physicians about incomplete records. d. A coder uses an encoder to assign a procedure code.

ANS: A REF: p. 122 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

19. Which statement about making corrections in the health record is true? a. the original note should be legible b. the original note should be completed obscured c. the Joint Commission should be notified d. new entries should be typed or written in red ANS: A REF: p. 124 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

20. Which control cannot be used retrospectively? a. corrective b. detective c. preventive d. root cause analysis (RCA) ANS: C REF: p. 123 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

21. A list of deficient or other problem data, usually generated by a computer, is called an error report or a. deficiency b. batch control c. exception d. root cause analysis (RCA)

report.

ANS: C REF: p. 123 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

3

22. A patient with a seafood allergy had a reaction to the contrast dye used during her x-ray hysterosalpingography (HSG). The facility began a to determine how the error happened. a. detective control b. nonrepudiation analysis c. exception report d. root cause analysis (RCA) ANS: D REF: p. 124 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

23. Which is a function of information governance? a. monitoring data quality and integrity within the EHR b. ensuring accurate data collection by patient access staff c. regular meetings of the forms committee d. making policy for how data will be used in a health information exchange (HIE) ANS: D REF: p. 125 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

24. Data governance is concerned with: a. policies for collecting data at the point of care. b. release of information policy. c. monitoring staff credentials. d. how the facility’s systems interface with pharmacies ANS: A REF: p. 125 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

25. The patient account number and medical record number a. are listed on the discharge register. b. change with each visit or encounter. c. are two names for the same data element. d. are assigned by the medical coder.

ANS: A REF: p. 127 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

26. The HIM department can verify which patient records are available for processing by referring to the a. admission register b. audit trail c. discharge register d. exception report ANS: C REF: p. 127 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

27. Housekeeping is notified to clean the room a. once a new patient is ready to be admitted. b. after a patient is discharged. c. after the discharge register is created. d. after the midnight census.

ANS: B REF: p. 125 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

28. The set of procedures by which paper portions of the record are ordered for scanning or further processing is a. assembly b. quantitative analysis c. point-of-care documentation d. abstracting ANS: A REF: p. 128 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

4

29. Using record by bar code. a. batch scanning b. abstracting c. encryption d. indexing

, many paper documents are digitized at once, after which software sorts the documents into the correct

ANS: A REF: p. 128 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

30. What is another term that refers to the period postdischarge? a. concurrent b. nonrepudiation c. quantitative d. retrospective ANS: D REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

31. Documents entered into the health record as images must be a. scanned b. indexed c. rekeyed d. abstracted

for identification and future retrieval.

ANS: B REF: p. 128 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

32. Which patient would be found on a discharge register for May 1st? a. A patient who was admitted to the hospital on May 1st and discharged on May 2nd b. A patient who was admitted to the hospital on May 1st and died on May 2nd c. A patient who was admitted to the hospital on April 30 and discharged on May 1st d. A patient who was dead on arrival on May 1st ANS: C REF: p. 126 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

33. Quantitative analysis is usually performed by a(n) a. case manager b. site surveyor c. HIM professional d. medical assistant ANS: C REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

34. Each element of the record must be properly dated, timed, and in accordance with the rules and regulations of state or accrediting agencies that apply to the facility, with the authors clearly identified. a. authenticated b. completed c. transcribed d. corrected ANS: A REF: p. 133 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

35. Which is NOT identified during quantitative analysis? a. missing signature on a physician progress note. b. discharge report has not been dictated. c. requested cardiology consultation was not performed. d. history and physical (H&P) was dictated and transcribed on the third day of the admission.

ANS: C REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

5

36. The assignment of physicians to cases—attending, consultants, and surgeons—is called a. authentication b. assembly c. attribution d. completion

.

ANS: C REF: p. 130 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

37. The Joint Commission (TJC) considers incomplete acute care records delinquent a. 15 days after discharge. b. 5 days after discharge. c. 30 days after discharge. d. 150 days after discharge.

ANS: C REF: p. 131 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

38. When a patient is being admitted for a health-related issue, the physician must state the patient’s a. symptoms b. procedures c. chief complaint d. diagnosis

.

ANS: D REF: p. 133 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

39. A patient’s record was not completed as of the 26th day after the patient’s discharge from the hospital. This record is considered: a. deficient. b. delinquent. c. in process. d. invalid.

ANS: A REF: p. 130 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

40. Community Hospital, an acute care facility, is preparing for TJC survey. The Chief Operating Officer is reviewing the following data from the HIM department: Month January 1,000 February March 1 April 1

# of Discharges 1,000 1,200 100 100

# of Delinquent Records 450 600 500 600

Using the information above, at the end of April, is Community Hospital in compliance with TJC rules regarding the number of delinquent records permitted? a. Yes. b. No. c. Not enough information is given to answer the question. d. The question is moot, since TJC does not permit delinquent records.

ANS: B REF: p. 131 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

41. Acute care facilities are permitted to have delinquent records, but the number of delinquent records must not exceed: a. 2% of the average monthly discharges. b. 50 records. c. 50% of the average monthly discharges. d. 9 records.

ANS: C REF: p. 131 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

6

42.

specialists assist physicians in achieving the best possible documentation of their medical decision-making process. a. Clinical documentation improvement (CDI) b. The Joint Commission (TJC) c. Patient Navigation d. Revenue Cycle ANS: A REF: p. 133 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

43. Why is concurrent coding beneficial? 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 estimate the length of the patient’s hospital stay.

ANS: D REF: p. 133 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

44. Which describes computer-assisted coding (CAC)? a. The software analyzes documents and assigns codes b. The software reads codes and creates health records c. The software analyzes symptoms and assigns codes d. The coder uses software to look up codes ANS: A REF: p. 134 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

45. At registration, the patient access clerk searches the at the facility on a previous occasion. a. abstract database b. batch control form c. discharge register d. master patient index (MPI)

history files to determine whether the patient has been treated

ANS: D REF: p. 134 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

46. Why do HIM professionals look for duplicate medical record numbers of the same patient and merge them? a. to facilitate continuity of care in a single record b. to save space in the file room, on the server, or in the cloud c. to reuse old medical record numbers d. to prevent staff from creating new patients in the master patient index ANS: A REF: p. 135 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

47. A summary of the patient’s record is created during the a. abstracting b. indexing c. coding d. record completion

step of postdischarge processing.

ANS: A REF: p. 135 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

48. Patient records are sometimes abstracted for a. data sets b. registries c. indices d. vital statistics

, collections of data specific to a disease, diagnosis, or procedure.

ANS: B REF: p. 137 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

7

49. The processing status of records is listed on the a. deficiency sheet b. batch control form c. exception report d. workflow ANS: B REF: p. 137 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

50. Which is a hallmark of efficient paper record processing? a. records are moved as little as possible b. steps are completed at the same time (concurrently) whenever possible c. the record is coded before it is scanned d. photocopies of the record are kept in the master file ANS: A REF: p. 138 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

51. When speech recognition software is used for transcription: a. the author can view the transcription concurrently b. no digital signature is necessary c. properly formatted reports are not an issue d. physicians are discouraged from typing or writing by hand ANS: A REF: p. 139 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

52. In the electronic environment, workflow describes how the electronic record moves from one a. queue b. batch c. file d. database

to another.

ANS: A REF: p. 139 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

53. The release of information function is part of the a. storage b. security c. access d. governance

component of record retention.

ANS: C REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

54. When an individual enters a user identification and password into the EHR system, the content shown is a. limited by security clearance b. limited by facility privileges c. limited by user role d. unlimited ANS: C REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

55. Under the Health Insurance Portability and Accountability Act (HIPAA), which is a business associate? a. provider b. transcription service c. health insurer d. patient ANS: B REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

8

56. Sam, the HIM Director at Providence Hospital, suspects that some of his employees have been viewing patient records that they do not need to access for their work. What should Sam do? a. Change all employee passwords. b. Review an audit trail. c. Contact the Office for Civil Rights (OCR). d. Change their user roles in the system.

ANS: B REF: p. 119 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

57. Which part of the Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to perform a risk assessment and establish administrative, technical, and physical safeguards? a. The Privacy Rule b. The Security Rule c. The Protected Health Information (PHI) Rule d. The Integrity Rule ANS: B REF: p. 141 | p. 142 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

58. Which statement about protected health information (PHI) is true? a. it may only be seen by the patient b. health care professionals may view it at any time c. it may only be disclosed when the patient consents, with no exceptions d. health care professionals may only access it on a need-to-know basis ANS: D REF: p. 142 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

59. Which is an example of protected health information (PHI)? a. A list of patient names on a sign-in sheet at a clinic b. A chart showing the number of discharges for the year c. A printout of patients who have had Cesarean sections. d. A pamphlet on Type 2 diabetes.

ANS: C REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

60. The medical assistant is curious why her brother-in-law, who is the patient of a provider at a different branch of the health care organization, has so many doctor’s appointments. Is it legal for her to look at his health record? Why or why not? a. No, because she has no clinical or administrative reason to do so. b. No, because MAs cannot access health records. c. Yes, because the MA is a family member. d. Yes, because the MA is an employee of the same health care organization.

ANS: A REF: p. 142 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

61. Melissa had back surgery six months ago, and is still having some pain. Which situation would require her to sign a release of information (ROI) form? a. to authorize the payer to reimburse the provider b. to consent to another surgical procedure c. to obtain a copy of her operative report d. to allow the surgeon to view her operative report ANS: C REF: p. 142 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

62. Overseas hackers gained access to the hospital’s EHR and threatened to make health records public unless they received a large sum of money. When the crisis is over and the hospital regains control, what is the problem with the health records? a. their integrity is in question b. they may not be encrypted c. they are no longer interoperable d. they may have viruses or malware ANS: A REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

9

63. Which scenario is a breach? a. Nurses discussing Mrs. Logan’s patient care during morning report b. An HIM employee discussing his migraines with his neighbor c. A hospital employee reviewing the record of a celebrity currently admitted to the facility d. An administrator who left sales figures on the train ANS: C REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

64. The new nursing supervisor is discussing her plans for the unit with you. She wants to hang a board on the wall of the nursing unit listing each patient’s name, room number, working diagnosis, and medication schedule. You advise her that: a. this is a violation of physician privileges b. this is a violation of record integrity c. the display of patient-identifiable information in a public place is a violation of the Security Rule d. the display of patient-identifiable information in a public place is a violation of the Privacy Rule ANS: D REF: p. 141 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

65. Which is a technical safeguard? a. automatic logoffs b. sharing of passwords among health care providers c. a locked filing cabinet d. the appointment of a security officer ANS: A REF: p. 142 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

66. Which statement is true about the use of the Internet in the health care setting? a. the Health Insurance Portability and Accountability Act (HIPAA) makes it illegal for anyone in the facility to use the Internet. b. Per Freedom of Information Act rules, employers may not forbid employees from accessing the Internet. c. Employees may only use the Intranet or the facility-wide Wifi. d. The facility does not need policies describing appropriate use of the Internet.

ANS: C REF: p. 143 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

67. Which statement is true about the use of the patient’s health record in a legal dispute? a. the health record cannot be used in a court of law b. the health record is in the public domain and may be accessed freely c. the health record may be used to defend the provider’s actions d. the health record is only used for legal matters when the patient is injured ANS: C REF: p. 130 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

68. Which is an external use of health information? a. develop community awareness of health care issues b. demonstrate compliance with regulations and accreditation c. support reimbursement d. develop facility resource utilization statistics ANS: A REF: p. 144 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

69. Which is an internal use of health information? a. to develop new treatment protocols b. to influence national policy on health care issues through legislation. c. to support and collect reimbursement. d. to supply vital statistics to public health agencies.

ANS: C REF: p. 144 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

10

70. Which patient has low health literacy? a. the patient who avoids going to the doctor b. the patient who does not understand discharge instructions c. the patient who cannot afford to pay d. the patient who is addicted to painkillers ANS: B REF: p. 144 | p. 145 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

71. Which patient is health literate? a. the patient who understands medical terms b. the patient who understands the risks and benefits of a treatment c. the patient who correctly diagnoses himself using information from the Internet d. the patient who reads American Sign Language (ASL) ANS: B REF: p. 144 | p. 145 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

72. Which is an example of health information being used by facility administration? a. providing disease statistics to a state agency b. using outcomes data to develop a new treatment c. counting diagnoses to evaluate the need for new services d. faculty teaching students about a disease process ANS: C REF: p. 145 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

73. A facility may use health information for a. managed care b. marketing c. research d. administration

, the promotion of its services, to patients who have opted in.

ANS: B REF: p. 147 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

74. Healthy People is a a. local b. regional c. state d. national

program that compiles data on indicators of health.

ANS: D REF: p. 146 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

COMPLETION 1. The level of detail with which data is collected is known as data

.

ANS: granularity REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

2. Monitoring functions for compliance within set standards is called quality noncompliance, and follow-up on the correction.

, which also requires action to correct

ANS: assurance REF: p. 128 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

3. The quality of data being correct is called data

.

ANS: accuracy REF: p. 118 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

11

4. The quality characteristic that data reflect the known or acceptable range of values for the specific data is called data

.

ANS: validity REF: p. 118 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

5. If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be by the supervisor.

ANS: countersigned REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

6. In order to

a document or other data collection device, a physician may sign the document or enter a password.

ANS: authenticate REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

7. A quantitative analysis is a

control designed to identify incomplete data in a record.

ANS: detective REF: p. 129 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

8. During assembly, paper components are typically document management system (EDMS).

into the computer system through the use of an electronic

ANS: scanned REF: p. 127 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

9. Another word for an incomplete system is a(n)

system.

ANS: deficiency REF: p. 130 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

10. Assignment of ICD-10-CM codes to clinical data while the patient is still being treated is

coding.

ANS: concurrent REF: p. 133 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

11.

procedures govern the storage of records, including duration, location, security, and access.

ANS: Retention REF: p. 140 OBJ: 3. Discuss organizational policies to safeguard patient records.

MSC: CAHIIM, II.2. Apply security strategies to health information.

12. The data quality characteristic of data being present or existing in its entirety is

.

ANS: completeness REF: p. 121 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

12

13. The term

means that a person can be identified by their signature.

ANS: nonrepudiation REF: p. 129 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, I.4. Determine compliance of health record content within the health organization.

14.

analysis is the process of determining the cause of an error.

ANS: Root cause REF: p. 124 OBJ: 1. Apply policies and procedures to ensure the accuracy and integrity of health data.

MSC: CAHIIM, I.2. Apply policies, regulations, and standards to the management of information.

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

ANS: coding REF: p. 132 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

16. Before creating a new patient health record, registrars always check the has been a patient at the facility before.

patient index to see if an individual

ANS: master REF: p. 134 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

17. The process of

identifies or names a part of the record so that it can be located in the computer-based health record.

ANS: indexing REF: p. 127 OBJ: 2. Explain the flow of postdischarge processing of health information and how those activities support a complete health record according to organizational policies, external regulations, and standards.

MSC: CAHIIM, III.2. Utilize technologies for health information management.

18. Each month the tumor registry personnel are required to report the of new cases of breast cancer.

of breast cancer for the facility, or the number

ANS: incidence REF: p. 145 | p. 146 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

19. Health information may be used in

to support the plaintiff’s claim.

ANS: litigation REF: p. 146 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

20. The

rate refers to how often disease occurs within a population.

ANS: morbidity REF: p. 146 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

21. The number of existing cancer cases reported by the tumor registry is known as

.

ANS: prevalence REF: p. 145 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

13

22. In health care, documentation from previous patient care allows physicians and scientists to improve, develop, or change patient care and technology.

, gaining knowledge to

ANS: research REF: p. 147 OBJ: 4. List the uses of health information.

MSC: CAHIIM, VI.8. Describe consumer engagement activities.

14

Chapter 5: Coded Data Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. Which organization is NOT one of the four Cooperating Parties for the ICD-10-CM? a. American Medical Association (AMA) b. Centers for Medicare and Medicaid Services (CMS) c. National Center for Health Statistics (NCHS) d. The Joint Commission (TJC) ANS: A REF: p. 158 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

2. Which is NOT a common use of coded data? a. Reimbursement b. Compliance c. Scheduling d. Research ANS: C REF: p. 175 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

3. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the: a. reporting of diagnosis data to the National Center for Health Statistics (NCHS). b. adoption and use of ICD-10-CM. c. use of the EHR with point-of-care data capture. d. use of certain codes in electronic transmissions.

ANS: D REF: p. 153 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

4. Why is electronic data interchange (EDI) beneficial? a. computers can exchange information without human intervention b. information can only be “read” by the recipient c. messages contain unique identifiers that cannot be duplicated d. it works across reimbursement and clinical platforms ANS: A REF: p. 154 | p. 155 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

5. What is Accredited Standards Committee (ASC) X12 Version 5010? a. The code set used in inpatient settings for diagnoses b. the electronic data interchange (EDI) standard used for electronic versions of the Uniform Bill c. the name of the latest standard for transactions and code sets d. the form used to assign procedure codes in ambulatory care ANS: B REF: p. 154 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

6. Current Procedure Terminology (CPT) is a a. code set b. electronic data interchange (EDI) c. computer language d. reference manual ANS: A REF: p. 160 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

7. Because the patient record is a highly personal document, and therefore must be treated respectfully with regard to the coded data assigned, AHIMA has issued which of the following guidelines? a. HIPAA Official Guidelines for Coding and Reporting b. Standards of Ethical Coding c. Standards for transactions and code sets d. Federal Register ANS: B REF: p. 154 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

1

8. Current code sets under the Health Insurance Portability and Accountability Act (HIPAA) include all of the following, EXCEPT: a. SNOMED CT. b. National Drug Codes. c. HCPCS and CPT-4. d. ICD-10-CM and ICD-CM-PCS. ANS: A REF: p. 153 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

9. A health care organization numbers its site locations not by geographic area or function, but by the order in which the sites were opened. For example, the head office is 001, the primary care physician group practice is 002, the urgent care office on the east side of town is 003, the imaging center is 004, and the urgent care office on the west side of town is 005. What type of coding system is this? a. map b. nomenclature c. classification d. taxonomy ANS: B REF: p. 154 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

10. A list of preferred terms and their meanings is a a. clinical vocabulary b. nomenclature c. data dictionary d. taxonomy ANS: A REF: p. 155 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

11. Tracking codes to determine the volume of cases seen at the facility is a a. outcomes measurement b. research c. reimbursement d. resource utilization

use of coded data.

ANS: D REF: p. 154 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

12. The way a code set is organized is its a. clinical vocabulary b. nomenclature c. data dictionary d. taxonomy ANS: D REF: p. 156 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

13. A standard in which data are able to be transmitted, communicated, and understood by the sending and receiving computer systems, allowing the exchange of information, is also called a(n) a. electronic data interchange (EDI). b. transaction code set. c. standard for code sets. d. taxonomy.

ANS: A REF: p. 153 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

14. O32.1XX2 is an example of a code from which code set? a. ICD-9-CM b. National drug codes (NDC) c. ICD-10-CM d. Current procedural terminology (CPT) ANS: C REF: p. 157 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

2

15. 0D5N4ZZ Destruction of Sigmoid Colon, Perc Endo Approach, is an example of a code from which code set? a. ICD-9-PCS b. ICD-10-PCS c. SNOMED CT d. DSM-IV ANS: B REF: p. 159 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

16. The second character of the code 0DJ86ZZ indicates which of the following? a. Root Operation b. Device c. Body System d. Approach ANS: C REF: p. 160 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

17. The 5th character of the code 0DJ76ZZ indicates which of the following? a. Location b. Device c. Body System d. Approach ANS: D REF: p. 160 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

18. An example of a CPT-4 (Health Care Common Procedure Coding System [HCPCS] Level 1) code is: a. C1715 b. 0DJD8ZZ c. 4557003 d. 43251 ANS: D REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

19. An example of an HCPCS Level 2 code is: a. C1715 b. 0DJD8ZZ c. 4557003 d. 43251 ANS: A REF: p. 161 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

20. The first three characters of an ICD-10-CM code represent the code: a. etiology. b. severity. c. category. d. anatomic site.

ANS: C REF: p. 157 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

21. When are ICD-10-CM coding changes issued? a. January of each year b. April of each year c. October of each year d. April and October of each year ANS: D REF: p. 158 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

3

22. CPT-4 code changes become effective a. January b. April c. October d. April and October

of each year.

ANS: A REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

23. What coding classification or nomenclature system is used to code professional and technical services by physicians and other health care professionals for services performed in outpatient settings? a. ICD-O b. CPT-4 c. ICD-10-CM d. SNOMED CT ANS: B REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

24. HCPCS is composed of Level I and Level II codes; the differences between the two levels are: a. Level I codes are used to report outpatient procedures and services, whereas Level II codes are used to report products, supplies, and services not included in Level I. b. Level I codes are maintained by the AMA, whereas Level II codes are developed by hospitals as part of their chargemaster. c. Level I codes are submitted separately from Level II codes for reimbursement. d. Insurance companies need Level II codes to process claims; insurers do not process Level I codes.

ANS: A REF: p. 160 | p. 161 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

25. The NDC code for one 28-tablet bottle of the chronic hepatitis medication Harvoni, made by Gilead Sciences, is 61958-1801-1.

The number “61958” is the a. labeler code b. product code c. packaging code d. batch code ANS: A REF: p. 165 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

26. Which code set is alphanumeric? a. ICD-10-PCS b. NDC c. CPT-4, Category 1 d. SNOMED CT ANS: A REF: p. 159 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

27. SNOMED CT is a(n) a. multiaxial b. classification c. nomenclature d. alphanumeric

system.

ANS: C REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

28. All of the following are examples of multiaxial classification systems, EXCEPT: a. SNOMED CT. b. ICD-10-PCS. c. ICD-O. d. ICD-10-CM. ANS: A REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

4

29. An example of a CDT code is: a. C1715. b. D5410. c. I20. d. 43251.

ANS: B REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

30. Which organization does NOT develop, report, or maintain a classification and/or code set for health care purposes? a. The Joint Commission. b. the AMA. c. the American Psychiatric Association (APA). d. the International Health Terminology Standards Development Organization (IHTSDO).

ANS: A REF: p. 160 | p. 161 | p. 162 | p. 163 | p. 164 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

31. Which statement about SNOMED CT is false? a. it can assign codes from free text b. it makes systems interoperable across countries and languages c. there is a one-to-one translation between SNOMED CT and ICD-10-CM d. it has the potential to be useful during patient care, rather than after ANS: C REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

32. Which classification system is used to track neoplasms? a. SNOMED CT b. ICD-10-CM c. ICD-O d. CDT ANS: C REF: p. 163 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

33. The axis of an ICD-O-3 code indicates the site of a neoplasm in the body. a. morphology b. oncology c. topography d. pathology ANS: C REF: p. 163 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

34. In an ICD-O-3 code, which part is the behavior code, indicating whether a tumor is malignant, benign, in situ, or uncertain? a. the first four digits of the morphology axis b. after the slash on the morphology axis c. the letter character on the topographical axis d. the numerical characters on the topographical axis ANS: B REF: p. 163 | p. 164 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

35. Which is a requirement for a valid ICD-10-CM code? a. has seven characters b. begins with a letter character. c. ends with a letter d. has a dot ANS: B REF: p. 163 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

5

36. A character value of X in the Qualifier position of certain ICD-10-PCS codes indicates a(n): a. placeholder for the 7th character. b. biopsy. c. external approach. d. device left in the body.

ANS: B REF: p. 159 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

37. In the third character of an ICD-10-PCS code, the main difference between the definitions of the Root Operations excision and resection is: a. excision involves cutting out of or off, without replacement, all of a body part, while in a resection the body part is replaced. b. excision involves cutting out of or off, with replacement, all of a body part; while in a resection all of a body part is cut off but no replaced. c. excision involves cutting out of or off a portion of a body part; a resection involves cutting all of a body part out of or off. d. excision involves cutting out of or off a portion of a body part, while a resection involves cutting out of or off all of a body part.

ANS: C REF: p. 160 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

38. Using the figure, which is the ICD-10-PCS code for an endoscopic colonoscopy?

a. b. c. d.

ODJD8ZZ ODJD7ZZ ODJ68ZZ ODJ67ZZ

ANS: A REF: p. 159 OBJ: 3. Apply diagnosis/procedure codes according to current guidelines.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

39. The auditor was reviewing the hospital bills and noticed that for several cases billed to a commercial payer the DRG assignment, based on the MS-DRG description of the DRG code, did not match the diagnosis/procedure codes. One possible reason for this is: a. the coder made an error assigning the DRG. b. the grouper isn’t working properly. c. that payer uses a different DRG than Medicare. d. the MS-DRG description is incorrect.

ANS: C REF: p. 167 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

40. What is the lowest level of medical complexity represented by CPT E/M codes? a. straightforward b. problem-focused c. low complexity d. detailed ANS: A REF: p. 161 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

6

41. Why might a coding manager automatically review and/or revise patients assigned to DRG 469 (MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC) or DRG 470 (MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC)? a. The hospital might not be entitled to the reimbursement for these DRGs. b. The federal government always reviews these DRGs for fraud and abuse. c. There is something incorrect with the codes assigned and/or data when a patient is grouped into either of these DRGs. d. These DRGs are on the OIG workplan this year.

ANS: D REF: p. 175 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

42. Major Diagnostic Categories (MDCs) usually consist of which two main sections? a. principal diagnosis and principal procedure b. with or without secondary diagnosis “CC” codes c. medical partitioning and surgical partitioning d. with or without organ transplant ANS: C REF: p. 169 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

43. What patient attributes are important to grouper assignment? a. Age and gender b. Age and length of stay c. Length of stay and gender d. Age, gender and discharge status ANS: D REF: p. 167 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

44. It is the coder’s responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must: a. follow all software prompts that will add a “cc” code. The software program is written so that the coder does not have to review the medical record. b. use coding software to sequence the best principal diagnosis for the highest reimbursement. c. code and sequence according to the documentation in the medical record, using the software to optimize the coding. d. adjust the principle diagnosis as needed to achieve the right DRG for the patient’s needs.

ANS: C REF: p. 173 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

45. Patients are “grouped” into the same DRG because they have all of the following criteria in common, EXCEPT similar: a. diagnosis. b. resource intensity. c. treatment. d. length of stay.

ANS: D REF: p. 169 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

46. What software checks ICD-10 codes for age conflicts, such as a newborn jaundice code assigned to a middle-aged man? a. the Medicare Code Editor (MCE) b. the grouper c. the encoder d. the I-MAGIC algorithm ANS: A REF: p. 169 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

7

47. Where does the grouper search for a comorbidity or complication (CC) or major comorbidity or complication (MCC)? a. principal diagnosis codes b. secondary diagnosis codes c. E/M codes d. SNOMED CT codes ANS: B REF: p. 170 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

48. Why does the presence of a hospital-acquired condition (HAC) result in lower reimbursement? a. it is relatively easy to treat b. it is usually owing to a poor lifestyle choice by the patient c. it is considered by Medicare to be preventable d. it occurs mostly in areas with a lower cost of living ANS: C REF: p. 174 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

49. What trend in the case mix might trigger a CMS audit? a. an unusually high number of complex cases for a period of time b. a large number of maternity and newborn cases c. a decrease in MS-DRG complexity d. fewer trauma patients ANS: A REF: p. 175 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

50. A coder or group of coders is said to demonstrate cases. a. reliability b. validity c. volume d. compliance

when codes are consistently assigned for similar or identical

ANS: A REF: p. 176 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

51.

occurs when the coding results in the MS-DRG that most accurately represents the facility's utilization of resources, on the basis of the diagnoses and procedures, and is completely substantiated by documentation. a. Maximization b. Validity c. Optimization d. Compliance ANS: C REF: p. 177 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

52. Which is the best way for HIM department managers to determine if charts are being coded at the proper volume? a. monitoring volume data from coders in the facility over time b. assuming the coder’s role for a day and counting completed charts c. comparing the volume data in a facility with the same number of beds d. comparing the volume data in a facility with the same EHR system ANS: B REF: p. 177 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

53. How does computer-assisted coding (CAC) work? a. the software scans specific free text and discrete data in the record and assigns codes b. the coder looks up codes in a database c. the provider selects codes from a drop-down menu d. the software creates a diagnosis from vital signs, orders, and physician notes ANS: A REF: p. 177 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

8

54. Who audits the coding of Medicare patient records? a. The Joint Commission b. Quality Improvement Organizations (QIOs) c. the state Board of Health d. the state attorney general ANS: B REF: p. 178 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

55. Why are coding audits performed by payers insufficient for determining coding accuracy? a. the payer only checks records for the patients they have reimbursed b. the payer only performs targeted reviews on “problem” DRGs c. payers will only audit when there is a change in case mix d. payers are ultimately more interested in volume rather than accuracy ANS: A REF: p. 178 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

56. An example of fraudulent and unethical coding is: a. re-reviewing documentation after initial coding to search for a CC code or MCC code. b. performing concurrent coding and questioning the physician about documentation prior to patient discharge. c. assigning codes to the highest degree of specificity documented in the medical record. d. following software prompts to add CC codes or MCC codes to obtain maximum reimbursement without ensuring corresponding, supporting documentation.

ANS: D REF: p. 173 OBJ: 6. Identify discrepancies between supporting documentation and coded data.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

57. You are an auditor reviewing a spreadsheet that shows all of the records for the year in which the patient was on a mechanical ventilator. You are reviewing these records because, in every case, the coder has assigned a procedure code indicating that the patient was on mechanical ventilation for over 96 hours. When queried, the coder remarked that the hospital gets a higher reimbursement for that code than for a lower number of hours. You should: a. accept the coder’s explanation, because it is up to the coder to decide what codes to assign to a case. b. discuss the finding with the Health Information Management Director as a potential abuse or fraud issue. c. change some of the procedure codes so at least some of them are under 96 hours. d. ask the coder to re-review all of the records.

ANS: B REF: p. 173 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

58. The clinical documentation improvement specialist works to improve the specificity of patient documentation: a. before the patient is admitted b. during the patient’s stay c. after discharge d. after a claim is denied ANS: B REF: p. 179 | p. 180 OBJ: 6. Identify discrepancies between supporting documentation and coded data.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

59. In which case would a CDI physician champion be involved? a. a provider and a clinical documentation improvement specialist disagree on what should be included in the plan of care b. a nurse is slow to input progress notes c. a coder adds complications and comorbidities that are unsupported by documentation d. a provider will not authenticate his verbal orders in a timely manner ANS: A REF: p. 180 OBJ: 6. Identify discrepancies between supporting documentation and coded data.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

9

60. Structured communication between a clinical documentation improvement (CDI) specialist and a physician is a a. case mix b. query c. E/M code d. coding compliance plan ANS: B REF: p. 180 OBJ: 6. Identify discrepancies between supporting documentation and coded data.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

61. Which is an appropriate measure of the success of a clinical documentation improvement (CDI) program? a. a more complex case mix b. higher reimbursements c. shorter average length of stay d. diagnosis documentation changes ANS: D REF: p. 181 OBJ: 6. Identify discrepancies between supporting documentation and coded data.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines. | CAHIIM, IV.4 (RM). Determine diagnosis and procedure codes according to official guidelines.

COMPLETION 1. Coding is the assignment of numeric or

values to diagnosis and procedure descriptions.

ANS: alphanumeric REF: p. 153 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

2. The law commonly known as names standards for transactions and code sets, which are national standards for exchanging health information electronically.

ANS: HIPAA REF: p. 153 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

3. In a multiaxial code structure, such as ICD-10-PCS, the position of each

has specific meaning.

ANS: character REF: p. 159 OBJ: 1. Explain the purpose and importance of coding in the delivery of health care.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

4. Level

of HCPCS is also known as Current Procedural Terminology (CPT).

ANS: I REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

5. A is a statistical distribution of patients according to their utilization of resources. It also refers to the grouping of patients by clinical department or other meaningful distribution, such as health insurance type.

ANS: case mix REF: p. 175 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

6. CMS publishes non-patient-identifiable data compiled to provide information about a group called be used to compare hospital performance.

data that can

ANS: aggregate REF: p. 176 OBJ: 5. Understand the uses for coded information and efforts to improve the quality of coded data.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

10

7. DSM-5 diagnoses are coded using the ICD-10-

code set.

ANS: CM REF: p. 176 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

8. The strength, dosage, and formulation of the drug are indicated by the

code, the second segment of the NDC.

ANS: product REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

9. The I-

algorithm maps SNOMED CT codes to the more specific ICD-10-CM code set.

ANS: MAGIC REF: p. 163 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

10. ICD-10-CM diagnosis and procedures codes are used to derive the DRG by following the flowchart in a(n)

.

ANS: grouper REF: p. 167 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

11. The process of determining the most accurate DRG payment is

.

ANS: optimization REF: p. 177 OBJ: 4. Explain diagnostic-related groups and apply grouping codes.

MSC: CAHIIM, IV.1. Recognize assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.

MATCHING Match the following terms with their definitions. a. HCPCS b. ICD-10-CM c. SNOMED CT d. ICD-O e. ICD-10-PCS f. DSM-5 g. CPT h. NDC i. UHDDS j. CDT 1. Level II of the HCPCS used to report drugs, equipment, supplies, and other auxiliary health care services rendered 2. A nomenclature and coding system developed and maintained by the AMA in order to facilitate billing for physicians and other services 3. A code set used for the diagnosis of diseases 4. A code set used for coding procedures in the acute care setting 5. Systematized nomenclature of human and veterinary medicine clinical terms; a reference terminology that, among other things, links common or input medical terminology and codes with the output reporting systems in an EHR 6. The coding system used to record and track the occurrence of neoplasms (i.e., malignant tumors, cancer) 7. A classification of behavior and mental health care diagnoses 8. A code set used to identify drugs by the firm, labeler, and batch 9. Also known as the Code, it is used for reporting dental services and procedures to payers 10. A data set used to report details of inpatient stays to the government 1. ANS: A REF: p. 161 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

2. ANS: G REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

3. ANS: B REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

11

4. ANS: E REF: p. 159 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

5. ANS: C REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

6. ANS: D REF: p. 163 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

7. ANS: F REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

8. ANS: H REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

9. ANS: J REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

10. ANS: I REF: p. 169 OBJ: 1. Discuss different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

Match the following organizations with the code sets they maintain. a. AMA b. APA c. WHO d. IHTSDO e. CMS f. ADA g. FDA 11.

12.

13.

14.

15.

16.

17.

ICD-10-CM ICD-10-PCS SNOMED CPT CDT DSM-5 NDC

11. ANS: C REF: p. 156 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

12. ANS: E REF: p. 159 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

13. ANS: D REF: p. 162 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

14. ANS: A REF: p. 160 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

15. ANS: F REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

16. ANS: B REF: p. 164 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

17. ANS: G REF: p. 165 OBJ: 2. List different coding and classification systems and their uses.

MSC: CAHIIM, I.5. Explain the use of classification systems, clinical vocabularies, and nomenclatures.

12

Chapter 6: Financial Management Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. The 82-year-old patient presented in the physician’s office for a routine physical examination. He gave the receptionist two cards, evidencing his primary, government-funded insurance plan that pays for most of the bill and an additional, private plan that covers the remaining charges. The patient’s secondary insurance is called: a. TRICARE. b. supplemental. c. Medicare. d. capitation.

ANS: B REF: p. 192 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

2. The physician charged the patient $75 for an office visit. The patient paid the physician $15 and the patient’s insurance company paid the physician $60. The patient’s portion of the payment is called a: a. premium. b. deductible. c. coinsurance. d. copayment.

ANS: D REF: p. 191 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

3. Which is a way the Affordable Care Act aimed to lower health insurance premiums? a. increasing the number of healthier covered lives in the risk pool b. underwriting individuals based on biometrics and health status c. allowing insurance to be sold across state lines d. requiring insurance companies to cover pre-existing conditions ANS: A REF: p. 197 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

4. Some employers offer a used for health care and child care expenses. a. indemnity plan b. flexible spending account (FSA) c. minimum essential coverage plan d. health maintenance organization (HMO)

toward which employees can contribute money tax-free, which may then be

ANS: B REF: p. 198 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

5. Before his insurer will pay for a visit to a dermatologist, it requires Mr. Akers to visit his primary care provider (PCP) and obtain a referral to an in-network dermatologist. Mr. Akers’ insurance plan is most likely a(n): a. indemnity plan. b. preferred provider organization c. Medicare wraparound policy d. health maintenance organization (HMO) ANS: D REF: p. 195 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

6. Which payment model features unlimited access to an independent primary care physician in exchange for a monthly fee? a. concierge medicine b. preferred provider organization c. health sharing plan d. Medicaid ANS: A REF: p. 198 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

1

7. In the , the organization owns the facilities, employs the physicians, and provides essentially all health care services. a. staff model health maintenance organization (HMO) b. preferred provider organization (PPO) c. indemnity company d. health sharing plan ANS: A REF: p. 197 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

8. Medicare claims are processed by: a. the Centers for Medicare and Medicaid Services (CMS) b. Quality Improvement Organizations (QIOs) c. Medicare Administrative Contractors (MACs) d. individual states ANS: C REF: p. 199 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

9. Which of the following is NOT a way in which managed care organizations may influence and/or control the patient’s choices in selecting health care services? a. The patient must select a primary care provider. b. Only approved services are reimbursed. c. The managed care organization decides what services are “medically necessary.” d. The managed care organization only pays for primary care services.

ANS: D REF: p. 196 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

10. An HMO contracted with a group of physicians to provide health care services to its members. This is characteristic of a(n) model HMO. a. staff b. group practice c. independent practice association d. gatekeeper ANS: B REF: p. 197 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

11. One major difference between a PPO and an HMO is: a. under PPOs, patients can choose any health care provider without penalty. b. HMOs require copays. c. HMOs do not typically reimburse for out-of-network providers. d. PPOs require copays.

ANS: C REF: p. 197 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

12. How did the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 change health care reimbursement? a. it required insurers to cover dependents of subscribers up to age 26 b. it offered tax breaks to employers who offered health insurance coverage c. it required Medicare to adopt a prospective payment system (PPS) for inpatients d. it required emergency department to treat all patients regardless of their ability to pay ANS: C REF: p. 201 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

13. A contractor who manages health care claims for Medicare is a: a. Blue Cross/Blue Shield organization. b. Medicare Administrative Contractor (MAC) c. preferred provider organization (PPO). d. recovery audit contractor (RAC).

ANS: B REF: p. 199 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

2

14. What is the fixed amount a health insurance policyholder pays each month? a. deductible b. coinsurance c. copay d. premium ANS: D REF: p. 191 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

15. When is a claim usually submitted? a. during the patient’s visit or stay b. after treatment c. once a month d. after the admitting diagnosis is assigned ANS: B REF: p. 191 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

16. Which type of health insurance is obtained through an employer? a. group plan b. indemnity plan c. Marketplace plan d. health maintenance organization (HMO) plan ANS: A REF: p. 193 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

17. A family pays a monthly premium of $1,000 for a health insurance plan with a $2,000 deductible, a 10% coinsurance for inpatient stays, and a yearly out-of-pocket maximum for $6,000 per family member. The first medical event of the year was a family member having gallbladder surgery, which was a covered procedure. The charges from the hospital are $26,000, the charges from the surgeon are $1,500, and the charges from the anesthesiologist are $900. For what amount will the family pay out-of-pocket? a. $6,000 b. $1,000 c. $4,600 d. $2,000 ANS: C REF: p. 192 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

18. Which part of Medicare covers hospital, nursing home, and home health visits? a. Part A b. Part B c. Part C d. Part D ANS: A REF: p. 199 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

19. Which program pays for the care of a veteran’s spouse and dependents? a. CHAMPVA b. TRICARE c. VHA d. TEFRA ANS: A REF: p. 200 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

20. A health plan will have lower monthly premiums if a. the risk pool is smaller b. the people in the risk pool are older c. the deductible and co-insurance is higher d. the network is larger ANS: C REF: p. 192 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

3

21. A woman visits her nurse practitioner (NP) for sciatic nerve pain, called sciatica. After an examination, the provider recommends stretching exercises and prescribes ibuprofen, an NSAID. A few weeks later the woman receives an EOB from her insurance company denying coverage of the visit. She subsequently received a bill from the NP in the amount of $146.00. What is this amount called? a. the copayment b. the coinsurance c. the charges d. the cost ANS: C REF: p. 202 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

22. The payment rate established by an insurance company, based on its knowledge of the regional charges for a service, is called: a. discounted fee for service. b. fee for service. c. usual, customary, and reasonable (UCR) fees. d. capitation.

ANS: C REF: p. 202 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

23. A managed care insurer negotiates with a provider to pay 11% less than the provider’s standard charge for a certain service. This reimbursement methodology is called: a. discounted fee for service. b. fee for service. c. a prospective payment system. d. capitation.

ANS: A REF: p. 202 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

24. Which statement is true about the Resident Assessment Instrument (RAI), used to collect data in skilled nursing facilities (SNFs)? a. It is only performed at the end of a patient’s stay. b. It contains less data than either the uniform hospital discharge data set (UHDDS) or the uniform ambulatory care data set (UACDS). c. It is used to populate the Minimum Data Set (MDS 3.0). d. It is also used in behavioral health facilities.

ANS: C REF: p. 209 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

25. The term for the demands and costs associated with treating specific types of patients is a. fees b. charges c. resource intensity d. medical severity ANS: C REF: p. 204 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

26. When hospitals began to be reimbursed based on diagnosis-related groups, the average patient length of stay decreased. Why? a. Coding became timelier and more accurate. b. A PPS implies a financial incentive to discharge patients sooner. c. More patients were admitted with illnesses that did not require long stays. d. Diagnoses became more accurate and therefore patients could be treated more quickly.

ANS: B REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

4

27. A patient was admitted to an acute care facility for alcoholic liver disease. The patient stayed in the facility for 10 days. The actual charges incurred were $21,821. The PPS rate is $6,487.12. The per diem rate is $672.24 per day. For this case, Medicare will most likely pay: a. $21,821.00. b. $6,487.12. c. $6, 722.40. d. $672.24.

ANS: B REF: p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

28. What is the conceptual basis for the prospective payment system (PPS)? a. certain diagnoses and procedures consume similar resources and warrant similar reimbursement b. accurate reimbursement is best determined after services are rendered c. physicians require payment before services can be rendered d. monies are more efficiently spent when patients are treated on a case-by-case basis ANS: A REF: p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

29. Which statement is a common criticism of the prospective payment system? a. “The PPS makes it more difficult to treat patients on an individualized basis.” b. “The PPS makes it harder to budget.” c. “The PPS promotes inefficiencies among physicians.” d. “The PPS has disincentives for keeping costs down.”

ANS: A REF: p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

30. The Medicare patient presented to the emergency department with chest pain and shortness of breath. The patient was treated and released. The emergency department charges were $430. The APC amount was $250. Two days later, the patient returned to the emergency department with congestive heart failure and was admitted to the hospital. The length of stay for the admission was 2 days. The inpatient charges were $4,700. The DRG amount was $3,500. What is the expected reimbursement for these visits? a. $3,500. b. $3,750. c. $4,700. d. $5,130.

ANS: A REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

31. A hospital’s case mix index is derived by: a. organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth. b. computing the average relative weight of all the cases discharged in a given period. c. the cost of living, regional labor costs, and graduate medical education in the area. d. the sum of gross revenue divided by the number of discharges for a time period.

ANS: B REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

32. DRG 380 has a relative weight of 0.5143, while DRG 401 has a relative weight of 1.2343. From this information, which statement is true? a. It takes more resources to treat DRG 380. b. DRG 380 is being treated in a teaching hospital, or its labor costs are higher. c. DRG 401 is being treated in a teaching hospital, or its labor costs are higher. d. It takes more resources to treat DRG 401.

ANS: D REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

5

33. DRG 299 has a relative weight of 0.5000. If Hospital A has a blended rate of $5000, how much money will the hospital receive for a case assigned to DRG 299? a. $5,000 b. $299 c. $25,000 d. $2,500 ANS: D REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

34. The hospital discharged 299 patients in February with a combined relative weight for all patients of 349.3522. What is the case mix index for February? a. 148.3522 b. 0.8559 c. 1.1684 d. 104,456.3078 ANS: C REF: p. 205 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

35. What is the average reimbursement per patient for the facility in a month with a CMI of 1.1000 and a blended rate for $4,500? a. $4,091 b. $4,500 c. $4,950 d. $5,600 ANS: C REF: p. 205 | p. 206 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

36. All of the following statements about ambulatory payment classifications (APCs) are true, EXCEPT: a. patients may be assigned to more than one APC for an encounter. b. APC assignment is based on ICD-10-PCS procedure codes. c. there are approximately 2,000 APCs. d. APCs apply only to ambulatory care.

ANS: B REF: p. 206 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

37. The basis for payment for skilled nursing facility (SNF) services for Medicare patients is: a. resource utilization groups (RUGs). b. the resource-based relative value system (RBRVS). c. the Minimum Data Set (MDS). d. all-payer diagnosis resource groups (AP-DRGs).

ANS: A REF: p. 209 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

38. The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is: a. health information management. b. utilization review. c. patient registration. d. patient financial services.

ANS: D REF: p. 211 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

39. If a facility is to receive reimbursement for an item such as an aspirin, the item and the cost of the item must be included in the facility’s: a. Chargemaster. b. codemaster. c. formulary. d. superbill.

ANS: A REF: p. 211 | p. 212 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

6

40. A patient presented to a hospital three times in 1 month. One visit was for a throat culture in the clinic. One visit was for a suture of a laceration in the emergency department. One visit was for a same-day stay for a hernia repair. The hospital would submit: a. one bill at the end of the month totaling all charges under one account number and one medical record number; a new account number would be assigned next month. b. one bill for the throat culture under one account number, and another bill with another account number for the suture and hernia repair, because these were surgical procedures to be grouped together; both bills would have the same medical record number. c. a separate bill for each visit with a new medical record number and new account number. d. a separate bill for each visit with the same medical record number but different account numbers.

ANS: D REF: p. 211 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

41. Which data element is collected differently on the CMS-1500 than on the UB-04? a. Race b. Diagnosis code c. Reason for visit d. Total charges ANS: B REF: p. 214 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

42. The HIM department is allowed $250 per month for supplies. At the end of the third quarter, the department has spent $3,000 on supplies. This means that the HIM department is: a. under budget YTD by $750. b. over budget YTD by $2,750. c. exactly as it should be on budget for supplies. d. over budget by $750.

ANS: D REF: p. 218 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

43. What might explain a positive variance in budgeted salary expenses? a. Salaries were frozen as planned. b. An employee resigned and was not replaced. c. There were merit raises. d. Additional employees were hired to support a new service.

ANS: B REF: p. 223 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

44. Which accounting method recognizes additions of money when it is earned and subtractions of money when expenses are incurred, regardless of when the funds enter or leave the bank accounts? a. accrual basis b. cash basis c. capital basis d. balance basis ANS: A REF: p. 218 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

45. A not-for-profit children’s hospital has $100 million dollars in property, cash, inventory and monies it expects to receive. It has $50 million in debt. What is the term on the balance sheet for the $50 million in debt? a. assets b. liabilities c. revenue d. profit ANS: B REF: p. 218 | p. 219 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

7

46. A not-for-profit children’s hospital has $100 million dollars in property, cash, inventory and monies it expects to receive. It has $50 million in debt. What is the hospital’s fund balance? a. $1M b. $50M c. $100M d. $150M ANS: B REF: p. 218 | p. 219 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

47. A(n) is a summary of revenue and expense activity over a period. a. balance sheet b. budget c. income statement d. statement of change in financial position ANS: C REF: p. 220 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

48. Large purchases that are expected to last for years are included in the a. capital b. cash c. operational d. strategic

budget.

ANS: A REF: p. 220 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

49. A new computer costs $5,000 and is expected to save $500 per month in employee time because of its speed. It has an expected life of 3 years. What is the payback period for the computer? a. 10 months b. 1 year c. 2 years d. 3 years ANS: A REF: p. 220 | p. 221 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

50. A new computer costs $5,000 and is expected to save $500 per month in employee time because of its speed. It has an expected life of 3 years. How much of the equipment cost is recovered per year? a. 10% b. 33% c. 80% d. 120% ANS: D REF: p. 221 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

51. A new computer costs $5,000 and is expected to save $500 per month in employee time because of its speed. It has an expected life of 3 years. Using straight-line depreciation, how much is the computer worth at the beginning of the second year? a. $500 b. $4,500 c. $3,333.34 d. $1,666.66 ANS: C REF: p. 221 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

52. How are variable expenses estimated in the operational budget? a. by examining prior year activities and anticipating changes b. by planning for capital expenses c. by depreciating the prior year’s assets d. by totaling the payroll for the prior year and budgeting a % increase for raises ANS: A REF: p. 223 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

8

53. Brett makes $60,000/year before getting a 3% raise in July. How much should the department manager budget for Brett’s monthly salary from July through December? a. $5,000 b. $5,150 c. $1,800 d. $6,180 ANS: B REF: p. 223 OBJ: 4. Explain accounting methodologies, plan budgets, and calculate budget variances.

MSC: CAHIIM, VI.5. Utilize financial management processes.

COMPLETION 1. Two types of managed care organizations are health maintenance organizations and

provider organizations.

ANS: preferred REF: p. 193 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

2. A specified dollar amount for which the patient is personally responsible, before the payer reimburses for any claims, is called the .

ANS: deductible REF: p. 193 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

3.

is a formal system of providing funding for health care for low-income populations.

ANS: Medicaid REF: p. 200 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

4. Federal health care for individuals with certain disabilities or with end-stage renal disease requiring dialysis or kidney transplantation is offered under the program.

ANS: medicare REF: p. 199 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

5. Paired with a high deductible health plan, a(n) expenses on a pre-tax basis.

account allows individuals to set aside funds for health

ANS: health savings REF: p. 198 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

6. Medicare and Medicaid are called age, condition, or employment status.

programs because eligibility for these programs is automatic, being based on

ANS: entitlement REF: p. 199 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

7. The primary care system where a PCP limits access to other parts of the health care delivery system is called a model.

ANS: gatekeeper REF: p. 196 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

9

8. The exchange of cash for professional services rendered at a rate less than the normal fee for the service, is called the reimbursement model.

ANS: discounted fee for service REF: p. 202 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

9. The exchange of cash, goods, or services for professional services rendered at a specific rate, typically determined by the provider, and associated with specific activities (such as a physical examination) is called .

ANS: fee for service REF: p. 202 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

10. A(n) assumes the risk of paying some or all of the cost of providing health care services in return for the payment of a premium.

ANS: insurer REF: p. 191 OBJ: 1. Discuss types of health insurance and government payers.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

11. Cois a type of cost-sharing reduction in which an individual is responsible for a percentage of the amount owed to the provider.

ANS: insurance REF: p. 192 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

12. The application to an insurance company for reimbursement is called the

.

ANS: claim REF: p. 191 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

13. The blending of the insurance and provider roles in health care delivery is characteristic of

.

ANS: managed care REF: p. 195 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

14. The potential exposure to loss, financial expenditure, and/or other undesirable events is called

.

ANS: risk REF: p. 192 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

15. Any of several reimbursement methods that pay an amount predetermined by the payer, based on the diagnosis, procedures, and other factors (depending on setting) rather than actual, current resources expended by the provider, is called .

ANS: prospective payment REF: p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

10

16. Payments calculated based on the number of days are called

.

ANS: per diem REF: p. 202 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

17. The systematic reimbursement to a health care provider based on the number of patients contractually in the physician’s care, regardless of diagnoses or services rendered, is called .

ANS: capitation REF: p. 202 | p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

18. In the reimbursement methodology called payment, the amount of reimbursement is based on DRGs, a collection of health care descriptions organized into statistically similar categories.

ANS: prospective REF: p. 203 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

19. The Outpatient Prospective Payment System (OPPS) uses services.

(APCs) to reimburse for Medicare outpatient

ANS: ambulatory patient classifications REF: p. 206 OBJ: 2. Compare the major health care reimbursement methodologies.

MSC: CAHIIM, IV.3. Summarize regulatory requirements and reimbursement methodologies | CAHIIM, IV.6 (RM). Evaluate compliance with regulatory requirements and reimbursement methodologies.

20. To standardize and facilitate accurate billing, health care facilities maintain a database of all potential services to a patient called a(n) .

ANS: chargemaster REF: p. 211 | p. 212 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

21. The systematic collection of specific charges for services rendered to a patient is called

.

ANS: charge capture REF: p. 212 OBJ: 3. Evaluate the revenue cycle management process and the role of coding in this process.

MSC: CAHIIM, IV.2. Describe components of revenue cycle management and clinical documentation | CAHIIM, IV.5 (RM).

Evaluate revenue cycle processes.

11

Chapter 7: Statistics and Data Analytics Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. Which statement about health informatics is true? a. it is concerned with technology-based solutions b. it is not widely used in ambulatory care c. it is primary used to reveal trends and improve efficiency d. it helps administrators track progress toward organizational objectives ANS: A REF: p. 232 OBJ: 1. Differentiate the disciplines of statistics, data analytics, health informatics, and decision support, and discuss the HIM professional’s role in these fields.

MSC: CAHIIM, III.1. Apply health informatics concepts to the management of health information.

2. Which statement refers to key performance indicators? a. they are generated daily b. physicians use them to develop care plans c. they are exclusively used in revenue cycle management (RCM) aspects of health care d. they are used primarily in inpatient settings ANS: A REF: p. 232 OBJ: 1. Differentiate the disciplines of statistics, data analytics, health informatics, and decision support, and discuss the HIM professional’s role in these fields.

MSC: CAHIIM, III.1. Apply health informatics concepts to the management of health information.

3. The field of a. statistics b. data analytics c. health informatics d. applied research

creates information from raw data and uses that information to improve processes.

ANS: B REF: p. 232 OBJ: 1. Differentiate the disciplines of statistics, data analytics, health informatics, and decision support, and discuss the HIM professional’s role in these fields.

MSC: CAHIIM, III.1. Apply health informatics concepts to the management of health information.

4. The case mix index is an example of a frequently used a. query b. key performance indicator (KPI) c. vital statistic d. outlier ANS: B REF: p. 232 OBJ: 1. Differentiate the disciplines of statistics, data analytics, health informatics, and decision support, and discuss the HIM professional’s role in these fields.

MSC: CAHIIM, III.1. Apply health informatics concepts to the management of health information.

5. Primary data is originally reported or recorded by: a. the Centers for Disease Control and Prevention. b. researchers at teaching hospitals. c. HIM employees reviewing the record. d. clinicians treating the patient.

ANS: D REF: p. 233 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

6. The patient abstract is an example of a. demographic b. primary c. secondary d. tertiary

data.

ANS: C REF: p. 234 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

7. Which statement below requests aggregate health information? a. Request for report of total number of DRG 127 cases for the month of June b. Request for patient information, MR# 02-34-65, DRG 127 c. Request for first case of congestive heart failure (CHF) for the third quarter d. Request for record of patient #197808, under the care of Dr. S. S. Schoner ANS: A REF: p. 240 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

1

8. A sample is a small group within a: a. data set. b. database. c. aggregate group. d. population.

ANS: D REF: p. 241 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

9. The is a committee that is charged with ensuring that research conducted within the facility or by its employees and associates conforms to all applicable rules and regulations. a. Joint Commission (TJC) b. Institutional Review Board (IRB) c. board of directors d. forms committee ANS: B REF: p. 265 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

10. Which type of sampling divides the population into groups of similar patients, and studies a set number of members within each group? a. cluster samples b. random samples c. systemic samples d. stratified samples ANS: D REF: p. 242 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

11. A patient’s personal identifier, gender, race, and ethnicity are all examples of what type of data? a. quantitative data b. ordinal level data c. interval data d. nominal data ANS: D REF: p. 243 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

12. The Likert scale, a depiction of categories on a line, consists of what type of data? a. ratio data b. ordinal data c. interval data d. categorical data ANS: B REF: p. 243 | p. 244 | p. 245 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

13. Which is true of interval data? a. values have no arithmetic relationship b. it contains an absolute zero c. it is made of categories with a hierarchy d. the values are potentially infinite ANS: A REF: p. 245 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

14. What data type has a logical order or ranking, meaningful, consistent intervals, and includes an absolute zero in its order? a. interval data b. ratio data c. discrete data d. integer data ANS: B REF: p. 245 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

15. A temperature scale (if it is 0°F outside, it doesn’t mean that there is no temperature at all) is an example of what type of data? a. interval level data b. ratio level data c. continuous data d. qualitative data ANS: A REF: p. 245 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

2

16. Patient ages, weights, lengths of stay, salaries, and billing charges are examples of what type of data? a. discrete data b. nominal data c. continuous data d. categorical data ANS: C REF: p. 245 OBJ: 3. Differentiate nominal, ordinal, interval, and ratio level data.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

17. Suppose there are six males in a class of 20 students. What term could be used to describe the volume of males with respect to females? a. Ratio b. Proportion c. Percentage d. Rate ANS: A REF: p. 245 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

18. What is the mean for the following frequency distribution: 10, 15, 20, 25, 25? a. 25 b. 10 c. 20 d. 19 ANS: D REF: p. 246 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

19. The blood pressure of patients discharged in June 2019 with a diagnosis of hypertension was reviewed. The 36 samples are below. The diastolic pressures (in mm Hg) were as follows: 88 98 78 84 77 81 90 82 75 72 100 92 85 92 84 77 82 92 87 74 80 95 77 90 87 77 80 83 86 80 88 90 79 82 93 88 What is the mode? a. 77 b. 82 c. 84 d. 85 ANS: A REF: p. 248 | p. 249 | p. 250 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

20. The blood pressure of patients discharged in June 2019 with a diagnosis of hypertension was reviewed. The 36 samples are below. The diastolic pressures (in mm Hg) were as follows: 88 98 78 84 77 81 90 82 75 72 100 92 85 92 77 84 77 82 92 88 74 80 95 90 87 80 83 77 86 80 88 90 79 82 93 88 What is the mean? a. 84. 6 b. 87. 9 c. 86. 2 d. 82. 1 ANS: A REF: p. 246 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

21. Of 15,000 discharges last year, Medicare was the primary payer for 6,000 patients. Medicare made up what percentage of this hospital’s payer mix? a. 4% b. 55% c. 60% d. 40% ANS: D REF: p. 251 | p. 252 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

3

22. The following patients were discharged from pediatrics for the week 7/16/20–7/22/20: Patient Name Alex Groot Sue Schoner Fran Brown Robbie Kowalski Lee Zhong Frank Paluck

Admission Date 7/13/20 7/12/20 7/11/20 7/10/20 7/09/20 6/29/20

Discharge Date 7/15/20 7/15/20 7/16/20 7/20/20 7/19/20 7/17/20

The average length of stay of these patients is: a. 6.5 days. b. 7 days. c. 7.2 days. d. 8 days.

ANS: D REF: p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

23. Zak was admitted to the hospital on August 20 and discharged on October 6. The length of stay is a. 47 b. 48 c. 66 d. 67

days.

ANS: A REF: p. 257 | p. 258 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

24. Richard S. was admitted to the hospital on September 13 and discharged on September 30. The length of stay is a. 13 b. 17 c. 18 d. 30

days.

ANS: B REF: p. 257 | p. 258 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

25. In May, 290 women were admitted to the Obstetrics service. Of these, 262 women delivered vaginally; 18 deliveries were by C-section. What is the denominator for calculating the C-section rate? a. 18 b. 262 c. 280 d. 290 ANS: C REF: p. 261 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

26. Which unit of measure is used to indicate the services received by one inpatient in a 24-hour period? a. Inpatient service day b. Volume of services c. Bed count d. Length of stay ANS: A REF: p. 259 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

27. Suppose that three patients stayed in the hospital for a total of 18 days. Which term would be used to describe the result of the calculation 18 ÷ 3? a. Total length of stay b. Average patient census c. Average bed count d. Average length of stay ANS: D REF: p. 256 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

28. What rate is used to indicate the percentage of the hospital’s beds occupied by inpatients for a given time period? a. percent occupancy b. total length of stay c. case mix d. average length of stay ANS: A REF: p. 260 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

4

29. The inpatient census at 12:01 AM is 62. Two patients were admitted at 8 AM; one died at 7:30 PM and the other was discharged at 8:15 PM. Calculate the inpatient service day. a. 62 b. 64 c. 63 d. 65 ANS: B REF: p. 259 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

30. On May 12, the midnight census is 80. However, four patients were admitted and discharged that same day. The hospital bed count is 92. Calculate the bed occupancy rate. a. 4% b. 13% c. 87% d. 91% ANS: D REF: p. 260 | p. 261 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

31. Data for June: Bed count 50 Admissions 140 Discharges 143 IP service days 1203 Discharge days 1001 Calculate the average length of stay for this month. a. 1.5 days b. 2.3 days c. 7 days d. 7.2 days ANS: C REF: p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

32. Compute the length of stay for the following patient: Admitted 5/25/2019 Discharged 5/25/2019 a. 0 days b. 1 day c. Cannot be determined d. -1 day ANS: B REF: p. 256 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

33. What is the denominator when calculating the gross autopsy rate? a. inpatient deaths b. discharges c. admissions d. autopsies performed ANS: A REF: p. 261 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

34. Which design would yield quantitative data regarding the patients’ experiences at the free clinic? a. A survey with closed-ended questions b. Interviews with a sample of patients c. A suggestion box at the exit d. Observation of clinician-patient interaction ANS: A REF: p. 264 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

35. You are asked to research the opinions of your staff. What is the first thing you need to know? a. What is the hypothesis? b. What data gathering method will you use? c. What is the question to be answered? d. In what format should the report be presented?

ANS: C REF: p. 264 | p. 265 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

5

36. Which is the most authoritative source about a medication? a. A focus group of users b. A website blog with testimonials from users and physicians c. The manufacturer’s web site d. A double-blind placebo study conducted by a university ANS: D REF: p. 263 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

37. You are working with a team from Patient Access to improve the patient experience at registration. The discussion turns to wait times. Select an operational definition of wait time. a. The amount of time a patient has to wait b. The number of minutes and seconds a patient has to wait before being registered c. The difference between the time the patient is seen by the registrar and the time the patient arrived. d. The difference in minutes and seconds between the time the patient begins the registration process, recorded by the registrar, and the time the patient arrived, recorded by the greeter.

ANS: D REF: p. 264 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

38. You want to conduct a research study to determine whether a longer lunch break will improve coding productivity. In framing your hypothesis, which represents a useful measurement of the independent variable? a. The coder’s historic productivity b. The coder’s productivity during the study c. The duration of lunch breaks d. The number of coders on staff ANS: C REF: p. 263 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

39. You have been asked to query your staff to determine their satisfaction with a number of variables, such as break scheduling and collaboration between teams. What type of research design should you use? a. Survey b. Mixed Method c. Experimental d. Meta analysis ANS: A REF: p. 264 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

40. What type of research collects numerical data? a. quantitative research b. applied research c. basic research d. qualitative research ANS: A REF: p. 264 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

41. What type of research uses both quantitative and qualitative methods? a. clinical outcome analysis b. applied research c. basic research d. mixed method research ANS: D REF: p. 264 OBJ: 6. Discuss research methodologies and how they are used in health care.

MSC: CAHIIM, III.5. Describe research methodologies used in health care.

42. Which process populates the patient database used to generate indices like the physician index, the diagnosis index, and the procedure index? a. abstracting b. assembly c. retention d. coding ANS: A REF: p. 268 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

6

43.

is how many new cases of a particular disease or condition have been identified in a particular period in comparison with the population as a whole. a. Prevalence b. Incidence c. Mortality d. Morbidity ANS: B REF: p. 269 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

44. What information is found in the trauma registry that cannot be collected by the UHDDS? a. cause of injury b. site of injury on body c. patient demographics d. effectiveness of treatments ANS: D REF: p. 269 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

45. Birth certificates, completed by the health care facility, are registered with the Department of: a. Motor Vehicles. b. Live Births. c. Complete Statistics. d. Vital Records.

ANS: D REF: p. 270 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

46. The CEO requests information on the number of arthroscopies performed annually. What information should be requested from the database to be included on the report so that individual cases can be reviewed, if necessary? a. Patient name only b. Patient name, MRN, ICD-10-CM procedure code, discharge date, surgeon c. Patient name, procedure description, surgery date d. Surgeon ANS: B REF: p. 240 OBJ: 8. Explain the criteria for creating a report from a database.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

47. Given a request for the number of Medicare CHF cases for the month of April, how would you query the database to sort the report? a. Patient gender b. Patient age c. Financial class d. Diagnosis ANS: D REF: p. 243 OBJ: 8. Explain the criteria for creating a report from a database.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

48. Which of the following graphs would best illustrate the following information: of the 440 discharges for the month of June, 340 were Medicare, 60 were Medicaid, 20 were insurance, and 20 were self-pay? a. pie chart b. line graph c. bar graph d. histogram ANS: A REF: p. 272 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

49. Suppose that you want to display the number of deaths due to prostate cancer for the years 2010 through 2019. What graphic technique would you choose? a. Line graph b. Histogram c. Pie chart d. Bar graph ANS: A REF: p. 270 | p. 271 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

7

50. Which data presentation tool best displays the frequency of observations? a. pie chart b. histogram c. line graph d. table ANS: B REF: p. 271 | p. 272 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

51. According to the graph, which race/ethnicity has the lowest mortality rate from injuries?

a. b. c. d.

Asian or Pacific Islander Hispanic or Latino White (non-Hispanic) Black or African American (non-Hispanic)

ANS: A REF: p. 271 | p. 275 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

52. Review the following graph. What is the incidence of varicella (chickenpox) trend from 1990 to 2014 in these four states?

Varicella incidence per 100,000 population in states that have reported varicella cases to CDC annually since before implementation of the varicella vaccination program — Illinois, Michigan, Texas, and West Virginia, 1990–2014.

Source: Lopez AS, Zhang J, Marin M. Epidemiology of Varicella During the 2-Dose Varicella Vaccination Program — United States, 2005–2014. MMWR Morb Mortal Wkly Rep 2016; 65:902–905. DOI: http://dx.doi.org/10.15585/mmwr.mm6534a4. a. downward b. upward c. flat d. mixed ANS: A REF: p. 270 | p. 271 | p. 272 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

8

53. According to the pie chart, what was the discharge disposition for the least number of schizophrenic patients?

a. b. c. d.

Home Home Health Transfer to Acute Care AMA

ANS: C REF: p. 272 | p. 275 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

54. A a. b. c. d.

is a series of key performance indicators (KPIs) arranged in a summarized format. relational database histogram dashboard pivot table

ANS: C REF: p. 276 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

COMPLETION 1. A report of a group of patients including their age is an example of

data.

ANS: aggregate REF: p. 234 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

2. Named and identifiable pieces of data that can be queried and reported in a meaningful way are called

.

ANS: discrete data REF: p. 235 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

3.

is a method of sampling a population so that all cases have an equal chance of being selected.

ANS: Random selection REF: p. 242 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

4. The subjective portion of SOAP notes is

data.

ANS: primary REF: p. 232 | p. 233 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

5. When the clerk requests a report from a computer system, he or she is said to

the database.

ANS: query REF: p. 235 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

9

6. The result of a query is also known as a(n)

.

ANS: report REF: p. 235 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

7. To study only the female students registered for this class is to examine a(n)

of the population.

ANS: sample REF: p. 242 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

8. The diagnosis index may be

to remove patient identifiers.

ANS: redacted REF: p. 234 OBJ: 2. Differentiate primary and secondary data and use data collected in the facility to support organizational objectives.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

9. The way in which a variance of values behaves over time is called a

.

ANS: trend REF: p. 252 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

10. A value in a sample or population much higher or lower than the average is called a(n)

.

ANS: outlier REF: p. 247 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

11. A measure of variance called the

shows how closely the observations are distributed around the mean.

ANS: standard deviation REF: p. 254 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

12. Frequency distributions that are not symmetrical are

.

ANS: skewed REF: p. 254 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

13. A frequency distribution organizes data into groups called

.

ANS: class intervals REF: p. 251 OBJ: 4. Calculate statistics used in health care, including measures of central tendency, measures of frequency, and measures of variance.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

14. The number of patients present in the health care facility, counted at the same time each day, is called the

.

ANS: census REF: p. 259 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

10

15. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged Patient A 25-May 25-May Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient A is

day(s).

ANS: 1 REF: p. 256 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

16. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged 25-May 25-May Patient A Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient B is

day(s).

ANS: 1 REF: p. 256 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

17. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged Patient A 25-May 25-May Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient C is

day(s).

ANS: 14 REF: p. 256 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

11

18. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged Patient A 25-May 25-May Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient D is

day(s).

ANS: 7 REF: p. 256 | p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

19. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged 25-May 25-May Patient A Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient E is

day(s).

ANS: 2 REF: p. 256 | p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

20. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged Patient A 25-May 25-May Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient F is

day(s).

ANS: 37 REF: p. 256 | p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

12

21. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged Patient A 25-May 25-May Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient G is

day(s).

ANS: 15 REF: p. 256 | p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

22. Use the data below to calculate the length of stay for each patient. Assume that the dates are in the same year and that it is not a leap year.

Admitted Discharged 25-May 25-May Patient A Patient B 15-May 16-May Patient C 11-May 25-May Patient D 27-May 3-Jun Patient E 31-May 2-Jun Patient F 29-May 5-Jul Patient G 26-Dec 10-Jan Patient H 22-Dec 7-Mar The length of stay for Patient H is

day(s).

ANS: 75 REF: p. 256 | p. 257 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

23. The inpatient census at 11: 59 PM, May 20, was 95. One patient was admitted May 21 around 6: 00 AM and discharged around 7: 00 PM on the same day. Two patients were admitted at noon that day; one died at 5: 00 PM that same afternoon while the other patient was transferred to a nursing home around 2: 30 PM. What is the daily inpatient census for May 21?

ANS: 95 REF: p. 259 OBJ: 5. Utilize and compute routine institutional health care statistics.

MSC: CAHIIM, III.3. Calculate statistics for health care operations.

24. A user would query the diagnosis, physician, or procedure

to retrieve specific data from the HIM database.

ANS: index REF: p. 268 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

25. A database of specific cancer or trauma information is an example of a(n)

.

ANS: registry REF: p. 269 OBJ: 7. Understand the generation of reports within the facility, and the reporting of data to outside agencies.

MSC: CAHIIM, III.6. Describe the concepts of managing data | CAHIIM, III.8. Manage data within a database system (DM).

26. The

graph is an illustration of the frequency of items in categories.

ANS: bar REF: p. 271 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

13

27. An organization of data elements in rows and columns is called a(n)

.

ANS: table REF: p. 270 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

28. A

table summarizes parts of a larger table.

ANS: pivot REF: p. 270 OBJ: 9. Apply data visualization tools, present data graphically, and identify trends.

MSC: CAHIIM, III.4. Report health care data through graphical representations.

14

Chapter 8: Confidentiality and Compliance Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. All of the following are elements of the business record rule, EXCEPT: a. documentation is contemporaneous with the events it describes. b. records are maintained in the normal course of business. c. records are kept in accordance with The Joint Commission (TJC) standards. d. documentation is recorded by those who are in a position to know the facts of the events they describe.

ANS: C REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

2. In litigation, lawyers may request documentation from the health information management (HIM) department during the process. a. certification b. filing c. pretrial hearing d. discovery ANS: D REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

3. During litigation, who is responsible for certification of medical records? a. privacy offer b. security officer c. provider d. custodian ANS: D REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

4. The responsibility for harm or damage caused by actions or inactions is known as: a. liability. b. tort. c. negligence. d. malpractice.

ANS: A REF: p. 287 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

5. An officer of the court’s direction to produce documents is called: a. subpoena duces tecum. b. subpoena ad testificandum. c. malfeasance. d. jurisdiction.

ANS: A REF: p. 288 | p. 289 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

6. Which is an element of a valid subpoena that HIM staff should recognize when following the subpoena process? a. Name of the judge who authorized the subpoena b. Proof of identity of the patient whose record is being subpoenaed c. Docket number of the case d. Reason for litigation, such as alleged malpractice ANS: C REF: p. 290 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

1

7. A valid consent for release of information contains all of the following, EXCEPT: a. patient’s name. b. patient’s marital status. c. patient’s date of birth. d. date of the request.

ANS: B REF: p. 302 | p. 303 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

8. The Conditions of Admission are an example of: a. prospective consent. b. retrospective consent. c. access. d. jurisdiction.

ANS: A REF: p. 301 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

9. A 16-year-old woman presents in the emergency room for the treatment of stomach pain, accompanied by her mother and husband. She is conscious, alert, and oriented. Of the following, who is the appropriate individual to sign the consent for treatment? a. The patient. b. The patient’s mother. c. The patient’s husband. d. No consent is necessary for this emergency treatment.

ANS: A REF: p. 303 | p. 304 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

10. What part of the U.S. Constitution invalidates any local, state, or federal laws that conflicts with the Constitution? a. The Preamble b. The Bill of Rights c. The Emoluments Clause d. The Supremacy Clause ANS: D REF: p. 285 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

11. Which type of subpoena compels a person to testify? a. Subpoena duces tecum b. Subpoena ad litem c. Subpoena ad testificandum d. Subpoena respondeat superior ANS: C REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

12. Posting about a patient’s health on social media would be which tort? a. libel b. slander c. invasion of privacy d. defamation ANS: C REF: p. 287 | p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

13. Which is the crime of the threat of harming another person? a. Assault b. Battery c. Kickback d. Defamation ANS: A REF: p. 286 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

2

14. A physician’s brother is a speech pathologist, so the physician refers patients to him for services. Which law is the physician breaking? a. False Claims Act b. Sunshine Act c. Stark Law d. The Health Insurance Portability and Accountability Act ANS: C REF: p. 286 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

15. Upcoding is which crime? a. fraud b. battery c. tort d. defamation ANS: A REF: p. 286 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

16. A patient complains that they do not agree with certain information in their designated record set and asks to make an amendment. Your current Patient Rights Policy and Procedure on Access to Personal Health Records, as required under HIPAA, states that the patient must be provided with an amendment/correction form. The patient completes the form. What should be the next step, under HIPAA, in your Policy and Procedure? a. Contact the physician whose documentation the patient disagrees with and request the physician to make an amendment to the patient’s record. b. Review the amendment/correction form and respond to the patient within 60 days, either accepting or denying the amendment. c. Require the patient to provide documentation proving their identity and, if the documentation is valid, enter the amendment/correction form into the patient’s record, noting the date of entry. d. Assist the patient by filing the amendment/completion form with the U. S. Department of Health and Human Services (DHHS) and the Office of Civil Rights, ensuring their complaint is heard.

ANS: B REF: p. 298 | p. 299 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

17. Which would be known as a business associate under the HIPAA guidelines? a. The laundry service that picks up and drops off scrub sets. b. The clinical laboratory where the medical office sends specimens. c. The vendor that supplies water and snacks for the medical office. d. The company that services the elevator.

ANS: B REF: p. 296 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

18. The nurse is curious why his sister-in-law, who is the patient of a provider at a different branch of the health care organization, has so many doctor’s appointments. Is it legal for him to look at her health record? Why or why not? a. No, because health information is only disclosed to those who need it to care for the patient. b. No, because nurses cannot access medical records without permission from a provider. c. Yes, because the nurse is a family member. d. Yes, because the nurse is an employee of the same health care organization.

ANS: A REF: p. 301 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

19. What form authorizes the provider to treat the patient? a. informed consent b. advance directive c. Conditions of Admission d. accounting of disclosures ANS: A REF: p. 291 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

3

20. HIM staff overseeing release of information know they must comply with two types of required disclosures under the HIPAA Privacy Rule, which are: a. to the individual who is the subject of the information, and for treatment, payment, or health care operations. b. for public priority purposes (breeches), and to the secretary of the DHHS for purposes of determining compliance. c. for treatment, payment or health care operations, and for public priority purposes (epidemics). d. to the individual who is the subject of the information, and to the secretary of the DHHS for purposes of determining compliance.

ANS: D REF: p. 297 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

21. Which is a way the HITECH Act strengthened Health Insurance Portability and Accountability Act (HIPAA) regulations? a. it required all health records be subject to the business record rule b. it required plain language for all Notice of Privacy Practices (NPP) documents c. it required the information disclosed from one covered entity to another for health care operations to be limited to the minimum necessary d. it required the use of the electronic health record (EHR) among providers who meet a threshold of annual revenues or discharges ANS: C REF: p. 297 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

22. The practice of maintaining confidentiality in health care is based on: a. prospective consent. b. retrospective consent. c. physician-patient privilege. d. attorney-client privilege.

ANS: C REF: p. 302 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

23. An insurance company may obtain patient records by all of the following, EXCEPT: a. prospective consent under the conditions of admission. b. by subpoena for disclosure of chemical dependency information. c. prospective consent obtained when the patient became insured. d. retrospective consent obtained after the patient is discharged.

ANS: B REF: p. 304 | p. 305 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

24. The Privacy Rule addresses the uses and disclosure of a. protected health b. confidential c. private d. secure

information.

ANS: A REF: p. 296 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

25. The Notice of Privacy Practices is provided to the patient prior to each admission and contains all of the following required information, EXCEPT: a. the facility’s privacy policies. b. the physician’s signature. c. discussion of how the facility discloses patient information. d. the privacy officer contact information.

ANS: B REF: p. 297 | p. 298 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

4

26. The owns the physical or electronic record; the a. patient; patient b. facility; patient c. facility; facility d. patient; facility

owns the information in the record.

ANS: B REF: p. 294 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

27. Which is a violation of patient confidentiality? a. reporting cases of abuse, neglect, or domestic violence without patient consent b. discussing patient care in the provider’s office c. writing the patient’s allergies on the folder or binder outside the room where anyone can see d. using the EHR in a place where passers-by could see the monitor ANS: D REF: p. 295 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

28. Which of the following situations is NOT an exception to permitted disclosures of patient information under the Privacy Rule? a. About victims of abuse, neglect, or domestic violence b. For workers’ compensation (as authorized by law) c. For a journalist to verify a story d. For judicial and administrative proceedings ANS: C REF: p. 297 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

29. Which term describes the right of the individual to control access to information? a. Privacy b. Confidentiality c. Physician-patient privilege d. Security ANS: A REF: p. 294 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

30. The following providers/departments make internal requests for patient health information routinely, EXCEPT: a. utilization review. b. performance improvement. c. quality assurance. d. attending physician.

ANS: D REF: p. 301 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

31. If the patient refuses to authorize disclosure, the release of which kind of health information requires a court order rather than a subpoena? a. terminal diagnosis b. chemical dependency c. sexual orientation d. demographics ANS: B REF: p. 305 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

32. A patient may be denied access to his or her own health record: a. if the patient is terminally ill. b. if the patient is a felon. c. if the provider believes the information would be harmful to the patient. d. if the provider prefers to exercise professional privilege.

ANS: C REF: p. 303 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

5

33. Which is reported to public health agencies? a. cases of rabies b. knife wounds c. transfusions d. cases of chickenpox ANS: A REF: p. 302 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

34. Even though, legally, the facility may disclose health information without patient authorization for reimbursement, it is common practice for Patient Access to have patients to sign a form authorizing the release of PHI to financially responsible parties. a. Conditions of Admission b. informed consent c. accounting of disclosures d. continuity of care ANS: A REF: p. 292 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

35. If a facility is purchased by a new owner, what happens to the health records? a. they are destroyed b. they are returned to patients c. they become the property of the new owner d. they are sent to offsite storage ANS: C REF: p. 307 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

36. In the absence of state laws regarding retention of health care records, CMS requires that records be maintained for a. 10 b. 21 c. 30 d. 5

_ years.

ANS: D REF: p. 306 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

37. Policies and procedures should include specific language regarding the sensitivity of health information pertaining to which patients? a. Facility employees b. Behavioral health patients c. Celebrity patients d. Law enforcement patients ANS: A REF: p. 302 OBJ: 3. Adhere to policies and procedures surrounding access and disclosure of protected health information to patients and to care providers.

MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

38. The purpose of TJC Steering Committee is: a. risk management b. release of information (ROI) c. disaster planning d. compliance with accreditation standards ANS: D REF: p. 309 OBJ: 4. Apply standards for accreditation, licensure, and/or certification.

MSC: CAHIIM, II.3. Identify compliance requirements throughout the health information life cycle.

39. To operate, the health care facility must obtain a license from: a. The Joint Commission (TJC). b. the American Medical Association (AMA). c. the municipality in which the facility is zoned. d. the state in which the facility is located.

ANS: D REF: p. 309 OBJ: 4. Apply standards for accreditation, licensure, and/or certification.

MSC: CAHIIM, II.3. Identify compliance requirements throughout the health information life cycle.

6

40. How does accreditation differ from licensure? a. Accreditation is voluntary. b. Licensure is voluntary. c. Licensure does not require site surveys. d. Accreditation does not require site surveys.

ANS: A REF: p. 309 OBJ: 4. Apply standards for accreditation, licensure, and/or certification.

MSC: CAHIIM, II.3. Identify compliance requirements throughout the health information life cycle.

41. A type of record review in which The Joint Commission monitors how health care is being delivered and documented in “real time” is called a. designated record set b. site survey c. tracer methodology d. retention ANS: C REF: p. 310 OBJ: 4. Apply standards for accreditation, licensure, and/or certification.

MSC: CAHIIM, II.3. Identify compliance requirements throughout the health information life cycle.

42. Who conducts mock surveys to prepare for a Joint Commission visit? a. the Office of the Inspector General (OIG) b. site surveyors c. risk managers d. TJC Steering Committee members ANS: D REF: p. 309 OBJ: 4. Apply standards for accreditation, licensure, and/or certification.

MSC: CAHIIM, II.3. Identify compliance requirements throughout the health information life cycle.

43. To prepare for unexpected events such as a bomb threat, hurricane, or flood, The Joint Commission requires a(n): a. record review b. retention schedule c. disaster plan d. Blue Button Pledge ANS: C REF: p. 311 OBJ: 5. Promote risk management functions within the organization as they relate to compliance with accreditation and regulatory bodies.

MSC: CAHIIM, V.3. Identify the components of risk management related to health information management.

44. A potentially compensable event (PCE) is documented in the a. health record b. risk management binder c. incident report d. sensitive records binder ANS: C REF: p. 311 OBJ: 5. Promote risk management functions within the organization as they relate to compliance with accreditation and regulatory bodies.

MSC: CAHIIM, V.3. Identify the components of risk management related to health information management.

45. To prevent accidental destruction, health records and computer systems are often kept in a(n): a. fire compartment b. water compartment c. safe room d. secret location ANS: A REF: p. 313 OBJ: 5. Promote risk management functions within the organization as they relate to compliance with accreditation and regulatory bodies.

MSC: CAHIIM, V.3. Identify the components of risk management related to health information management.

COMPLETION 1. A(n) business practices.

is a facility-wide system of policies, procedures, and guidelines that help to ensure legal and ethical

ANS: compliance program REF: p. 285 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

7

2. In civil law, the

brings a lawsuit against the defendant.

ANS: plaintiff REF: p. 287 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

3. A permission that is given after the event to which the permission applies is

.

ANS: retrospective consent REF: p. 301 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

4.

is a permission given by a competent individual, of legal age, with full knowledge or understanding of the risks, potential benefits, and potential consequences of the permission.

ANS: Informed consent REF: p. 291 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

5. A(n)

is a law that has been passed by the legislative branch of government.

ANS: statute REF: p. 285 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

6. The process of engaging in the legal proceedings of a lawsuit is

.

ANS: litigation REF: p. 287 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

7. The period in which lawyers are preparing their case and obtaining documents and testimonies is called

.

ANS: discovery REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

8.

is consideration of a patient as an adult even though the patient is younger than the statutory age.

ANS: Emancipation REF: p. 291 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

9. A(n)

is defined as a written document such as a living will or durable power of attorney for health care.

ANS: advance directive REF: p. 293 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

8

10. Many HIM professionals serve as the , the designated official in the health care organization who oversees privacy compliance and handles complaints as required by the Health Insurance Portability and Accountability Act (HIPAA).

ANS: privacy officer REF: p. 296 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

11. Only the

may waive the right to physician-patient privilege.

ANS: patient REF: p. 302 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

12. Individually identifiable health information that is transmitted or maintained in any form or medium by covered entities or their business associates is abbreviated .

ANS: PHI REF: p. 296 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

13. The right or responsibility to make legal decisions for someone else as a result of a legal document is

.

ANS: power of attorney REF: p. 291 | p. 292 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

14. The giving of health information to another, whether oral, photocopies, faxes, or emails, is called

.

ANS: disclosure REF: p. 297 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

MATCHING Match the following terms with their descriptions. a. Amendment b. Right to revoke c. Accounting of disclosures d. Notice of privacy practices e. Right to complain f. Designated record set g. Malpractice h. Negligence i. potentially compensable event (PCE) 1.

2.

3.

4.

5.

6.

7.

8.

9.

carelessness or lack of foresight that leads to harm failure to provider competent medical care that leads to harm The patient’s right to discuss his or her concerns about privacy violations.

A notice, written in clear and simple language, summarizing a facility’s privacy policies and the conditions for use or disclosure of patient health information.

A change to the original document.

The listing of the identity of those to whom certain protected health information has been disclosed.

A specific portion of the patient’s health information, consisting of medical records, reimbursement and payer information, and other information used to make health care decisions, all of which may be accessed by the patient under HIPAA provisions.

The right to withdraw consent or approval for a previously agreed on or approved procedure.

An event that could trigger litigation of cause financial harm

1. ANS: H REF: p. 287 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

9

2. ANS: G REF: p. 287 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

3. ANS: E REF: p. 300 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

4. ANS: D REF: p. 301 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

5. ANS: A REF: p. 298 | p. 299 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

6. ANS: C REF: p. 299 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

7. ANS: F REF: p. 298 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

8. ANS: B REF: p. 299 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

9. ANS: I REF: p. 311 OBJ: 5. Promote risk management functions within the organization as they relate to compliance with accreditation and regulatory bodies.

MSC: CAHIIM, V.3. Identify the components of risk management related to health information management.

Match the following terms with their descriptions. a. Conditions of admission b. Business record rule c. Hearsay rule d. Jurisdiction e. Custodian f. Subpoena ad testificandum g. Subpoena duces tecum h. Covered entity 10. A direction from an officer of the court to provide documents.

11. Under HIPAA and HITECH provisions, any organization that collects and manages health information.

12. An exception to the hearsay rule. It allows health records to be admitted as evidence in legal proceedings because they are kept in the normal course of business, recorded concurrently with the events that they describe, and are recorded by individuals who are in a position to know the facts of the events that are described.

13. The authority of a court to decide certain cases. May be based on geography, money, or type of case.

14. A direction from an officer of the court to provide testimony.

15. The court rule that prohibits most testimony regarding events by parties who were not directly involved in the event.

16. The legal agreement between the health care facility and a patient (or the patient’s legal agent) to perform routine services. It may also include the statement of the patient’s financial responsibility and prospective consent for release of information and examination and disposal of tissue.

17. The person entrusted with the responsibility to care for the confidentiality, privacy, and security of medical records.

10. ANS: G REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

11. ANS: H REF: p. 296 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

12. ANS: B REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

13. ANS: D REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

14. ANS: F REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

10

15. ANS: C REF: p. 288 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

16. ANS: A REF: p. 292 OBJ: 1. Understand the legislative and legal landscape as it pertains to health care delivery and health care documentation, and apply legal concepts and principles to the practice of health information management.

MSC: CAHIIM, V.1. Apply legal processes impacting health information.

17. ANS: E REF: p. 305 OBJ: 2. Comply with legal, ethical, and professional standards to protect patient privacy, especially regarding the provisions of the Health Insurance Portability and Accountability Act (HIPAA) MSC: CAHIIM, II.1. Apply privacy strategies to health information; V.2. Demonstrate compliance with external forces.

11

Chapter 9: Management and Leadership Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. In an organization chart, boxes indicate: a. subordination. b. authority. c. responsibility. d. departments or positions.

ANS: D REF: p. 320 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 2. Broken lines on an organization chart indicate: a. span of control. b. colleagues and coworkers. c. indirect or shared responsibility. d. departments or positions.

ANS: C REF: p. 320 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 3. Which is a function of the health care organization’s governing body? a. admit patients b. monitor progress toward objectives c. audit health records for compliance d. supervise staff ANS: B REF: p. 320 | p. 321 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 4. In dual governance, the governing body extends authority to the Chief Executive Officer (CEO) and the: a. Chief Information Officer b. Chief Nursing Officer c. Chief Operations Officer d. Chief Medical Officer ANS: D REF: p. 320 | p. 321 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 5. The number of employees or departments that report to one individual is referred to as the: a. span of control b. unity of command c. matrix reporting d. governing body ANS: A REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 6. A supervisor would most likely perform which task? a. Review financial reports for the health care facility. b. Develop a yearly budget for the health care facility. c. Conduct subordinate employee evaluations. d. Develop policies and procedures for various hospital departments.

ANS: C REF: p. 344 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 7. In the HIM department, Judy, the physician record clerk, is responsible to Deenie, the supervisor, and Michelle, the director.

Sometimes Judy is uncertain whose directions to follow. This violates the principle. a. unity of command b. span of control c. chain of command d. shared governance ANS: A REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None

1

8. Which is characteristic of shared governance? a. staff participate in decision-making b. two lines of control extend from the governing body c. supervisors are hands-on in departments d. clinical staff have more authority than non-clinical staff ANS: A REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 9. A cross-departmental chain-of-command that does not maintain a strict unity of command is: a. span of control b. shared governance c. matrix reporting d. workflow ANS: C REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 10. Managers perform to look for ways to streamline tasks and functions in the HIM department. a. workflow analysis b. matrix reporting c. performance improvement plans d. employee evaluation ANS: A REF: p. 323 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 11. Which is a function of a technical employee in the HIM department? a. assembly b. coding c. analysis d. supervision ANS: B REF: p. 323 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 12. “The suspension procedure will be performed weekly (as approved in the bylaws).” This is an example of a(n): a. plan. b. goal. c. objective. d. mission.

ANS: C REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

13. The HIM director established the following: “The HIM department delinquency percentage will not exceed 50% of average monthly discharge (AMD) by July 1.” This is an example of a(n): a. plan. b. goal. c. objective. d. mission.

ANS: B REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

14. Policies and procedures should be reviewed: a. annually and when significant changes occur. b. as needed. c. monthly. d. by the CEO through delegated authority from the governing board.

ANS: A REF: p. 328 | p. 329 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

15. Which would be a consideration in the development of a strategic plan? a. a community revitalization project downtown b. a new high-capacity printer-copier-scanner in the HIM department c. creating a second clinical documentation improvement (CDI) specialist position d. writing objectives to meet the goal of 95% positive patient surveys ANS: A REF: p. 325 | p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

2

16. The department’s accomplish. a. vision; mission b. mission; vision c. goal; objective d. objective; goal

statement defines its purpose, while its

statement indicates what it expects to

ANS: B REF: p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

17. Creation of organizational policies and procedures regarding how data are used is called: a. data governance b. information governance c. shared governance d. dual governance ANS: B REF: p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, I.6. Describe components of data dictionaries and data sets (DM) | CAHIIM, VI.1. Demonstrate fundamental leadership skills.

18. The development of policies and procedures to ensure the integrity and quality of data is called: a. data governance b. information governance c. shared governance d. dual governance ANS: A REF: p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, I.6. Describe components of data dictionaries and data sets (DM) | CAHIIM, VI.1. Demonstrate fundamental leadership skills.

19. Which is characteristic of a strong and meaningful objective? a. it supports the vision b. it effects policy c. it is measurable d. it is broad and far-reaching ANS: C REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

20. Which employment law prohibits discrimination based on race, color, religion, or sex? a. Fair Labor Standards Act b. Civil Rights Act c. Americans with Disabilities Act (ADA) d. Age Discrimination in Employment Act ANS: B REF: p. 332 OBJ: 2. Interpret compliance with local, state, and federal labor regulations.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

21. Which is NOT the responsibility of the human resources (HR) department? a. maintaining personnel records b. ensuring compliance with labor laws c. organizing department workflow d. terminating employees ANS: C REF: p. 331 | p. 332 | p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

22. To comply with ADA stipulations, a job description must include: a. the facility’s provider number. b. the starting salary for the position. c. educational requirements for the position. d. physical requirements of the position.

ANS: D REF: p. 332 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

3

23. The workload in the HIM department is determined by: a. the chief executive officer (CEO). b. the department director. c. admissions. d. the number of discharges, patient type, and length of stay.

ANS: D REF: p. 341 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

24. An employee who works fewer than 20 hours each week, who may earn partial benefits, is considered: a. full-time b. temporary c. part-time d. per diem ANS: C REF: p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

25. Which term is synonymous with the term “temporary employee?” a. full-time equivalent (FTE) b. per diem c. exempt d. outsourced ANS: B REF: p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

26. An HIM department budgets three FTEs for coding. If a full-time employee usually works 40 hours a week, how many hours per week are available for coding? a. 3 hours b. 40 hours c. 120 hours d. 100 hours ANS: C REF: p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

27. The normal work week is 40 hours and human resources are allocated based on total hours of effort per week. The HIM department is allowed 400 hours per week. This equals how many FTEs? a. 4.5 b. 22.5 c. 10 d. 45 ANS: C REF: p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

28. An advantage to outsourcing of HIM services to a vendor is: a. the facility is not responsible for the quality and integrity of the outsourced services. b. less internal time is required to monitor the expert, outsourced vendor services. c. the employee management responsibility is shifted to the outsourcing vendor. d. the signed contract is confirmation that the vendor is reputable.

ANS: C REF: p. 349 | p. 350 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

29. After being promoted to department manager, Rhea sits down with each staff member to record a(n) all the tasks the employee does. a. job analysis b. job description c. performance evaluation d. workflow analysis

, a list of

ANS: A REF: p. 361 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

4

30. Which is included in a job description? a. salary range b. required skills c. vacation time and benefits d. dress code ANS: B REF: p. 334 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

31. Which is indicative of poor employee retention? a. high salaries b. low productivity c. high turnover d. few internal candidates ANS: C REF: p. 336 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

32. Which interview question may be perceived as discriminatory? a. “Where do you see yourself in 5 years?” b. “How old are you?” c. “Do you have reliable transportation?” d. “Have you ever worked on a team?”

ANS: B REF: p. 339 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

33. Performance standards specify: a. education or skills requirements for a position. b. physical requirements for a position. c. the quality and quantity of work to be done in a given amount of time. d. number of employees in the department.

ANS: C REF: p. 340 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

34. One method of monitoring the amount of work an employee performs is: a. reviewing the organizational chart. b. reviewing the productivity report. c. HIM processing. d. patient care analysis.

ANS: B REF: p. 342 | p. 343 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

35. A(n) can be designed to obtain information manually about an employee’s performance, such as the time it takes to complete each task. a. manual productivity report b. computerized productivity report c. performance improvement plan d. employee evaluation ANS: A REF: p. 342 | p. 343 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

36. In a day’s work, a coder would expect to code the fewest of which type of record? a. ambulatory surgery records b. urgent care visit records c. inpatient records d. emergency department records ANS: C REF: p. 343 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

5

37. Which is a benefit of the employee evaluation? a. It is an opportunity to offer employee feedback. b. The findings are part of a job analysis. c. It is an opportunity to revise the job description. d. There is always a pay increase.

ANS: A REF: p. 344 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

38. Which should be the first step in addressing an employee’s poor performance? a. written warning b. probation or suspension c. consulting with HR d. counseling or verbal warning ANS: D REF: p. 344 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

39. What is the purpose of the performance improvement plan (PIP)? a. to notify employee of poor performance b. to increase department productivity c. to provide employee feedback d. to provide supervisor feedback ANS: A REF: p. 344 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

40. To make an employee familiar with his or her job and new surroundings, the employee must attend: a. training. b. orientation. c. in-service. d. department meeting.

ANS: B REF: p. 344 | p. 345 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

41. In an organization-wide orientation, the new employee is introduced to all of the following, EXCEPT: a. organization mission statement. b. infection control. c. confidentiality/Health Insurance Portability and Accountability Act (HIPAA). d. specific job responsibilities.

ANS: D REF: p. 344 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

42. Which is NOT found in the employee handbook? a. how many employees will be in the employee’s department. b. facility dress code. c. attendance policy. d. recognized holidays.

ANS: A REF: p. 346 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

43. In which way is the health information management department orientation different from the organization-wide orientation? a. The department orientation addresses infection control. b. The department orientation addresses specific job responsibilities. c. The department orientation addresses employee benefits. d. The department orientation includes a tour of the facility.

ANS: B REF: p. 348 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

6

44. Which topic is addressed during the physician orientation to the HIM department? a. suspension policy b. performance improvement plan (PIP) c. dress code d. building safety and security ANS: A REF: p. 348 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

45. Which of the following organization-wide orientation topics might be presented by an HIM employee? a. Safety b. Infection control c. Marketing strategies d. Confidentiality ANS: D REF: p. 347 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

46. Which is NOT a hallmark of good customer service? a. identifying customers by name b. greeting the customer with a smile c. finding someone else who can help the customer d. speaking in a serious tone ANS: D REF: p. 347 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

47. The “R” in the common safety acronym RACE used to describe the employee’s expected response to a fire means: a. red. b. run. c. rescue. d. reassure.

ANS: C REF: p. 347 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

48. Which is a frequent topic of communication between HIM department employees and physicians? a. information governance b. release of information c. hospital privileges d. the physician’s caseload ANS: B REF: p. 331 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

49. The HIM manager encourages the nine inpatient coders to discuss difficult cases with each other via the facilities’ internal e-mail system during certain days and at certain times. What is a likely outcome? a. Resentment for interruptions during the designated days and time b. Enhanced productivity c. Increase in gossip among the coders d. Unresolved disagreements ANS: B REF: p. 342 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

50. Which manager needs further training to handle conflict in the workplace? a. Jill makes sure both sides know that she respects their perspectives, even if she disagrees. b. Bill handles brings all parties to a private location to discuss the problem. c. Francis listens each employee. d. Selma does not offer a compromise; she lets the employees find a solution.

ANS: D REF: p. 351 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

7

51. An in-service on e-mail etiquette should mention that: a. email messages are not private communication. b. messages should be comprehensive. c. all-capital letters should be used when the message is extremely important. d. the supervisor should always be blind carbon copied (bcc’d).

ANS: A REF: p. 352 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

52. The first item on the monthly HIM department meeting agenda is: a. call to order. b. review of old business. c. new business. d. adjournment.

ANS: A REF: p. 353 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

53. Which is not on a meeting agenda? a. minutes from the previous meeting b. new business c. old business d. employee evaluation results ANS: D REF: p. 353 | p. 354 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

54. Which is used as a guide to prepare meeting minutes? a. Employee evaluations b. Meeting agenda c. Job description d. Memorandum ANS: B REF: p. 353 | p. 354 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

55. Who typically leads a meeting? a. timekeeper b. chairperson c. secretary d. recorder ANS: B REF: p. 356 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

56. An employee charged with developing a communication method for notifying physicians of records needing completion should ensure that the communication method is: a. strongly worded. b. friendly and chatty. c. brief and clear. d. apologetic.

ANS: C REF: p. 351 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

57. Which person leads by example? a. Elaine shifts responsibilities junior staff so that their supervisors have more time for professional development. b. Serena takes earned time off regardless of the needs of the department or facility. c. Reggie supports employees who disagree with certain facility policies. d. Don welcomes a non-English-speaking customer to the department.

ANS: D REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

8

58. One of your employees has reported to you that there is some negative gossip surrounding the food being eaten by one of your staff, who is from another country. What should you do about this report? a. Ignore it—you don’t manage based on gossip and rumors. b. Confront the “offending” staff member and tell them to eat only inoffensive food in the office. c. In collaboration with human resources, assess your staff for diversity and determine whether an in-service or some other training is needed. d. Counsel the employee who reported the gossip that gossip is inappropriate and what people eat is none of anyone else’s business.

ANS: C REF: p. 358 | p. 359 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

59. Which is an appropriate discussion in the HIM department? a. Whether the dress code should prohibit the wearing of religious clothing b. Creating a policy stating that religion is never a topic for discussion c. Creating a policy stating when it is acceptable to avoid another staff member because of their religion d. How to arrange holiday coverage, so that each person can recognize his or her individual religious holidays ANS: D REF: p. 359 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

60. An HIM department learns that a part of their release of information function is being outsourced to employees located in another country. The HIM department staff have commented negatively about the people who live in this country and are reluctant to work with them. What is one step that should be taken to address this situation so that the release of information function can succeed? a. Review cultural assumptions, biases, and stereotypes related to the things that make the people in the other country different. b. Validate the staff’s concerns by agreeing with them. c. Lighten up the atmosphere by making jokes about the other country. d. Make working with the people from the other country on a volunteer basis only.

ANS: A REF: p. 358 | p. 359 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

61. Which is a part of the AHIMA Code of Ethics? a. valuing the needy more than the wealthy b. promoting the self-actualization of every person c. being mindful of differences d. respecting the rights of workers ANS: C REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

62. Which individual displays cultural competence? a. James plays a different kind of music in the office every day. b. Kerra is tolerant of the differences she sees in others. c. MacKenzie changes her behavior depending on the needs of her customers. d. Gail treats everyone the same.

ANS: C REF: p. 358 | p. 359 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

63. Which is one of the National Standards on Culturally and Linguistically Appropriate Services (CLAS)? a. no-cost preventative care services to members of minority groups b. free language assistance services c. improved access to complementary and alternative medicine d. recruitment and promotion of racial and ethnic minorities in leadership positions ANS: B REF: p. 359 | p. 360 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

9

64. What type of leader is also called a micromanager? a. democratic b. laissez-faire c. autocratic d. diminutive ANS: C REF: p. 357 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

65. Which manager needs more education on effective leadership? a. Bryn delegates responsibilities as she can. b. Scott encourages his staff to think of ways to improve. c. John maintains a “closed door” policy. d. Finley comes to work early and stays late.

ANS: C REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

66. The first step in planning training or in-service program is: a. assessment of education needs. b. selecting a trainer. c. choosing a site for training. d. identifying the proper format.

ANS: A REF: p. 361 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

67. Which dates are critical to the continuing education of inpatient coders? a. January 1 & 2 b. April 1 and October 1 c. December 1 and July 30 d. July 1 and December 31 ANS: B REF: p. 362 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

68. What type of training provides continuing education for current employees, mandated by some accreditation agencies? a. orientation b. in-service c. RACE training d. performance improvement plans (PIPs) ANS: B REF: p. 360 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

69. The coding manager conducts a monthly audit of inpatient cardiac surgical cases and finds an average error rate of 10% for all of the coders. A training session is scheduled that includes a group lecture on cardiac surgery by an intern, and a presentation of the corresponding correct codes by the coding manager, followed by individual tests. What training formats are described? a. Passive and active b. Active and collaborative c. Passive, active, and collaborative d. Collaborative and passive ANS: A REF: p. 361 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

70. What distinguishes development from training? a. Development is the continuation of initial training specific to a job function. b. Development is an investment in the employee by the organization that will pay off in the future. c. Training is for new employees while development is for employees who have passed their probation period. d. Training involves a general overview of a job function, while development involves the details of a job function.

ANS: B REF: p. 360 | p. 361 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

10

COMPLETION 1. In his HIM department, Steve decided it would be more efficient to perform the transcription process at the same time as assembly. Steve is going to change the in the department.

ANS: workflow REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 2.

is the formal authority and decision-making structure within an organization.

ANS: Chain of command REF: p. 320 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None

3. The organization.

is an illustration used to describe the relationship between departments, positions, and functions within an

ANS: organization chart REF: p. 320 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 4. Janet is a supervisor responsible for eight coding employees. This statement represents Janet’s

of control.

ANS: span REF: p. 322 OBJ: 1. Describe the organizational and governance structures of health care organizations and HIM departments.

MSC: None 5. The purpose of the organization documented in a formal statement is known as the

.

ANS: mission REF: p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

6. Above and beyond the mission statement, a(n)

sets a direction for the organization for the future.

ANS: vision REF: p. 326 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

7. The following is a(n) tested.

of Diamonte Hospital, an equal opportunity employer: All new hires will be drug

ANS: policy REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

8. A process that describes how to comply with a policy is a(n)

.

ANS: procedure REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

9. To reach a desired goal the department must establish measurable

, directions for achieving a goal.

ANS: objectives REF: p. 328 OBJ: 2. Articulate the process of strategic and operational planning.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

11

10. A full-time facility.

works 32-40 hours each week excluding overtime, earning benefits as offered by the health care

ANS: equivalent REF: p. 333 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

11. A formal list of the employee’s responsibilities associated with his or her job is called a(n)

.

ANS: job description REF: p. 334 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

12.

is the amount of work produced by an employee in a given time frame.

ANS: Productivity REF: p. 342 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

13. A(n) employee’s job.

involves the review of a function to determine all of the tasks or components that make up an

ANS: job analysis REF: p. 361 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

14.

are set guidelines explaining how much work an employee must complete.

ANS: Performance standards REF: p. 340 OBJ: 3. Articulate the value of human resources and human resources processes to the work of the organization and the delivery of health care.

MSC: CAHIIM, VI.3. Identify human resource strategies for organizational best practices.

15. The term memo, a written/typed communication tool used to communicate or provide information to members of an organization, is short for .

ANS: memorandum REF: p. 351 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

16. A(n)

is used to organize the topics to be discussed during a meeting.

ANS: agenda REF: p. 353 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

17.

are used to record the events, topics, and discussions of a meeting.

ANS: Minutes REF: p. 353 | p. 354 OBJ: 4. Practice professional oral and written communication in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills.

12

18. As the new supervisor, Sandra feels overwhelmed by the number of projects needing her attention. One way that Sandra work more efficiently is to some of the projects to her employees.

ANS: delegate REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

19. The term used to describe the training to familiarize a new employee with the job is

.

ANS: orientation REF: p. 344 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

20. Many facilities require a training session before new employees are given access to their computer systems, and The Joint Commission requires that new employees complete this training within days.

ANS: 7 REF: p. 348 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

21.

education may be required after attaining a position, credential, or degree to keep those persons knowledgeable in core content areas.

ANS: Continuing REF: p. 364 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

22. The period of time, also known as a grace period, given to a new employee to learn the job and reach the performance standards associated with that job is known as the period.

ANS: probation REF: p. 344 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

23. Melissa has been working in the HIM department as an assembly clerk for the past 6 months, but during her evaluation she asked her supervisor if she could train to become a coder. The supervisor has approved Melissa’s .

ANS: cross-training REF: p. 361 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

24. An in-service is training provided to

for continued or reinforced education.

ANS: employees REF: p. 360 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

25. Whether an employer provides training or not, HIM professionals must earn a certain number of year to maintain their credentials.

(CE) hours each

ANS: continuing education REF: p. 364 OBJ: 6. Facilitate training and development for health care professionals.

MSC: CAHIIM, VI.9. Identify processes of workforce training for health care organizations.

13

MATCHING Match the following leadership qualities with an example of each. a. Delegation b. Leading by example c. Support the staff with regular feedback d. Remove obstacles e. Be accessible f. Encourage improvement g. Develop staff 1.

2.

3.

4.

5.

6.

7.

Behave in a manner that encourages the best in others Ensure the staff has the right equipment and the appropriate workload Allow others to handle duties and responsibilities Praise staff for a job well done Maintain an “open door” policy Solicit suggestions from staff Invest in staff training and career counseling

1. ANS: B REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

2. ANS: D REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

3. ANS: A REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

4. ANS: C REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

5. ANS: E REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

6. ANS: F REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

7. ANS: G REF: p. 358 OBJ: 5. Identify leadership strategies and advocate for diversity in the workplace.

MSC: CAHIIM, VI.1. Demonstrate fundamental leadership skills. | CAHIIM, VI.6. Examine behaviors that embrace cultural diversity | CAHIIM, VI.7. Assess ethical standards of practice.

14

Chapter 10: Performance Improvement and Project Management Davis: Foundations of Health Information Management, 5th Edition MULTIPLE CHOICE 1. The term a. benchmarking b. sentinel event c. affinity d. outcome

describes the results of a patient’s treatment and is often used to judge quality.

ANS: D REF: p. 372 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

2. CMS reviews to inspect the quality of health care delivery and to address beneficiaries’ concerns about the health care provider care are completed by: a. National Committee for Quality Assurance (NCQA). b. The Joint Commission (TJC). c. quality improvement organizations (QIOs). d. The Department of Health and Human Services (DHHS).

ANS: C REF: p. 376 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

3. Which pattern of behavior might prompt a Quality Improvement Organization (QIO) review? a. ordering x-rays instead of CT scans b. rarely using CC or MCC codes c. discharging patients too soon d. taking too many transfers ANS: C REF: p. 376 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

4. What is the focus of quality improvement in health care? a. the facility b. the payer c. the patient d. the provider ANS: C REF: p. 376 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

5. The assignment of deemed status grants Medicare COP certification when a facility is accredited by The Joint Commission or which other organization? a. National Committee for Quality Assurance (NCQA) b. National Integrated Accreditation for Health care Organizations (NIAHO) c. Commission on Accreditation of Rehabilitation Facilities (CARF) d. Health care Facilities Accreditation Program (HFAP) ANS: B REF: p. 374 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

6. How does the American National Standards Institute (ANSI) promote quality? a. by accrediting institutions of higher learning b. by accrediting accreditation agencies c. by accrediting hospitals d. by accrediting standards developers ANS: D REF: p. 374 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

7. Which is a component of the Total HAC Score under the CMS Hospital-Acquired Condition Reduction Program? a. cases of urinary tract infections from catheters b. cases of pneumonia from ventilators c. cases of mumps d. accidental needle sticks ANS: A REF: p. 375 | p. 376 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

1

8. What is the source of data for the CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? a. a random selection of discharged patients b. providers with privileges at the institution c. independent auditors d. HIM department supervisors ANS: A REF: p. 376 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

9. Which program provides a report that can be used by the hospital to initiate an internal review of overcoding, undercoding and other billing accuracy problems? a. Program for Evaluating Payment Patterns Electronic Report (PEPPER) b. Comprehensive Error Rate Testing (CERT) program c. recovery audit contractor (RAC) program d. Hospital Compare ANS: A REF: p. 377 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

10. Which is an initiative to detect and prevent fraud? a. Program for Evaluating Payment Patterns Electronic Report (PEPPER) b. Comprehensive Error Rate Testing (CERT) program c. QualityCheck d. Hospital Compare ANS: B REF: p. 377 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

11. Which process determines the facility’s compliance with documentation standards? a. Physician profile review b. Record review c. Medication review d. PDSA ANS: B REF: p. 382 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

12. Which example would a health care administrator use to improve HIM department quality? a. The percent of records that are not complete within a 30-day period b. The percent of bed occupancy c. The percent of patients who obtained a nosocomial infection d. The average length of stay ANS: A REF: p. 381 | p. 382 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

13. Ensuring the documentation in a health record is complete is part of: a. quantitative analysis. b. qualitative analysis. c. utilization review. d. case management.

ANS: A REF: p. 388 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

14. The term used to describe the continuous improvement of processes within a facility is: a. quality assurance. b. quality management. c. performance improvement. d. brainstorming ANS: C REF: p. 381 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

15. A surgeon left a surgical instrument in a patient’s abdomen. This is an example of a occur. a. sentinel b. affinity c. evidence-based d. GANTT

event, which should never

ANS: A REF: p. 381 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

2

16. Who is responsible for the quality management theory that aims for zero defects from the standard? a. Juran b. Crosby c. Deming d. Donabedian ANS: B REF: p. 379 OBJ: 2. Explain quality management efforts within the HIM department and the facility.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

17. In the popular PDSA quality improvement method, which step of the process involves monitoring effectiveness of the solution over a period of time? a. Plan b. Do c. Study d. Act ANS: C REF: p. 383 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

18. Which of the following medical staff committees reviews medication usage? a. Surgical case review b. P&T committee c. Medical executive committee d. Credentials committee ANS: B REF: p. 388 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

19. Which of the following committees acts as a liaison from the departments of the medical staff to the governing board of the facility? a. Surgical case review b. P&T committee c. Medical executive committee d. Credentials committee ANS: C REF: p. 388 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

20. The committee often responsible for reviewing health care records according to accreditation standards, physician record completion statistics, and acting as a consultant to the director of health information management is the committee. a. health information management (HIM) b. safety c. infection control d. P&T ANS: A REF: p. 388 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

21. What does Shewhart use to graph unacceptable variances in key process indicators? a. GANTT chart b. fishbone chart c. process control chart d. PERT chart ANS: C REF: p. 379 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

22. What helps new team members get to know each other? a. ice breakers b. icebergs c. decision matrices d. root cause analysis ANS: A REF: p. 389 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

3

23. In the fishbone diagram, what does the head of the fish represent? a. the solution b. the problem c. the input d. the purpose ANS: B REF: p. 390 | p. 391 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

24. What does the PERT chart show? a. the shortest possible time in which the project can be completed. b. the longest possible time the project will take. c. the number of people required to work on a project. d. the unity of command within the project.

ANS: B REF: p. 397 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

25. Which is a characteristic of a GANTT chart? a. upper and lower thresholds b. standardized symbols showing an action c. the display of factors that can change a variable d. the sequence of events of a project ANS: D REF: p. 396 | p. 397 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

26. A GANTT chart is useful during which process? a. change management b. project management c. risk management d. case management ANS: B REF: p. 396 | p. 397 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

27. Which is a principle of change management? a. a grassroots approach b. identification of key stakeholders c. communicating the need for change to all staff d. preparing disciplinary action for those who resist ANS: C REF: p. 397 | p. 398 | p. 399 OBJ: 4. Promote change management in the organization.

MSC: CAHIIM, VI.2. Identify the impact of organizational change 28. Which statement is true of change management? a. it happens organically b. it is more difficult for senior staff c. unexpected issues can arise d. it usually involves staffing changes ANS: C REF: p. 397 | p. 398 | p. 399 OBJ: 4. Promote change management in the organization.

MSC: CAHIIM, VI.2. Identify the impact of organizational change COMPLETION 1. The Joint Commission’s provide guidance or recommend procedures on issues like accurate patient identification, communication among health care providers, medicine safety, health care-associated infections, reduction of patient falls, and risk assessment.

ANS: National Patient Safety Goals REF: p. 374 | p. 375 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

2. In CMS’s Hospital Value-Based Purchasing Program, a hospital is reimbursed based on how much it improves from its .

ANS: baseline REF: p. 375 OBJ: 1. Discuss the evolution of quality initiatives in health care.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

4

3. The PI methodology called

seeks to improve a process by eliminating waste and inefficiency.

ANS: Lean REF: p. 385 | p. 386 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

4. To improve quality according to a standard, a health care facility may use superior performer.

, the comparison of itself to a similar or

ANS: benchmarking REF: p. 391 | p. 392 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

5.

is a quality improvement technique used to elicit participation and information from an entire group.

ANS: Brainstorming REF: p. 389 | p. 390 | p. 391 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

6. A supervisor and her team of employees are confronted with two solutions to a problem. Each solution involves time, money, and space. The supervisor might use a quality management tool called a(n) .

ANS: decision matrix REF: p. 396 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

7. A quality improvement effort regarding completion of the patient advance directive would require a(n) with members from different departments.

team,

ANS: interdepartmental REF: p. 381 | p. 382 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

8. A quality improvement effort to make batch scanning and indexing more efficient would require a(n) people from within the HIM department.

team of

ANS: intradepartmental REF: p. 381 | p. 382 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

9. A(n)

chart is useful for organizing the results of a brainstorming session.

ANS: fishbone REF: p. 389 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

10. A(n)

diagram is a method of grouping ideas based on relationships.

ANS: affinity REF: p. 391 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

11. In a(n)

group technique, group members offer solutions which are then ranked by favorability.

ANS: nominal REF: p. 391 OBJ: 3. Apply performance improvement techniques in health information management.

MSC: CAHIIM, VI.4. Utilize data-driven performance improvement techniques for decision making.

5