Medical Records Management Exam Preparation Guide
Course Introduction
Medical Records Management introduces students to the principles, practices, and technologies involved in maintaining and securing patient medical records within healthcare settings. The course covers the organization, storage, retrieval, confidentiality, and legal aspects of health information management. Emphasis is placed on electronic health records (EHR), data entry standards, privacy regulations such as HIPAA, and the role of accurate documentation in patient care and healthcare operations. Students also explore contemporary challenges in managing medical records and learn practical strategies to ensure the integrity and accessibility of vital health information.
Recommended Textbook
Health Information Management of a Strategic Resource 5th Edition by Mervat Abdelhak
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18 Chapters
1158 Verified Questions
1158 Flashcards
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Page 2
Chapter 1: Health Care Systems
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83 Verified Questions
83 Flashcards
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Sample Questions
Q1) Of the levels of health care, a complete physical examination would be categorized to which level?
A) Primary
B) Secondary
C) Tertiary
D) Alternative
Answer: A
Q2) The CEO is employed by and is directly responsible to the
A) Governing body.
B) Joint conference committee.
C) Medical staff organization.
D) Executive committee.
Answer: A
Q3) The accrediting agency for rehabilitation facilities is
A) Commission on the Accreditation of Rehabilitation Facilities
B) Community Health Accreditation Program
C) American Osteopathic Association
D) Accreditation Commission for Education in Nursing National League of Nursing
Answer: A
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Page 3
Chapter 2: The Health Informatics and Information
Management Profession
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50 Flashcards
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Sample Questions
Q1) The earliest medical records in the United States had some characteristics of a business record.
A)True
B)False
Answer: True
Q2) Fee-for-service reimbursement was mandated in the early 1980s for all inpatients and outpatients.
A)True
B)False Answer: False
Q3) Continuing education is mandatory for maintenance of certification as a health information professional.
A)True
B)False
Answer: True
Q4) Requirements for the licensing of health care organizations are called "regulations."
A)True
B)False
Answer: True
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Chapter 3: Health Information Infrastructure and Systems
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42 Flashcards
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Sample Questions
Q1) Governmental agencies participate in the Consolidated Health Information Initiative plan to share medical information with one another.
A)True
B)False
Answer: True
Q2) Describes clinical drugs.
A)HL7
B)DICOM
C)NCPDP
D)IEEE 1073
E)CHI
F)RxNorm
G)SNOMED
H)ASTM 1384
I)LOINC
J)HIPAA transactions
Answer: F
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Page 5
Chapter 4: Health Data Concepts and Information
Governance
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121 Verified Questions
121 Flashcards
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Sample Questions
Q1) Data uniformity is one characteristic of a health care data set.
A)True
B)False
Q2) RAI
A)Comprehensive assessment of a long-term care patient
B)Data content standard by ASTM
C)Data set for hospitals used by federal and state agencies for billing
D)Agency that collects vital statistics data
E)Data set for ambulatory care
F)Agency that accredits rehabilitation organizations
G)Data set for home health care
H)Agency that encourages the use of guidelines to improve health care
I)Data set for long-term care
Q3) Referring to the information below, is the list of sources complete?
Coding Scheme for Admission Type
1 = physician office
2 = emergency services
3 = outpatient clinic
4 = PPO, IPO
5 = transfer from a nursing home
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Chapter 5: Data Access and Retention
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Sample Questions
Q1) Name one component of a quality proposal for acquisitions approval.
Q2) In a paper and hybrid health record environment, preparation for disaster recovery includes
A) Training staff in locating and when and how to use sprinkler shutoff valves.
B) Training staff on how and when to use fire extinguishers.
C) Locating and researching restoration specialists.
D) All of the above.
Q3) Referring to the information above, when was Mr. Rocky States last treated as an outpatient?
Q4) In a file conversion to a terminal digit system, there are four project phases. The first three phases are 1) transport records to sort area and back to file, 2) rough-sort into 10 terminal digit sections, 3) secondary-sort into 00, 01, 02, and so on. The last project phase is
Q5) The health information manager is analyzing the "Unsatisfied Requests Listing" produced by the automated record tracking system. Is this a management-type report produced by the system?
A)True
B)False
Q6) List an advantage of using color coding in a storage and retrieval system.
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Chapter 6: Electronic Health Record Systems
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Sample Questions
Q1) In an electronic health record system, how are chest x-rays processed?
A) Image
B) Video
C) Drawing
D) Signal
Q2) There is no easy way to check for data and information consistencies in paper records.
A)True
B)False
Q3) Expected electronic health record functions include
A) 24/7 availability.
B) Links to external databases.
C) Computerized practitioner order entry.
D) All of the above.
Q4) A repository of selected electronic information from several transaction systems such as clinical laboratory and dietary is called a(n) ____________________.
Q5) Contrast a decision-support and an executive information system.
Q6) A repository of electronic information about a single patient compiled during an inpatient stay is called a(n) ______________________________.
Page 8
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Chapter 7: Classification Systems, Clinical Vocabularies and Terminology
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66 Flashcards
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Sample Questions
Q1) Develops standards for pharmacy information
A)MeSH
B)ASTM
C)DICOM
D)CHI
E)CAP
F)RELMA
G)HITSP
H)LOINC
I)NCVHS
J)NCPDP
K)IEEE
L)ISO
M)WHO
N)UMLS
O)NDC
Q2) What is the purpose of using a naming nomenclature and standard document titles in an electronic health record system?
Q3) List five characteristics of useful clinical terminologies.
Q4) Describe the purposes of coding diseases and operations.
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Chapter 8: Technology, Applications and Security
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Sample Questions
Q1) The Health Insurance Portability and Accountability Act (HIPAA) Security Rule specifies specific software applications that are required for two-factor authentication.
A)True
B)False
Q2) A point-of-care health information system includes bedside workstations, biomedical devices, and local area networks (LANs).
A)True
B)False
Q3) List one benefit of using an interface engine instead of a point-to-point interface.
Q4) In the relational model, a patient has two different patient identification numbers from different clinics within a health system. How would the relationship be defined for the patient's social security number and these patient identifiers?
Q5) QR code technology allows for all kinds of documents to contain a QR code and be able to be read without a specialized bar code scanner.
A)True
B)False
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Chapter 9: Health Information Systems: Collaboration,
Analysis, Design, Implementation, and Operations
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Sample Questions
Q1) All of the following support principles of good interface design EXCEPT
A) Systems response to user commands should be quick.
B) Screens should be layered or windowed.
C) Navigation tools should be provided.
D) Display screens should have limited blank space.
Q2) The phases of development, growth maturity, and deterioration are generally considered the
A) Information systems life cycle.
B) System development life cycle.
C) General system life cycle.
D) Strategic Plan.
Q3) Which of the following questions would be considered a structured question in an interview process?
A) Which of the following word processing software do you use?
B) What do you consider to be the most critical problems with your current system?
C) What features in a computer system are most important to support your daily work tasks?
D) What are your three or four most important tasks?
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Chapter 10: Statistics and Data Presentation
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Sample Questions
Q1) The standard deviation is the most common measure of variation and is represented by the symbol S.
A)True
B)False
Q2) Ten patients were discharged from the obstetrical service on May 4 at Rocky Mountain Hospital. The day's stay for each patient was 3, 2, 1, 1, 6, 5, 1, 2, 2, and 4. What was the median day's stay for these patients?
A) 1
B) 2
C) 3
D) 4
Q3) In an 800-bed health care facility during the month of January the total inpatient days for adults were 13,500. What was the percentage of occupancy?
A) 54.9%
B) 54.4%
C) 60%
D) 55.4%
Q4) A whole number divided in 100 parts is a ____________________.
Q5) The ____________________ is the average number of observations.
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Chapter 11: Research and Epidemiology
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Sample Questions
Q1) Specificity
A)Faulty memory
B)The tendency to select persons under frequent medical care
C)The tendency to ask questions differently or probe more if it is known that the person has the disease
D)Quantifies the amount of risk due to a certain characteristic Ire/IRo
E)The ability of a test instrument to measure what it is supposed to measure
F)Identified by pre-existing records developed in the past
G)Accumulated period of time each person is in the study
H)Percent of all True non-cases correctly identified
I)Reliability between more than one research assistant or observer
J)Examples: all new employees within a hospital, all new students in the first grade
Q2) Life-table analysis is most appropriate for prospective or experimental studies.
A)True
B)False
Q3) In a cohort study, two groups free of disease are followed forward in time.
A)True
B)False
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13
Chapter 12: Performance Management and Patient Safety
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Sample Questions
Q1) To achieve lasting performance improvements, managers should focus on
A) Training people in performance management skills.
B) Testing redesigned processes.
C) Keeping abreast on changing regulations and incentives having to do with performance improvement.
D) All of the above.
Q2) Which of the following is not one of the core measure areas for the Joint Commission?
A) Acute myocardial infarction
B) Heart failure
C) Community-acquired pneumonia
D) Palliative care
Q3) Lean thinking is more about cost containment than about customer focus.
A)True
B)False
Q4) Structure measures of quality are dynamic indicators of organizational performance.
A)True
B)False
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Chapter 13: Data Analytics: Reporting, Interpretation, and Use
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58 Verified Questions
58 Flashcards
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Sample Questions
Q1) The International Classification of Diseases for Oncology, 3rd edition (ICD-O-3) serves as the basis for developing reportable cases for registry eligibility in a hospital cancer program.
A)True
B)False
Q2) Big data are characterized with Velocity, Volume, and Variety. Velocity is talking about
A) Collecting real-time data to capture live streaming events and moments with speed or frequency of data generation.
B) A large amount of data from patient care.
C) Data structured in different formats with multiple applications.
D) Both b and c
Q3) The Certified Health Data Analyst (CHDA) is a newly created credential offered by the American Cancer Society.
A)True
B)False
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15
Chapter 14: Public Health Informatics
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40 Flashcards
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Sample Questions
Q1) One Health Port services in Washington State include(s)
A) Standard mapping for the continuity of care document.
B) Physician orders for controlled substances.
C) Eligibility verifications.
D) Both a and c
Q2) The Healthcare Effectiveness Data and Information Set report card system aggregates data across health care plans and produces a report entitled
A) The Quality Chasm.
B) Healthy People 2020.
C) State of Health Care Quality.
D) Use Case Examples for Health Information Exchange.
Q3) Public health focuses on what society can do to assure healthy conditions for its citizens and concentrates on populations, not individuals.
A)True
B)False
Q4) Assuring and supporting healthy pregnancies is considered a core public health activity.
A)True
B)False
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Chapter 15: Privacy and Health Law
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Sample Questions
Q1) Persons who violate the patient's right to release his/her health information to another provider can be held liable.
A)True
B)False
Q2) Referring to the scenario below, would you agree that the defendant is more likely to win this case because the doctrine of res ipsa loquitur probably does NOT apply here? Assume that at a medical malpractice trial alleging postoperative infection, exactly 50% of the evidence favors the plaintiff, and 50% of the evidence favors the defendant physician and hospital. Among the defendant's evidence is some indication that the patient did not comply with postoperative care instructions, including taking antibiotics to fight infection.
A)True
B)False
Q3) By use of incident reports, nursing staff repeatedly report a physician for yelling at patients and their families. This action by the nurses may be grounds for the physician to claim that his good name is damaged or defamed.
A)True
B)False
Q4) The U.S. Bill of Rights is a source of ____________________ law.
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Chapter 16: Human Resource Management
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Sample Questions
Q1) Explain how the tool shown above would be useful in human resources planning.
Q2) When a HIM manager is using a systematic process to gather and analyze information to describe data analytic jobs, she is using
A) Strategic analysis.
B) Job evaluation.
C) Job analysis.
D) Pay structure.
Q3) The National Labor Relations Act prohibits employers from engaging in which specific unfair labor practices?
Q4) Effective diversity management
A) Suppresses all conflicts based on racial or ethnic tensions.
B) Insures that the number of employees in the workplace are equally balanced in terms of gender, race, disability status, and sexual orientation.
C) Provides a culture in which employees and clients accept and value individual differences.
D) All of the above.
Q5) What are some methods a manager may use to provide regular feedback to staff and keep communication lines open?
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Chapter 17: Operational Management
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Sample Questions
Q1) The work flow process chart is being used by the health information manager to gather data about the release-of-information (ROI) process. Which of the following represents data about a delay in the ROI process that would be found by using a work flow process chart?
A) The ROI employees have an attitude problem.
B) The ROI staff are not cross-trained.
C) One staff member is working a lot of overtime.
D) It takes 15 days to get a record copied.
Q2) When the chairman of the Health Record Committee writes to the HIM director about the quality of the monthly incomplete and delinquent medical record reports, he is providing the HIM director _______________.
Q3) When planning a project implementation in a small physician office, the _________________describes how the EHR system will function when fully implemented.
Q4) In the process of determining the ____________________ for health information services, answers must be developed for these questions: "Who are we?" and "What are we?"
Q5) The color red has the effect of putting workers to sleep.
A)True
B)False
Page 19
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Chapter 18: Revenue Cycle and Financial Management
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Sample Questions
Q1) The manager wants to calculate the operating margin ratio to evaluate the use of the department's resources in achieving its desired goals. What formula (data) should be used?
Q2) In preparation for implementing the system, the health information manager assigned a fee to the various services that will be provided by the Health Information Services department, including that for the new health information imaging service for physician offices. These charges will be incorporated in the ______________________________ by the managerial accountant.
Q3) Referring to the information given, compute the operating margin ratio.
Q4) In addition, the Capital Expenditure Committee will examine the _______ to determine objectively whether the benefits to be received from the optical imaging system are the best alternative use of the organization's investment funds.
A) Charge master
B) Opportunity cost
C) Ratio analysis
D) Both b and c
Q5) Referring to the information given, compute the operating margin ratio.
Q6) Define the terms variable costs and fixed costs. Give examples of each.
Q7) Referring to the information given, compute the current ratio.
Page 20
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