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A critical early step in designing an EHR is to develop a(n)___ in which the characteristics of each data element are defined. A. Accreditation manual 2 Once a hospital discharge abstract system were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: A. Data sets 3 In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: A. Provide uniform data definitions 4 A health information technician is responsible for designing a data collection form to collect data on patients in an acute care hospital. The first resource that he or she should us is: A. UHDDS 5 Which of the following is not a characteristic of the common healthcare data set such as UHDDS and UACDS? A. They define minimum data elements to be collected 6 A corporation is evaluating several health plans for its benefits package. The data set that provides the comparison information about health plan performance is: A. ORYX 7 The name of the government advisory group that makes proposals for improvement of basic data sets for health records and computer database is: A. Centers for Medicare and Medicaid Services 8 The primary purpose of a minimum data set in healthcare is to: A. Recommend common data elements to collected in health records 9 The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the: A. Ambulatory Care Data Set 10 Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: A. Performance improvement programs 11 The focus of out patient data collection in the UACDS is on: A. Reason for admission 12 In long-term care, the resident's care plan is based on data collected in the: A. UHDDS 13 Reimbursement for home health services is dependent on data collection from: A. HEDIS 14 Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for: A. Government regulations 15 A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is: A. Continuity of Care Record 16 The home health prospective payment system uses the _____ data set for patient assessments A. HEDIS 17 The government agency most closely involved in the development of healthcare data sets and information standards is: A. Centers for Medicare and Medicaid Services 18 The data set designed to organize data for public release about the outcomes of care is: A. UHDDS 19 OASIS data are used to assess the _____ of home health service. A. Outcome 20 Which of the following includes patient-identifiable information? A. MEDLINE 21 A notation for a diabetic patient in a physicians progress notes reads; "Occasionally gets hungry. No insulin reactions. Says she follows her diabetic diet." In which part of a POMR progress note would this be written? A. Subjective 22 A notation for a diabetic patient in a physicians progress note reads: "FBS 110 mg%, urine sugar, no acetone," In which part of POMR progress note would this be written? A. Subjective 23 A notation for hypersensitive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mg once daily. Return visit in 2 week." In which part of a POMR progress note would this be written? A. Subjective 24 A notation for a hypersensitive patient in ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this be written? A. Subjective 25 A specific set of terms that may be used in an EHR is referred to as a: A. Classification 26 Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services? A. Current Procedural Terminology 27 Which of the following is a classification system specifically for coding histology, topography, and behavior of neoplasms? A. Current Procedural Terminology 28 Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records? A Current Procedural Terminology 29 Which of the following is a system for classifying morbidity and mortality information for statistical purposes? A. Current Procedural Terminology 30 Which of the following is not a knowledge source for users of the Unified Medical Language System? A. Concept table 31 Nosology can be defined as the branch of medical science that deals with: A. Cosmetic surgery 32 Which of the following classifications is used exclusively for classifying cases of malignant disease? A. CPT 33 Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record? A. CPT 34 WHich of the following provides a set of codes used for collecting data about substance abuse and the mental health disorders? A. CPT 35 Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? A. Data compliance 36 Mrs. Smith's admitting data indicates that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? A. Data compliance 37 The term used to describe expected data value is: A. Data definition 38 The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as a carcinoma on the discharge summary. This is an example of a problem with: A. Data granularity 39 Which of the following is a primary weakness of the paper-based health record? A. Difficulty to provide availability to a number of providers at the same time 40 Which of the following elements is not a component of most patient records? A. Patient Identification 41 Which of the following is not a characteristic of high-quality healthcare data? A. Data relevancy 42 Which of the following represents an example of data granularity? A. A progress note recorded at or near the time of the observation 43 Which of the following is a primary purpose of the health record? A. Document patient care
delivery 44 Which of the following best describes data accuracy? A. Data are correct 45 Which of the following best describes data comprehensiveness? A. Data are correct 46 Which of the following best describes data accessibility? A. Data are correct 47 In which department or unit is the health record number typically assigned? A. HIM 48 Identify where the following information would be found in the acute-care record; "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion." A. Anesthesia report 49 Identify where the following information would be found in the acute-care record: "CBC, WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MVC 93." A. Medical laboratory report 50 Identify where the following information would be found in the acute-care record; "PA and Lateral Chest: The lungs are clear. the heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine." A. Medical Laboratory report 51 The attending physician is responsible for which of the following types of acute-care documentation? A. Consultation report 52 A nurse is responsible for which of the following types of acute-care documentation? A. Operative report 53 Which of the following is an example of clinical data? A. Admitting diagnosis 54 Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of speciality record? A. Home health 55 The following is documented in a acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear? A. History 56 The following is documented in acute-care record; "Microscopice: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear? A. History 57 The following is documented in an acute-care record: "Admit ti 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear? A. Physician order 58 The following is documented in an acute-care record: "The patient was places in the supine position and prepped and draped in the usual manner. Following induction of anesthesia, an incision was made." In which of the following would this documentation appear? A. Anesthesia record 59 The following is documented in an acute-care record: "Gluc 97, BUN 12, K 40, and PHOS 3.0." In which of the following would this documentation appear? A. Anesthesia report 60 The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear? A. Admission note 61 The following is documented in an acute-care record; "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear? A. Admission order 62 The following is documented in an acute-care record; "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following documentation would this appear? A. Admission note 63 The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral, Case manager to meet with patient and family." In which of the following documentation would this appear? A. Admission note 64 Which of the following is not usually a part of quantitative analysis review? A. Checking that all forms contain the patient's name and health record number 65 Which of the following materials is not documented in an emergency care record? A. Patient's instructions at discharge 66 Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? A. Anesthesia report 67 Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in which of the following records? A. Emergency 68 In a problem-oriented medical record, problems are organized: A. In alphabetical order 69 Which of the following best describes an integrated health record format? A. Each section of the record is maintained by the patient care department that provided the care 70 Which of the following represents documentation of the patient's current and past health status? A. Physical exam 71 Which of the following contains the physician's findings based on an examination of the patient? A. Physical exam 72 What is the function of a consultation report? A. Provides a chronological summary of the patient's medical history and illness 73 What is the function of physician's orders? A. Provide a chronological summary of the patient's illness and treatment 74 Which type of patient care record includes documentation of a family bereavement period? A. Hospice record 75 Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ___ review? A. Quantitative 76 Which of the following is a secondary purpose of the health record? A. Support for provider reimbursement 77 Use of health record by a clinician to facilitate quality patient care is considered: A. A primary purpose
of the health record 78 Use of the health record to monitor bioterrorism activity is considered a: A. Primary purpose of the health record 79 In designing an electronic health record, one of the best resources to use to define the structure and content and standardize data definitions are standards promulgated by the: A. Centers for Medicare and Medicaid Services 80 The ____ mandated the development of standards for electronic medical records. A. Medicare and Medicaid legislation of 1965 81 Messaging standards for electronic data interchange in healthcare have been developed by: A. HL7 82 A statement or guideline that directs decision making or behavior is called a: A. Directive
83 Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2? A. Current Procedural Terminology (CPT) 84 Which organization originally publishes ICD and it's revisions? A. American Medical Association 85 Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? A. Centers for Disease Control 86 At which level of the classification systems are the most specific ICD-9-CM codes found? A. Category level 87 What are five digit ICD-9-CM diagnosis codes referred to as? A. Category codes 88 What are four-digit ICD-9-CM diagnosis codes referred to as? A. Category
codes 89 Which of the following ICD-9-CM codes are always alphanumeric? A. Category codes 90 Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect? A. Category
codes 91 Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures? A. Volume 1 92 Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals? A. Current Procedural Terminology 93 Which of the following is used to report healthcare supplies, products, and services provided to patients by healthcare professionals? A. CPT 94 Which of the following is a standard terminology used to code medical procedures and services? A. CPT 95 Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures? A. Reliability 96 A patient is admitted to the hospital with acute lower abdominal pain. The principal dx is acute appendicitis. The patient also has a dx of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a co-morbid condition? A. Acute appendicitis 97 A Medicare patient had two physician office visits, underwent hospital radiology examinations, clinical lab tests, and received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system? A. Clinical Lab tests 98 Which payer does the hospital proportionately receive the least amount of payment A.
Medicare 99 What term is used for retrospective cash payments paid by the patient for services rendered by a provider? A. Fee-for-service 100 Which of the following is the condition established after the study to be the reason for hospitalization? A. Case mix 101 In which of the following payment systems is the amount of payment determined before the service is delivered? A. Fee-for-service 102 Which of the following is a prospective payment system implementation for payment of inpatient services? A. APC 103 In the Inpatient Prospective Payment System, assignment to a DRG begins with the: A. Principal Diagnosis 104 Which of the following types of hospitals are excluded from Medicare inpatient perspective payment systems? A. Children's 105 Diagnosis-related group are organized into: A. Case-mix classifications 106 MS-DRG may be split into a maximum of ____ payment tiers based on severity as determined by the prescence of a major complication/comorbidity, a CC; or no CC. A. Two 107 The purpose of the present on admission (POA) indicator is to: A. Differentiate between conditions present on admission and
conditions that develop during an inpatient admission 108 The present on admission (POA) indicator is a requirement for A. Inpatient Medicare claims submitted by all hospitals 109 Which of the following is associated with the Medicare fee schedule A. APC's 110 SNFs complete MDS assessments: A. On admission and once every 14 days What represents documentation of the patient's current and past health status?Medical charts contain documentation regarding a patient's active and past medical history, including immunizations, medical conditions, acute and chronic diseases, testing results, treatments, and more.
Which information should be included in the documentation of the patient's past medical history?In general, a medical history includes an inquiry into the patient's medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
What documentation should be in the patient's file?They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3) A record of the information given to patients. 4) A record of any drugs prescribed or other investigations or treatments performed.
Which of the following represents the attending physician's assessment of the patients current health status?Question 13 2 / 2 pts (CO 1) Which of the following represents the attending physician's assessment of the patient's current health status? Medical history Correct!
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What represents documentation of the patients current and past health status?
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