HIT 252 CCA EXAM 1 WEEK 1
HIT 252 CCA Exam 1
Which of the following is a form or view that is typically seen in the health record of a long-term care
patient but is rarely seen in records of acute care patients?
medical consultation
emergency record
physical exam
pharmacy consultation
The health care providers at your hospital do a very thorough job of periodic open record review to
ensure the completeness of record documentation. A qualitative review of surgical records would
likely include checking for documentation regarding
CFO.
Risk Management Department.
CEO.
HIM Department
The 2014 AHIMA Foundation's “Clinical Documentation Improvement Job Description Summative
Report” identified that most clinical documentation improvement specialists report directly to the
HIM Department
CEO.
Risk Management Department.
CFO.
The master patient index must, at a minimum, include sufficient information to
summarize the patient's medical history.
justify the patient's hospital bill.
list all physicians who have ever treated the patient.
uniquely identify the patient.
In determining your acute care facility's degree of compliance with prospective payment
requirements for Medicare, the best resource to reference for recent certification standards is the
CARF manual.
hospital bylaws.
, Federal Register.
Joint Commission accreditation manual.
The health record states that the patient is a female, but the registration record has the patient listed
as male. Which of the following characteristics of data quality has been compromised in this case?
data comprehensiveness
data accuracy
data precision
data granularity
Protected health information includes
individually identifiable health information in any format stored by a health care provider
or business associate.
only electronic individually identifiable health information.
individually identifiable health information in any format stored by a health care provider.
only paper individually identifiable health information.
A retrospective review as part of quality improvement activities is conducted after the patient has
been
discharged.
admitted.
released from the surgical recovery room.
cleared for surgery.
As the chair of a Forms Review Committee, you need to track the field name of a particular data field
and the security levels applicable to that field. Your best source for this information would be the
UHDDS.
MDS.
facility's data dictionary.
glossary of health care terms.
The first patient with cancer seen in your facility on January 1, 2018 was diagnosed with colon
cancer with no known history of previous malignancies. The accession number assigned to this
patient is
18-0001/00.
HIT 252 CCA Exam 1
Which of the following is a form or view that is typically seen in the health record of a long-term care
patient but is rarely seen in records of acute care patients?
medical consultation
emergency record
physical exam
pharmacy consultation
The health care providers at your hospital do a very thorough job of periodic open record review to
ensure the completeness of record documentation. A qualitative review of surgical records would
likely include checking for documentation regarding
CFO.
Risk Management Department.
CEO.
HIM Department
The 2014 AHIMA Foundation's “Clinical Documentation Improvement Job Description Summative
Report” identified that most clinical documentation improvement specialists report directly to the
HIM Department
CEO.
Risk Management Department.
CFO.
The master patient index must, at a minimum, include sufficient information to
summarize the patient's medical history.
justify the patient's hospital bill.
list all physicians who have ever treated the patient.
uniquely identify the patient.
In determining your acute care facility's degree of compliance with prospective payment
requirements for Medicare, the best resource to reference for recent certification standards is the
CARF manual.
hospital bylaws.
, Federal Register.
Joint Commission accreditation manual.
The health record states that the patient is a female, but the registration record has the patient listed
as male. Which of the following characteristics of data quality has been compromised in this case?
data comprehensiveness
data accuracy
data precision
data granularity
Protected health information includes
individually identifiable health information in any format stored by a health care provider
or business associate.
only electronic individually identifiable health information.
individually identifiable health information in any format stored by a health care provider.
only paper individually identifiable health information.
A retrospective review as part of quality improvement activities is conducted after the patient has
been
discharged.
admitted.
released from the surgical recovery room.
cleared for surgery.
As the chair of a Forms Review Committee, you need to track the field name of a particular data field
and the security levels applicable to that field. Your best source for this information would be the
UHDDS.
MDS.
facility's data dictionary.
glossary of health care terms.
The first patient with cancer seen in your facility on January 1, 2018 was diagnosed with colon
cancer with no known history of previous malignancies. The accession number assigned to this
patient is
18-0001/00.
