HEALTH DATA CONTENT AND STANDARDS FINAL QUI
1.1| ACTUAL QUESTIONS & CORRECT ANSWERS |
GRADED A+ 2025
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?
A) Physician Exam
B) Medical Consultation
C) Pharmacy Consultation
D) Emergency Record ANS >> C) Pharmacy Consultation
2. 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?
A) the quality of follow-up care.
B) the quality of follow-up care.
C) the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed.
D) whether the severity of illness and/or intensity of service warranted acute
level care. ANS >> C) The presence or absence of such items as preoperative and
postop- erative diagnosis, description of findings, and specimens removed.
3. For inpatients, the first data item collected of a clinical nature is usually
https://www.stuvia.com/user/Mboffin
, A) Expected Payer
B) Principal Diagnosis
C) Admitting diagnosis
D) Review of systems ANS >> C) Admitting Diagnosis
4. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
A) number control index
B) physicians index
C) patient index
D) disease index ANS >> D) Disease index
5. Joint Commission does not approve auto authentication of entries in a
health record. The primary objection to this practice is that
A) whether the severity of illness and/or intensity of service warranted acute
level care.
B) evidence cannot be provided that the physician actually reviewed and
https://www.stuvia.com/user/Mboffin
, approved each report.
C) it is too easy to delegate use of computer passwords.
D) tampering too often occurs with this method of authentication. ANS >> B)
Evidence cannot be provided that the physician actually reviewed and approved
each report.
6. 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
A) facility's data dictionary
B) glossary of health care terms
C) UHDDS (Uniform Hospital Discharge Data Set)
D) MDS (Minimum Data Set) ANS >> A) Facility's data dictionary
7. In the past, Joint Commission standards have focused on promoting the use
of a facility-approved abbreviation list to be used by hospital care providers.
With the advent of the commission's national patient safety goals, the focus
has shifted to the
A) Prohibited use of any abbreviations
B) flagrant use of specialty-specific abbreviations
C) Use of abbreviations in the final diagnosis
D) Use of prohibited or "dangerous" abbreviations ANS >> D) Use of
prohibited or "dangerous" abbreviations
8. One of the Joint Commission National Patient Safety Goals (NSPGs) re-
quires that health care organizations eliminate wrong-site, wrong-patient, and
wrong-procedure surgery. In order to accomplish this, which of the following
https://www.stuvia.com/user/Mboffin
1.1| ACTUAL QUESTIONS & CORRECT ANSWERS |
GRADED A+ 2025
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?
A) Physician Exam
B) Medical Consultation
C) Pharmacy Consultation
D) Emergency Record ANS >> C) Pharmacy Consultation
2. 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?
A) the quality of follow-up care.
B) the quality of follow-up care.
C) the presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed.
D) whether the severity of illness and/or intensity of service warranted acute
level care. ANS >> C) The presence or absence of such items as preoperative and
postop- erative diagnosis, description of findings, and specimens removed.
3. For inpatients, the first data item collected of a clinical nature is usually
https://www.stuvia.com/user/Mboffin
, A) Expected Payer
B) Principal Diagnosis
C) Admitting diagnosis
D) Review of systems ANS >> C) Admitting Diagnosis
4. You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's
A) number control index
B) physicians index
C) patient index
D) disease index ANS >> D) Disease index
5. Joint Commission does not approve auto authentication of entries in a
health record. The primary objection to this practice is that
A) whether the severity of illness and/or intensity of service warranted acute
level care.
B) evidence cannot be provided that the physician actually reviewed and
https://www.stuvia.com/user/Mboffin
, approved each report.
C) it is too easy to delegate use of computer passwords.
D) tampering too often occurs with this method of authentication. ANS >> B)
Evidence cannot be provided that the physician actually reviewed and approved
each report.
6. 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
A) facility's data dictionary
B) glossary of health care terms
C) UHDDS (Uniform Hospital Discharge Data Set)
D) MDS (Minimum Data Set) ANS >> A) Facility's data dictionary
7. In the past, Joint Commission standards have focused on promoting the use
of a facility-approved abbreviation list to be used by hospital care providers.
With the advent of the commission's national patient safety goals, the focus
has shifted to the
A) Prohibited use of any abbreviations
B) flagrant use of specialty-specific abbreviations
C) Use of abbreviations in the final diagnosis
D) Use of prohibited or "dangerous" abbreviations ANS >> D) Use of
prohibited or "dangerous" abbreviations
8. One of the Joint Commission National Patient Safety Goals (NSPGs) re-
quires that health care organizations eliminate wrong-site, wrong-patient, and
wrong-procedure surgery. In order to accomplish this, which of the following
https://www.stuvia.com/user/Mboffin
