HIT 101 Final Exam QUESTIONS AND
CORRECT ANSWERS
Every report in the patient record must contain patient identification data. - CORRECT
ANSWER True
The Uniform Rules of Evidence states that for a record to be admissible in a court of law, all
patient record entries must be dated and timed. - CORRECT ANSWER True
An advance directive and an informed consent are considered clinical data. - CORRECT
ANSWER False
The admitting diagnosis is the condition or disease for which the patient is seeking treatment.
- CORRECT ANSWER True
Third party payer information is classified as financial data, and it is obtained from the
patient at admission. - CORRECT ANSWER True
A complication is a preexisting condition that will cause an increase in the patient's length of
stay by at least one day. - CORRECT ANSWER False
A principal procedure is performed for definitive or therapeutic reasons. - CORRECT
ANSWER True
Health information personnel who abstract records assign ICD-9-CM codes to diagnoses and
procedures. - CORRECT ANSWER False
The Health Care Financing Administration is now called the Centers for Medicare and
Medicaid Services. - CORRECT ANSWER True
Upcoding or maximizing codes is considered DRG creep. - CORRECT ANSWER True
,The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients
age 21 and over that they have the right to an advance directive. - CORRECT
ANSWER False
A living will is a written document that informs a health care provider of a patient's desires
regarding life-sustaining treatment. - CORRECT ANSWER True
Persons under 18 years of age must have their parents' or guardians' consent to donate organs.
- CORRECT ANSWER True
The Joint Commission standards require a patient's consent to treatment and the record
contain evidence of that consent. - CORRECT ANSWER True
A consent to admission documents a patient's consent for all medical treatment including
procedures and surgeries to be completed during the current admission. - CORRECT
ANSWER False
The National Center for Health Statistics developed a standard certificate of birth that states
adopt for their use. - CORRECT ANSWER True
AOA requirements state that a patient record must be maintained for each patient treated in
the emergency department. - CORRECT ANSWER True
A discharge progress note can be documented in a patient record instead of a discharge
summary if a patient had an uncomplicated hospital stay of less than 48 hours. - CORRECT
ANSWER True
A delinquent record can result in a suspension of a physician's medical staff privileges. -
CORRECT ANSWER True
, The history of the present illness is the patient's description of their current medical condition
in their own words. - CORRECT ANSWER False
A consultation includes the examination of patient by a specialist who also provides an
opinion or advice. - CORRECT ANSWER True
All orders must be authenticated by the responsible provider. - CORRECT
ANSWER True
Integrated progress notes are documented by physicians, nurses, therapists, and other
professionals in the same section of the patient record. - CORRECT ANSWER True
An admission note documented by the attending physician can replace a dictated history and
physical examination. - CORRECT ANSWER False
Pre-anesthesia and post-anesthesia progress notes are often documented on a separate from to
facilitate documentation by the anesthesiologist. - CORRECT ANSWER True
The pathology report assists in the diagnosis and treatment of patients by documenting
analysis of tissue removed surgically. - CORRECT ANSWER True
The name of the attending physician is considered patient identification information. -
CORRECT ANSWER False
Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical
activity of the brain. - CORRECT ANSWER False
All ancillary report should be filed in the patient's record within 24 hours after interpretation
or test results. - CORRECT ANSWER True
The postpartum record is started in the physician's office and includes all tests performed,
pregnancy risks, and care given. - CORRECT ANSWER False
CORRECT ANSWERS
Every report in the patient record must contain patient identification data. - CORRECT
ANSWER True
The Uniform Rules of Evidence states that for a record to be admissible in a court of law, all
patient record entries must be dated and timed. - CORRECT ANSWER True
An advance directive and an informed consent are considered clinical data. - CORRECT
ANSWER False
The admitting diagnosis is the condition or disease for which the patient is seeking treatment.
- CORRECT ANSWER True
Third party payer information is classified as financial data, and it is obtained from the
patient at admission. - CORRECT ANSWER True
A complication is a preexisting condition that will cause an increase in the patient's length of
stay by at least one day. - CORRECT ANSWER False
A principal procedure is performed for definitive or therapeutic reasons. - CORRECT
ANSWER True
Health information personnel who abstract records assign ICD-9-CM codes to diagnoses and
procedures. - CORRECT ANSWER False
The Health Care Financing Administration is now called the Centers for Medicare and
Medicaid Services. - CORRECT ANSWER True
Upcoding or maximizing codes is considered DRG creep. - CORRECT ANSWER True
,The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients
age 21 and over that they have the right to an advance directive. - CORRECT
ANSWER False
A living will is a written document that informs a health care provider of a patient's desires
regarding life-sustaining treatment. - CORRECT ANSWER True
Persons under 18 years of age must have their parents' or guardians' consent to donate organs.
- CORRECT ANSWER True
The Joint Commission standards require a patient's consent to treatment and the record
contain evidence of that consent. - CORRECT ANSWER True
A consent to admission documents a patient's consent for all medical treatment including
procedures and surgeries to be completed during the current admission. - CORRECT
ANSWER False
The National Center for Health Statistics developed a standard certificate of birth that states
adopt for their use. - CORRECT ANSWER True
AOA requirements state that a patient record must be maintained for each patient treated in
the emergency department. - CORRECT ANSWER True
A discharge progress note can be documented in a patient record instead of a discharge
summary if a patient had an uncomplicated hospital stay of less than 48 hours. - CORRECT
ANSWER True
A delinquent record can result in a suspension of a physician's medical staff privileges. -
CORRECT ANSWER True
, The history of the present illness is the patient's description of their current medical condition
in their own words. - CORRECT ANSWER False
A consultation includes the examination of patient by a specialist who also provides an
opinion or advice. - CORRECT ANSWER True
All orders must be authenticated by the responsible provider. - CORRECT
ANSWER True
Integrated progress notes are documented by physicians, nurses, therapists, and other
professionals in the same section of the patient record. - CORRECT ANSWER True
An admission note documented by the attending physician can replace a dictated history and
physical examination. - CORRECT ANSWER False
Pre-anesthesia and post-anesthesia progress notes are often documented on a separate from to
facilitate documentation by the anesthesiologist. - CORRECT ANSWER True
The pathology report assists in the diagnosis and treatment of patients by documenting
analysis of tissue removed surgically. - CORRECT ANSWER True
The name of the attending physician is considered patient identification information. -
CORRECT ANSWER False
Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical
activity of the brain. - CORRECT ANSWER False
All ancillary report should be filed in the patient's record within 24 hours after interpretation
or test results. - CORRECT ANSWER True
The postpartum record is started in the physician's office and includes all tests performed,
pregnancy risks, and care given. - CORRECT ANSWER False
