C810 STUDY GUIDE QUESTIONS &
ANSWERS CORRECT 100%
A) Implant
B) HIV/AIDS
C) Birth defects
D) Trauma
C) Birth defects - ANSWERCase definition is important for all types of registries. Age
will certainly be an important criterion for accessing a case in a
__________________ registry
A) Completeness
B) Consistency
C) Clarity
D) Precision
D) Completeness - ANSWERThe coding supervisor notices that the coders are
routinely failing to code all possible diagnoses and procedures for a patient
encounter. This indicates to the supervisor that there is a problem with
A) Aggregate data
B) MPI data
C) Protocol data
D) Patient - identifiable data
A) Aggregate data - ANSWERYou are looking at statistics for your facility that
include average length of stay and discharge data by DRG/ What type of data are
you reviewing?
A) Timeliness
B) Completeness
C) Validity
D) Reliability
D) Reliability - ANSWERIn regard to quality of coding, the degree to which the same
results (same codes) are obtained by different coders or on multiple attempts by the
same coders refers to
A) Emergency record
B) Medical consultation
,C) Pharmacy consultation
D) Physical exam
C) Pharmacy consultation - ANSWERDetermine 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) The quality of follow up care
B) Whether a postoperative infection occurred and how it was treated
C) Whether the severity of illness and intensity of service warranted acute level care
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed
D) Precision - ANSWERA coder came across a medical record where a sputum
culture indicated bacterial pneumonia but the diagnosis did not indicate the cause of
the pneumonia. Documentation in the patient's record failed to meet which one of the
following criteria:
A) National Practitioner Data Bank
B) RxNorm
C) Vital statistics
D) MEDPAR
D) MEDPAR - ANSWERYou need to analyze data on the types of care provided to
Medicare patients in your geographic area by DRG. Which of the following would be
most helpful?
A) Validity
B) Timeliness
C) Reliability
D) Completeness
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed - ANSWERThe 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 or surgical
records would likely include checking for documentation regarding:
A) UHDDS
B) Glossary of healthcare terms
C) MDS
,D) Facility data dictionary
D) Facility data dictionary - ANSWERAs 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. Determine the best source for this information
A) Prohibited use of any abbreviations
B) Use of abbreviations in the final diagnosis
C) Flagrant use of specialty -specific abbreviations
D) Use of prohibited or dangerous abbreviations
D) Use of prohibited or dangerous abbreviations - ANSWERIn 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) Legal review
B) Quantitative analysis
C) Qualitative analysis
D) Utilization review
C) Qualitative analysis - ANSWERDuring a retrospective review of Rose Hunter's
inpatient health record, the health information clerk notes that on day 4 of
hospitalization, there was one missed dose of insulin. Determine what type of review
is this clerk performing?
A) Time and means of arrival
B) Instructions for follow up care
C) Physical findings
D) Lab/diagnostic results
A) Time and means of arrival - ANSWERDetermine the key data item you would
expect to find recorded on an ER record but would probably NOT see in an acute
care record
A) Security
B) Timeliness
C) Comprehensiveness
D) Accuracy
C) Comprehensiveness - ANSWERUsing a template to collect data for key reports
may help to prompt caregivers to document all required data elements in the patient
record. This practice contributes to data
, A) Condition on discharge
B) Chief complaint
C) Time and means of arrival
D) APGAR score
D) APGAR score - ANSWERDetermine the data item to include on a qualitative
review checklist of newborn inpatient health records that need NOT to be included
on adult records
A) Compliance with Medicare regulations
B) Compliance with Joint Commission standards
C) Compliance with Joint Commission standards for nonsurgical patients
D) Noncompliance with Joint Commission standards
D) Noncompliance with Joint Commission standards - ANSWERA qualitative review
of a health record reveals that the history and physical for a patient
admitted on June 26 was performed on June 30 and transcribed on July 1. Which of
the
following statements regarding the history and physical is true in this situation?
Completion and charting of the H&P indicates
A) Problem list
B) Patient's condition on discharge
C) Advance directive
D) Time and means of arrival
B) Patient's condition on discharge - ANSWEROne record documentation
requirement shared by both acute care and emergency departments is
A) Missing discharge summaries
B) Missing signatures on progress notes
C) Absence of SOAP format in progress notes
D) Missing operative reports
D) Missing operative reports - ANSWERIn preparation for an upcoming site visit by
Joint Commission, you discover that the number of delinquent records for the
preceding month exceeded 50% of discharged patients. Even more alarming was
the pattern you noticed in the type of delinquencies. Which of the following
represents the most serious pattern of delinquencies? Fifteen percent of delinquent
records show
A) Transfer record
B) Interdisciplinary patient care plan
C) Problem list
D) Discharge summary
ANSWERS CORRECT 100%
A) Implant
B) HIV/AIDS
C) Birth defects
D) Trauma
C) Birth defects - ANSWERCase definition is important for all types of registries. Age
will certainly be an important criterion for accessing a case in a
__________________ registry
A) Completeness
B) Consistency
C) Clarity
D) Precision
D) Completeness - ANSWERThe coding supervisor notices that the coders are
routinely failing to code all possible diagnoses and procedures for a patient
encounter. This indicates to the supervisor that there is a problem with
A) Aggregate data
B) MPI data
C) Protocol data
D) Patient - identifiable data
A) Aggregate data - ANSWERYou are looking at statistics for your facility that
include average length of stay and discharge data by DRG/ What type of data are
you reviewing?
A) Timeliness
B) Completeness
C) Validity
D) Reliability
D) Reliability - ANSWERIn regard to quality of coding, the degree to which the same
results (same codes) are obtained by different coders or on multiple attempts by the
same coders refers to
A) Emergency record
B) Medical consultation
,C) Pharmacy consultation
D) Physical exam
C) Pharmacy consultation - ANSWERDetermine 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) The quality of follow up care
B) Whether a postoperative infection occurred and how it was treated
C) Whether the severity of illness and intensity of service warranted acute level care
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed
D) Precision - ANSWERA coder came across a medical record where a sputum
culture indicated bacterial pneumonia but the diagnosis did not indicate the cause of
the pneumonia. Documentation in the patient's record failed to meet which one of the
following criteria:
A) National Practitioner Data Bank
B) RxNorm
C) Vital statistics
D) MEDPAR
D) MEDPAR - ANSWERYou need to analyze data on the types of care provided to
Medicare patients in your geographic area by DRG. Which of the following would be
most helpful?
A) Validity
B) Timeliness
C) Reliability
D) Completeness
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed - ANSWERThe 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 or surgical
records would likely include checking for documentation regarding:
A) UHDDS
B) Glossary of healthcare terms
C) MDS
,D) Facility data dictionary
D) Facility data dictionary - ANSWERAs 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. Determine the best source for this information
A) Prohibited use of any abbreviations
B) Use of abbreviations in the final diagnosis
C) Flagrant use of specialty -specific abbreviations
D) Use of prohibited or dangerous abbreviations
D) Use of prohibited or dangerous abbreviations - ANSWERIn 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) Legal review
B) Quantitative analysis
C) Qualitative analysis
D) Utilization review
C) Qualitative analysis - ANSWERDuring a retrospective review of Rose Hunter's
inpatient health record, the health information clerk notes that on day 4 of
hospitalization, there was one missed dose of insulin. Determine what type of review
is this clerk performing?
A) Time and means of arrival
B) Instructions for follow up care
C) Physical findings
D) Lab/diagnostic results
A) Time and means of arrival - ANSWERDetermine the key data item you would
expect to find recorded on an ER record but would probably NOT see in an acute
care record
A) Security
B) Timeliness
C) Comprehensiveness
D) Accuracy
C) Comprehensiveness - ANSWERUsing a template to collect data for key reports
may help to prompt caregivers to document all required data elements in the patient
record. This practice contributes to data
, A) Condition on discharge
B) Chief complaint
C) Time and means of arrival
D) APGAR score
D) APGAR score - ANSWERDetermine the data item to include on a qualitative
review checklist of newborn inpatient health records that need NOT to be included
on adult records
A) Compliance with Medicare regulations
B) Compliance with Joint Commission standards
C) Compliance with Joint Commission standards for nonsurgical patients
D) Noncompliance with Joint Commission standards
D) Noncompliance with Joint Commission standards - ANSWERA qualitative review
of a health record reveals that the history and physical for a patient
admitted on June 26 was performed on June 30 and transcribed on July 1. Which of
the
following statements regarding the history and physical is true in this situation?
Completion and charting of the H&P indicates
A) Problem list
B) Patient's condition on discharge
C) Advance directive
D) Time and means of arrival
B) Patient's condition on discharge - ANSWEROne record documentation
requirement shared by both acute care and emergency departments is
A) Missing discharge summaries
B) Missing signatures on progress notes
C) Absence of SOAP format in progress notes
D) Missing operative reports
D) Missing operative reports - ANSWERIn preparation for an upcoming site visit by
Joint Commission, you discover that the number of delinquent records for the
preceding month exceeded 50% of discharged patients. Even more alarming was
the pattern you noticed in the type of delinquencies. Which of the following
represents the most serious pattern of delinquencies? Fifteen percent of delinquent
records show
A) Transfer record
B) Interdisciplinary patient care plan
C) Problem list
D) Discharge summary
