QUESTIONS AND CORRECT
ANSWERS
The federally mandated resident assessment instrument used in long term care facilities consists of
three basic components, including the new care area assessments, utilization guidelines, and the
✅✅CORRECT ANSW-MDS or minimum data set
As Director of HIT program, your community college has been selected to participate in the
workforce develeopment of electronic health specialits as outlined by ARRA and HITECH. In order to
keep abreast of changes in this program, you will need regular access to the Web site of this
governmental agency. ✅✅CORRECT ANSW-ONC
A qualitative review of a health record reveals that the h and p for a patient admitted on June 26
was performed on June 30 and transcribed on July 1. Which of the following statements regarding
the h and p are true in the situation? Completion and charting of h and p indicates ✅✅CORRECT
ANSW-noncompliance with JC standards. H and P must be completed within 24 hours
The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon
cancer with no known history of previous malignancies. The accession number assigned to this
patient is ✅✅CORRECT ANSW-12-0001/00 because in accession number 12 represents the year
the patient first entered the database, 0001 represents the first case entered that year, and 00
indicates no previous known neoplasm.
Setting a drop down menu to make sure the registration clerk collects gender as male or female is a
method of ensuring data ✅✅CORRECT ANSW-Precision
Validity refers to the accuracy of data, while reliability refers to the consistency of the data.
Timeliness refers to the data being available when needed, and precision refers to data values that
are just large enough to support the application process.
In the past, the Joint Commission standards 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 ✅✅CORRECT ANSW-use of prohibited or
"dangerous" abbreviations
, A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports
and probable reasons for the fall. She would most likely find this information in the ✅✅CORRECT
ANSW-incident report
For continuity of care, ambulatory care providers are more likely than providers of acute care
services to rely on the documentation found in the ✅✅CORRECT ANSW-problem list
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
✅✅CORRECT ANSW-The Federal Register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the
daily Federal Register.
In an acute care hospital, a complete history and physical may not be required for a new admission
when ✅✅CORRECT ANSW-A legible copy of a recent h and p performed in the attending
physician's ofice is available.
An interval h and p can be used when a patient is readmitted for the same or related problem within
the 30 days, and no matter how long the patient stays an h and p is required.
The authors of all entries in a health care record should be ✅✅CORRECT ANSW-clearly identified
In creating a new form or computer view, the designer should be most driven by ✅✅CORRECT
ANSW-needs of the users
According to the following data, the most serious record delinquecy problem occurred in which
month?
Record Delinquency Mo. April May June
% incomplete records 70% 88% 79%
%delinquent records 51% 43% 61%
% delinquent DT minssing H&P 3% 1.4% .05% ✅✅CORRECT ANSW-April, because JC
reccommendation for improvement is indicated if the number of delinquent records is greater than
50% or if the % of delinquent records DT missing H&P exceeds 2% of average monthly discharges.
The % of incomplete records is irrelevant