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CHIMA NCE Data & EHR Questions

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CHIMA NCE Data & EHR Questions An organization's legal health record definition must identify the following regarding individually identifiable data: a. Sources b. Medium c. Location d. All of the above - Correct Answer d It is best practice to establish a ____ when defining the legal health record. a. Policy b. Master patient index c. Health record matrix d. Both a and c - Correct Answer d The legal health record can only be comprised of documentation that physically exists in an electronic system. True/False - Correct Answer False Which function is the first step in the creation of a patient's medical record and initiates the flow of patient information within the EHR? a. Analysis b. Patient registration c. Scheduling d. Coding - Correct Answer b Which of the following processes includes deficiency analysis and chart completion? a. Release of information b. Incomplete record c. Coding d. Chart reviews - Correct Answer d Malpractice cases generally fall into the category of _____. a. Negligence torts b. Intentional torts c. Fraud cases d. Criminal cases - Correct Answer a In a negligence case, a physician will be held to a standard of providing care that reflects what is called _____ care. a. Minimal b. Optimal c. Maximum d. Reasonable - Correct Answer d A physician who fails to treat a patient who is brought to him or her for care is guilty of _____. a. Malfeasance b. Misfeasance c. Nonfeasance d. Malpractice - Correct Answer c A physician who performs a surgical procedure without patient consent may be prosecuted for _____. a. Assault b. Battery c. Negligence d. Malfeasance - Correct Answer b Defaming another person in writing is called _____. a. Libel b. Slander c. Invasion of privacy d. Fraud - Correct Answer a To successfully prosecute an individual for slander, the plaintiff must prove that: a. Actual harm occurred b. There was harmful intent c. There was dissension between the parties involved

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Uploaded on
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Written in
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An organization's legal health record definition must identify the following regarding individually
identifiable data:

a. Sources

b. Medium

c. Location

d. All of the above - Correct Answer d



It is best practice to establish a ____ when defining the legal health record.

a. Policy

b. Master patient index

c. Health record matrix

d. Both a and c - Correct Answer d



The legal health record can only be comprised of documentation that physically exists in an electronic
system.

True/False - Correct Answer False



Which function is the first step in the creation of a patient's medical record and initiates the flow of
patient information within the EHR?

a. Analysis

b. Patient registration

c. Scheduling

d. Coding - Correct Answer b



Which of the following processes includes deficiency analysis and chart completion?

a. Release of information

b. Incomplete record

c. Coding

d. Chart reviews - Correct Answer d

,Malpractice cases generally fall into the category of _____.

a. Negligence torts

b. Intentional torts

c. Fraud cases

d. Criminal cases - Correct Answer a



In a negligence case, a physician will be held to a standard of providing care that reflects what is called
_____ care.

a. Minimal

b. Optimal

c. Maximum

d. Reasonable - Correct Answer d



A physician who fails to treat a patient who is brought to him or her for care is guilty of _____.

a. Malfeasance

b. Misfeasance

c. Nonfeasance

d. Malpractice - Correct Answer c



A physician who performs a surgical procedure without patient consent may be prosecuted for _____.

a. Assault

b. Battery

c. Negligence

d. Malfeasance - Correct Answer b



Defaming another person in writing is called _____.

a. Libel

b. Slander

, c. Invasion of privacy

d. Fraud - Correct Answer a



To successfully prosecute an individual for slander, the plaintiff must prove that:

a. Actual harm occurred

b. There was harmful intent

c. There was dissension between the parties involved

d. Lost wages resulted from the slander - Correct Answer a



Information systems which help with treatment choices, advance care planning and palliative care are
issues that result for those dealing with _____.

a. End of life

b. Integrated

c. Managed

d. Quality - Correct Answer a



Problems with verifying admissions to a facility and children's protective services are ethical issues for
those working with ______ information:

a. Drug, alcohol, sexual, and behavioral

b. Genetic

c. Managed care

d. Public health - Correct Answer a



Promoting the values of autonomy for each individual is ethical behavior for the following Code of Ethics
principle:

a. Facilitate interdisciplinary collaboration

b. Put service before self-interest

c. Put service before self-interest

d. Respect the dignity and worth of every person - Correct Answer d

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