The Canadian Association of Medical Records Librarians was established in:
a. 1947
c. 1929
b. 1962
d. 1942 - Correct Answer b
The patient record is necessary for:
b. data review, case research, legal needs
c. data review, quality review, case research
d. data review, quality review, legal needs
a. case research, quality review, legal needs - Correct Answer a
The CAML became a chartered organization under Consumer and Corporate Affairs in:
a. 1979
b. 1949
d. 1976
c. 1942 - Correct Answer a
The CHRA changed its name to CHIMA in:
a. 2005
b. 2003
c. 2000
d. 1999 - Correct Answer a
The government is responsible for setting and administering national principles or standards for the
healthcare system through the:
b. Canada Health Act
,c. Canadian Charter of Rights and Freedoms
d. Privacy Act
a. Public Hospitals Act - Correct Answer a
Acute care is received as an:
c. rehabilitative service
a. out-patient service
b. in-patient service
d. long term care service - Correct Answer a
The impetus for improving hospital health records began in the U.S. through the:
c. opening of the first incorporated hospital known as Pennsylvania Hospital
b. establishment of numerous hospital accreditation programs
d. creation of the American College of Surgeons (ACOS) hospital standardization program
a. organization of the American Health Information Management Association - Correct Answer a
Which would be considered a primary record?
b. utilization review committee minutes concerning patient Sally Smith
a. diagnostic index that contains ICD-10 codes on Sally Smith
c. Sally Smith's emergency department record dated January 1
d. emergency department log containing a January 1 entry for Sally Smith - Correct Answer a
The integrated health record format is identified by its:
c. organization of reports in strict chronological date order
d. standardized forms as recommended by the JCAHO
b. association of treatment and therapies with patient problems
a. arrangement according to the source of the information - Correct Answer a
Which of the following demonstrates the personal use of the health record?
,b. accreditation Canada survey of 100 records, including that of Sally Smith
c. quality assurance study that contains information from Sally Smith's record
d. malpractice case brought to trial that includes Sally Smith's record as evidence
a. information from Sally Smith's recorded included in a hospital statistical report - Correct Answer a
A rubber stamp of Dr. Day's signature is acceptable for use if:
c. Dr. Day signed a statement regarding its use; the statement is stored with the facility's administration
a. it is stored in the health information department and is used only by Dr. Day
b. it is used by Dr. Day and her clinical staff because she gave them permission to do so
d. it is utilized only by Dr. Day and the other physicians involved in her group practice - Correct Answer
a
Regulations about physician completion of health records are developed by the:
c. health care facility's governing body
b. acute care facility's medical staff
d. hospital's administrative offices
a. health information management department - Correct Answer a
The Master Patient Index should be kept
a. for 25 years
d. permanently
c. for 5 years
b. for 10 years - Correct Answer a
A final progress note may be substituted for a discharge summary when a (an):
c. obstetrical patient delivers a healthy female newborn in c-section
d. expected death of a terminal patient occurs within 48 hours of admission
b. circumcised newborn who develops an infection is discharged within 48 hours
a. patient's hospitalization is under 48 hours duration with minor problems - Correct Answer a
, The re-analysis of health records refers to:
d. computerized abstracting of health records after the provider has completed them
a. analysis after health providers have worked on records, but prior to permanent filing
c. authentication of incomplete health records after initial analysis has been done
b. the assembly of the health record upon receipt from the facility's nursing units - Correct Answer a
Reports that summarize administration of therapeutic radiation are documented:
b. on a weekly basis, summarizing several radiation therapies
a. at the conclusion of the administration of each radiation therapy session
c. by the practitioner administering the radiation therapy, at least monthly
d. at the end of the therapeutic radiation treatment for the particular patient - Correct Answer a
A post anesthesia evaluation is documented in the patient's record by the practitioner administering the
anesthetic:
a. immediately upon conclusion of the surgery
d. and authenticated by the patient's surgeon
b. within 24 hours after the surgery is performed
c. within 48 hours after the surgery is performed - Correct Answer a
The major advantages of a problem-oriented health record include all of the following EXCEPT:
d. it allows physicians and others to follow the course of any one problem more easily
a. it requires the attending physician to consider all of the patient's problems
b. it is easily accepted by physicians, nurses and allied health professionals
c. it clearly indicates the goals and methods of the physician in treating the patient - Correct Answer a
With alphabetical filing, which of the following names would be filed first?
b. Steven Peter Jones
a. S. Peter Jones
a. 1947
c. 1929
b. 1962
d. 1942 - Correct Answer b
The patient record is necessary for:
b. data review, case research, legal needs
c. data review, quality review, case research
d. data review, quality review, legal needs
a. case research, quality review, legal needs - Correct Answer a
The CAML became a chartered organization under Consumer and Corporate Affairs in:
a. 1979
b. 1949
d. 1976
c. 1942 - Correct Answer a
The CHRA changed its name to CHIMA in:
a. 2005
b. 2003
c. 2000
d. 1999 - Correct Answer a
The government is responsible for setting and administering national principles or standards for the
healthcare system through the:
b. Canada Health Act
,c. Canadian Charter of Rights and Freedoms
d. Privacy Act
a. Public Hospitals Act - Correct Answer a
Acute care is received as an:
c. rehabilitative service
a. out-patient service
b. in-patient service
d. long term care service - Correct Answer a
The impetus for improving hospital health records began in the U.S. through the:
c. opening of the first incorporated hospital known as Pennsylvania Hospital
b. establishment of numerous hospital accreditation programs
d. creation of the American College of Surgeons (ACOS) hospital standardization program
a. organization of the American Health Information Management Association - Correct Answer a
Which would be considered a primary record?
b. utilization review committee minutes concerning patient Sally Smith
a. diagnostic index that contains ICD-10 codes on Sally Smith
c. Sally Smith's emergency department record dated January 1
d. emergency department log containing a January 1 entry for Sally Smith - Correct Answer a
The integrated health record format is identified by its:
c. organization of reports in strict chronological date order
d. standardized forms as recommended by the JCAHO
b. association of treatment and therapies with patient problems
a. arrangement according to the source of the information - Correct Answer a
Which of the following demonstrates the personal use of the health record?
,b. accreditation Canada survey of 100 records, including that of Sally Smith
c. quality assurance study that contains information from Sally Smith's record
d. malpractice case brought to trial that includes Sally Smith's record as evidence
a. information from Sally Smith's recorded included in a hospital statistical report - Correct Answer a
A rubber stamp of Dr. Day's signature is acceptable for use if:
c. Dr. Day signed a statement regarding its use; the statement is stored with the facility's administration
a. it is stored in the health information department and is used only by Dr. Day
b. it is used by Dr. Day and her clinical staff because she gave them permission to do so
d. it is utilized only by Dr. Day and the other physicians involved in her group practice - Correct Answer
a
Regulations about physician completion of health records are developed by the:
c. health care facility's governing body
b. acute care facility's medical staff
d. hospital's administrative offices
a. health information management department - Correct Answer a
The Master Patient Index should be kept
a. for 25 years
d. permanently
c. for 5 years
b. for 10 years - Correct Answer a
A final progress note may be substituted for a discharge summary when a (an):
c. obstetrical patient delivers a healthy female newborn in c-section
d. expected death of a terminal patient occurs within 48 hours of admission
b. circumcised newborn who develops an infection is discharged within 48 hours
a. patient's hospitalization is under 48 hours duration with minor problems - Correct Answer a
, The re-analysis of health records refers to:
d. computerized abstracting of health records after the provider has completed them
a. analysis after health providers have worked on records, but prior to permanent filing
c. authentication of incomplete health records after initial analysis has been done
b. the assembly of the health record upon receipt from the facility's nursing units - Correct Answer a
Reports that summarize administration of therapeutic radiation are documented:
b. on a weekly basis, summarizing several radiation therapies
a. at the conclusion of the administration of each radiation therapy session
c. by the practitioner administering the radiation therapy, at least monthly
d. at the end of the therapeutic radiation treatment for the particular patient - Correct Answer a
A post anesthesia evaluation is documented in the patient's record by the practitioner administering the
anesthetic:
a. immediately upon conclusion of the surgery
d. and authenticated by the patient's surgeon
b. within 24 hours after the surgery is performed
c. within 48 hours after the surgery is performed - Correct Answer a
The major advantages of a problem-oriented health record include all of the following EXCEPT:
d. it allows physicians and others to follow the course of any one problem more easily
a. it requires the attending physician to consider all of the patient's problems
b. it is easily accepted by physicians, nurses and allied health professionals
c. it clearly indicates the goals and methods of the physician in treating the patient - Correct Answer a
With alphabetical filing, which of the following names would be filed first?
b. Steven Peter Jones
a. S. Peter Jones
