SOLUTIONS GRADED A+
◍ In performing quantitative analysis of an emergency room health
record, which of the following data elements would the health
information technician look for to be present in the record?
A. Advance directive, correspondence, anesthesia report
B. Patient identification, time and means of patient arrival, pertinent
history of illness
C. Consent for treatment, advance directive, consent to disclose
information
D. Results of tests, consent for treatment, anesthesia report. Answer:
B. Patient identification, time and means of patient arrival, pertinent
history of illness
◍ Reviewing a health record for missing signatures and medical
reports is called:
A. Assembly
B. Indexing
C. Analysis
D. Coding. Answer: C. Analysis
◍ This type of healthcare organization review is conducted at the
request of the healthcare facility seeking accreditation.
,A. Voluntary review
B. Complimentary review
C. Vocational review
D. Compulsory review. Answer: A. Voluntary review
◍ Where in an acute care health record would the documentation â
Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN.â be
found?
A. Laboratory report
B. Pathology report
C. History and Physical
D. Physician order. Answer: D. Physician order
◍ A patients registration forms, personal property list, RAI/MDS and
care plan and discharge or transfer documentation would be found
most frequently in which type of health record?
A. Rehabilitative care
B. Ambulatory care
C. Behavioral health
D. Long-term care. Answer: D. Long-term care
◍ Which database must a healthcare facility query as part of the
credentialing process when a physician initially applies for medical
staff privileges?
A. UHDDS
,B. NPDB
C. MEDPAR
D. HEDIS. Answer: B. NPDB National Practitioner Data Bank
◍ The Medical Record Committee is assessing various strategies to
improve documentation in the health record. Concerns have been
raised that current documentation practices may be insufficient to
support diagnoses or reflect the progress and clinical findings in
patient care. Which of the following would be the best first step to
help improve physician documentation?
A. Contact CMS for assistance
B. Determine the type and volume of documentation problems
C. Change the medical staff bylaws to require improved
documentation practice
D. Implement a documentation score card for each medical specialty.
Answer: B. Determine the type and volume of documentation
problems
◍ What does a healthcare organization create when it has a unique
numbering system to identify all forms used within the organization?
A. Forms standardization system
B. Forms distribution system
C. Forms quality management system
D. Form tracking system. Answer: D. Form tracking system
, ◍ Healthcare facilities must have processes in place to maintain and
correct the master patient index (MPI) against the quality issues of
duplicates, overlays, and overlaps on a continuous basis. Which of the
following is used to match patients so that patient information can be
merged?
A. Algorithm
B. Outguide
C. Encoder
D. Audit trail. Answer: A. Algorithm
◍ Deficiencies in a health record include which of the following?
A. Mistake in the patients age
B. Contradictory content
C. Missing document
D. Illegible content. Answer: C. Missing document
◍ What is the term that describes the data that defines and
characterizes other data within an electronic system?
A. Data quality
B. Data element
C. Metadata
D. Source data. Answer: C. Metadata
◍ The paper health record has been scanned and is now available
digitally. What is this known as?