Health Medical Homework Help

Per Joint Commission standards, all inpatient hospital records must be completed within ____ days after discharge, regardless of the storage media of the record. A.

In 2008 Medicare implemented APCs and relative payment weights to reimburse ________ for surgical procedures performed

Question 3

Suzie Smith wants to obtain a copy of her medical record. She can obtain a copy of all reports in her record EXCEPT for the

A. admission history and physical.

B. dental record.

C. psychotherapy notes.

D. treatment plan.

Question 4

The health information director is writing a policy to ensure the accuracy of an automated master patient index. The two departments that should be allowed to enter or update information in the master patient index are

A. admissions and nursing.

B. admissions and health information.

C. health information and nursing.

D. health information and medical staff.

Question 5

Ms. RHIT is analyzing and assembling a patient’s record and notices that a copy of a history and physical from the attending physician’s office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 (this year) and the patient was admitted to the hospital on January 5 (this year); the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is

A. acceptable as the H&P for this admission because it was placed on the record within 24 hours.

B. acceptable as the H&P for this admission because it was completed no more than seven days prior to admission.

C. unacceptable because only a newly documented inpatient history and physical is acceptable.

D. unacceptable because the office H&P was not completed within 24 hours prior to admission

Question 6

Which characteristic of electronic data interchange (EDI) below is incorrect?

A. determines claim status within 14 hours

B. faster payment of electronic claims

C. lower administrative costs result

D. on-line receipt is generated

Question 7

In which of the following cases would documentation of an interval history be acceptable?

A. Newborn admitted four days after birth for dehydration who is treated with IV fluids.

B. 17-year-old patient admitted for appendicitis who undergoes routine surgery during admission.

C. 34-year-old woman readmitted for chest pain following delivery of a baby girl three days ago.

D. 74-year-old readmitted for pneumonia seven days following discharge for this condition.

Question 8

Tom Top was admitted to Fresh Start, a drug and alcohol rehabilitation facility. A friend of his calls the facility to speak with him and to get his room number. The facility’s response should be

A. to provide only the patient’s room number.

B. to state that patients are not allowed to accept calls.

C. to say that the facility cannot confirm that Tom is a patient.

D. to transfer the call to Tom’s room phone.

Question 9

A common item not found on an admission data entry screen is:

A. admission diagnosis

B. date of birth

C. patient’s admission

D. discharge diagnosis

Question 10

When a patient is transferred to a different level of care within the same hospital, the summary report is called a:

A. discharge summary

B. progress summary

C. transfer summary

D. level of care summary

Question 11

Hillcrest Hospital is conducting research on Alzheimer’s disease and wishes to obtain information from its state’s registry. Which information below would be unavailable from the registry?

A. incidence of disease

B. number of cases

C. patient names

D. types of patients

Question 12

Ms. RHIT is writing a policy for filing alphabetic records. Which statement below should be included in the policy?

A. Arrange patient names according to given name, then surname.

B. When a hyphen is used in a patient’s name, ignore the letters that follow the hyphen.

C. Prefixes included as part of the patient’s last name are filed alphabetically.

D. When a patient is a senior or junior, file the record using senior or junior as the surname.

Question 13

Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care?

A. admission face sheet

B. consent

C.history and physical

D. discharge summary

Question 14

The medical record must be maintained according to

A. accreditation standards and case law.

B. case laws and regulations.

C. common laws and professional practice standards.

D. professional practice standards and federal/state regulation

Question 15

Which statement regarding the patient record is true?

A. All entries must be legible and complete.

B. An alias cannot be used in a patient record.

C. Only the front page of a two-page document must contain patient identification.

D. The author of each entry does not have to sign the note if another supervising professional has signed it.

Question 16

Information about the provision, coordination, and management of health care and services is known as _____ under HIPAA.

A. payment information

B. operational information

C. treatment information

D. patient information

Question 17

Sally Smith, a health information department employee, is placed on the witness stand during a court hearing. She may testify that

A. the patient’s cardiac arrest was drug-induced.

B. Dr. Top was the best physician to cover this case.

C. The patient was comatose upon arrival in the emergency room.

D. The progress notes were kept in the normal course of business.

Question 18

Ms. RHIT is developing an audit tool to be used to review records in preparation for the Joint Commission survey. Which of the following is a standard that should be included on the audit tool?

A. Each record needs to include a statistical summary sheet.

B. The attending physician must sign an attestation statement.

C. The record needs to document evidence of appropriate informed consent.

D. The discharge summary must be completed within 35 days of discharge.

Question 19

Which of the following is not documented as a part of a consultation report?

A. consulting physician’s signature

B. diagnosis and findings

C. recommendations and opinions

D. signature of requesting physician

Question 20

Dr. Smith documents in a patient’s record that the patient may be released from the recovery room. This would be documented as part of the

A.

operative report.

B.

postanesthesia note.

C.

postoperative note.

D.

progress notes.

Question 21

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the

A.

executive board

B.

forms committee.

C.

medical staff.

D.

surgery committee.

Question 22

Hillcrest Hospital and Endwell Hospital are merging. The new health information director for both hospitals needs to ensure that the two master patient indexes are accurately merged. Each hospital currently uses manual MPIs, and they will convert to one automated MPI. Which activity below should the director avoid?

A.

establish a merger plan for the hospital MPIs

B.

perform a manual alphabetical search to identify duplicate MPI files

C.

shred the manual MPI within four weeks after the conversion

D.

Use software to identify and correct errors in the automated MPI

Question 23

Dr.Smith enters the following information as part of a progress note: “2/3/YYYY Patient complains of right upper abdominal pain of four days’ duration.” This information represents the

A.

chief complaint.

B.

history of present illness.

C.

interval history.

D.

physical examination.

Question 24

The premature newborn death rate is calculated by dividing the _____by the number of premature newborn patients and multiplying by 100.

A.

number of newborns admitted

B.

number of premature newborn deaths

C.

number of newborn deaths

D.

number of newborn patients

Question 25

The admission and discharge date is considered:

A.

demographic information

B.

financial information

C.

medical information

D. clinical information