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Health Documentation
| Question | Answer |
|---|---|
| What do health maintenance organizations (HMOs), also known as managed care plans, provide? | Health coverage to voluntarily enrolled individuals in return for prepayment of a fixed fee, regardless of the services the individual enrollees use |
| What percentage of all healthcare services are performed in an ambulatory-care setting? | More than 50 percent |
| ______________ play a major role in referral and tracking of the patient’s use of specialty providers. | Primary-care physicians |
| Coordination of care is dependent upon the quality of ________________ provided by each of the healthcare providers involved in the patient’s treatment. | documentation |
| How has advanced technology like endoscopes and lasers affected the postoperative recovery period? | The recovery period is shorter. |
| How are patients using ambulatory surgical centers for elective surgical procedures classified? | Outpatient |
| Patients undergoing elective procedures in ambulatory surgical centers are typically released from the surgery center _______________________. | on the same day that the procedure is performed |
| According to Federated Ambulatory Surgery Association, what percentage of all surgeries in America are outpatient? | 70 percent |
| Which of the following specialties is not among the highest volumes for ambulatory surgical centers, in terms of annual Centers for Medicare and Medicaid Services (CMS) reimbursement dollars? | Obstetrics and gynecology |
| Birthing centers are usually staffed by what kind of healthcare provider? | Nurse-midwives |
| What organization is responsible for setting standards for cancer treatments? | The Commission on Cancer |
| Approximately what percent of all newly diagnosed cancer patients are treated in programs approved by the Commission on Cancer? | 80 |
| What kind of facility offers comprehensive, primary healthcare services to patients who otherwise would have limited access to healthcare? | Community health centers |
| What kind of ambulatory-care facilities require neither informed consent nor payment? | Correctional facility health clinics |
| What is the fastest-growing physician service in the United States? | Diagnostic imaging |
| How are industrial health clinics usually financed? | Through the employer’s workers’ compensation insurance plan |
| What organizations offer a wide range of healthcare services and coverage in return for prepayment of a fixed fee, regardless of the services the individual enrollees use? | Health maintenance organizations |
| What kind of facilities evaluate and treat conditions that are not severe enough to require treatment in a hospital emergency department but still require treatment beyond normal physician office hours? | Urgent-care centers |
| Which of the following is not one of the three predefined formats required for meaningful documentation in the ambulatory health record? | patient-oriented |
| Because it was developed to enhance comprehensive patient care, which record system format is especially appropriate for health maintenance organizations (HMOs) and neighborhood health centers, where a team of professionals offers total patient care? | problem-oriented record system |
| Which of the following basic components is recommended rather than required to appear in every record of ambulatory care? | 2, 5, 9, 13 |
| The registration record documents the _______________________ collected before or during the initial patient visit and is maintained and updated on subsequent visits, as needed. | basic demographic data |
| Which of the following is not an element that should be included on a problem or summary list? | Short-term illnesses that were resolved quickly |
| Which of the following is not a key data element in the medication list? | Dispensing pharmacy |
| Once a patient has filled out an initial history questionnaire with a provider, approximately how often should the patient complete a new questionnaire? | Every five years |
| Which of the following elements recommended for inclusion in a comprehensive medical history is not required when the patient presents for preventive care or health maintenance? | Present illness |
| The SOAP format is an example of a structured progress note commonly used with the ____________________ medical record. | problem-oriented |
| Which of the following is not required for physician’s orders? | The orders must be typed. |
| Ideally, instructions to patients should be communicated both verbally and in writing. Which of the items below is not also recommended for patient instructions? | The person receiving the instructions should sign the instructions to verify receipt and understanding. |
| _________________ is defined as recognition by an external entity of achievement of predefined standards of excellence. | Accreditation |
| __________________________ are the Joint Commission’s specific performance expectations and/or structures or processes that must be in place for an organization to pervade safe, high-quality care, treatment, and services. | Elements of Performance |
| Leaving a sponge or foreign body such as a sponge in a patient after surgery is an example of a(n) ________________. | sentinel event |
| Which of the following is an accrediting body for ambulatory surgery facilities? | AAAASF |
| A comprehensive _____________________ is designed to minimize the facility’s potential risks and, when an incident occurs, its losses. | risk management program |
| Under the Health Insurance Portability and Accountability Act (HIPAA) privacy standard, which of the following types of protected health information must be specifically identified in an authorization? | Psychotherapy notes |
| What portion of Americans is estimated to suffer from a diagnosable mental illness in any given year? | one-fifth |
| Which of the following is not a basic type of behavioral healthcare setting? | Forensic |
| ___________________ facilities provide patients with around-the-clock care. | Inpatient |
| _____________________ programs provide individuals with mental health treatment that is more intense than the services provided on an outpatient basis. | Partial stay |
| What is the most common diagnosis of patients needing in-patient care? | schizophrenia |
| facilities are staffed by behavioral health professionals who provide supervision and training to the residents in an alternative to the inpatient setting, while clients are often encouraged to achieve independence in daily functions with little assistanc | residential |
| facilities provide clients with access to a stable treatment provider on an outpatient basis; care may occur in a formal office setting or in the comfort of the individual’s home or residence. | Outpatient |
| are outpatient programs designed to provide employees immediate access to psychological counseling on a limited basis and may be provided on-site or through local providers. | Employee assistance programs |
| In most states, only ________________________ are allowed to issue orders for the use of seclusion or restraints. | licensed physicians |
| What percentage of patients admitted with suicidal thoughts who committed suicide in the hospital denied these thoughts during their last communication with hospital staff? | 75 percent |
| What is the subject of the most frequent lawsuits, settlements, and verdicts brought against psychiatrists? | Patients’ suicides |
| To qualify as psychotherapy or process notes, notes from counseling sessions must contain which of the following? | Extended direct quotations from both client and therapist |
| ________________________ is assumed when a patient voluntarily submits to treatment. | Implied consent |
| The _________________________ is a concise account of the patient’s illness, course of treatment, response to treatment, and condition at the time of discharge from the service. | discharge summary |
| Which of the following statements about documentation of behavioral care emergency situations? | Psychiatric emergency patients must be admitted to a hospital for ongoing acute psychiatric care treatment. |
| A seriously ill psychiatric emergency patient may be admitted to a hospital for ongoing acute psychiatric care treatment against his or her will if that patient is determined to be incompetent to provide for his or her own care. | true |
| Which of the following is not a widely accepted accrediting bodies for behavioral healthcare organizations? | American Psychological Association (APA) |
| What is a piece of legislation written and approved by a state or federal legislature and then signed into law by the state’s governor or the president? | Statute |
| What is it called when accrediting bodies such as the Joint Commission or American Osteopathic Association (AOA) can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government? | Deemed status |
| What is a rule established by a local government called? | Municipal code |
| Which of the following is a ruling handed down by a court to settle a legal dispute? | Judicial decision |
| General written guidelines that dictate behavior and/or direct and constrain decision making within the organization are known as what? | Policies |
| Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? | Tracer methodology |
| What type of data were the first to be subject to data standardization efforts? | Hospital discharge |
| The Joint Commission uses a set of standard performance ratings. What are they? | Insufficient compliance, partial compliance, satisfactory compliance, not applicable |
| When did the Joint Commission transition its accreditation process to unannounced surveys? | 2006 |
| Which type of standards describe the accepted methods for collecting, sharing, and/or analyzing healthcare data among computer systems? | Health informatics standards |
| Which Joint Commission accreditation activity focuses survey activities on the organization-specific issues that are most relevant to safety and quality of care? | Priority focus process |
| Which of the following accreditation categories would the Joint Commission assign to a hospital that is not in substantial compliance with applicable standards and must remedy identified problem areas through preparation and submission of Evidence of Stan | Conditional accreditation |
| What does the Joint Commission call unexpected occurrences that result in death or serious physical or psychological injury or the risk of death or serious injury? | Sentinel events |
| What type of organization works under contract with the Centers for Medicare and Medicaid Services (CMS) to conduct Medicare/Medicaid certification surveys for hospitals? | State licensure agencies |
| Written instructions that describe how functions and processes must be carried out are what kind of documents? | Procedures |
| What type of standard establishes uniform definitions for clinical terms? | Vocabulary standard |
| What type of standard establishes clear descriptions of the data elements to be collected? | Structure and content standard |
| What type of standard ensures the confidentiality of patient-identifiable health information and protects it from unauthorized disclosure, alternation, and destruction? | Security standard |
| What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? | Identifier standard |
| According to the Joint Commission, how should the unanticipated death of a full-term infant be reported? | As a sentinel event |
| Which of the following is not an example of a long-term care? | Hospice |
| What is the only differentiation between a long-term acute-care hospital (LTCH) and a short-term acute-care hospital? | Length of stay |
| What is the definitional length of stay for long-term acute-care hospitals? | 25 days or greater |
| The _ notifies physicians that Medicare payment to the facility is partly based on the patient’s principal and secondary diagnoses, as well as the major procedures performed, and that falsification of records can lead to fines, imprisonment, or civil pen | physician acknowledgment statement |
| Long-term acute-care hospitals must have an agreement with a quality improvement organization (QIO) for periodic review. Which of the following is not among the items reviewed? | Outcome of treatment |
| Long-term acute care is paid under which of the following Medicare Systems? | Medicare Severity Diagnostic Related Groups (MS-DRGs) |
| What is the name of the form—usually the first page of a patient’s health record—that contains the demographic data and insurance information for the patient? | Face sheet |
| What is the name of the form used to help clarify principal and secondary diagnoses? | Physician query form |
| Within what period of time after admission to a LTCH must the history and physical be completed and placed in the health record? | 24 hours |
| Determination of __________________________ is considered to be one of the most difficult documentation issues facing the long-term care environment including the LTCH | principal diagnosis or reason for admission |
| A _________________ captures relevant past and current problems of each patient. | problem list |
| The _______________ is a snapshot of a patient’s status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focused on a specific disease process or pathway. | care plan |
| Which of the following organizations is not an accrediting body for long-term acute-care hospitals? | Centers for Medicare and Medicaid |
| Which of the following describes a skilled-nursing facility? | all of the above |
| Which of the following is not a component of the Resident Assessment Instrument (RAI)? | The resident’s health record |
| The ____________________ is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for long-term care (MDS 3.0). | Resident Assessment Instrument (RAI) |
| The ___________________________ is/are used to gather information about specific health status factors and include information about specific risk factors in the resident’s care. | Minimum Data Set (MDS) |
| __________________ are problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions). | Resident Assessment Protocols (RAP) |
| The Preadmission Screening Assessment and Annual Resident Review (PASARR) is a requirement mandated by ______________________ that provides a mechanism for screening mental illness and mental retardation (MI/MR). | Both the federal and state government |
| A facility should strive to be restraint free, but in specific circumstances to ____________________________, a least-restrictive restraining device may be required. | maintain or improve the resident’s medical condition |
| A(n) ________________________ may be completed in the long-term care setting to help summarize the care given to the resident over time. | monthly summary |
| Collectively, home health agencies, home care, personal-care providers, and hospices are known as _________________________. | home care organizations |
| bout how many individuals require services because of acute illness, long-term health conditions, permanent disability, or terminal illness? | 8,000,000 |
| The Centers for Medicare and Medicaid Services’ _____________________ developed a quality-monitoring system that makes highly specific data collection and information management demands on home care providers. | Home Health Initiative |
| The ________________ changed Medicare and Medicaid home care reimbursement from a cost-based system to a system of fixed-fee reimbursement based on a patient-need classification system | prospective payment system |
| The Joint Commission’s ORYX and Centers for Medicare and Medicaid Services’ OASIS are data sets that function as benchmarks of ___________________within and among organizations. | performance improvement |
| Data quality management (DQM) functions involve continuous improvement for data quality throughout an organization. Which of the following is not a key process for DQM? | Presentation |
| In data quality management, _________________ is the purpose for which data are collected | Application |
| Which of the following is not among the general categories that govern admission criteria? | Medical necessity |
| Medicare Conditions of Participation 484.55 requires that each patient receive, and a home health agency provide a patient-specific _______________ | comprehensive assessment |
| For Medicare patients, how often must the home health agency’s assessment and care plan be updated? | At least every 60 days or as often as the severity of the patient’s condition requires |
| Which of the following may be included in an assessment of a hospice patient and his or her family? | All of the above |
| When Medicare patients elect hospice care, Medicare reimbursement continues for treatment of their principal (terminal) diagnosis and related conditions outside of care provided by the designated hospice, by another hospice provided under arrangements mad | false |
| To be eligible for the Medicare hospice benefit, a patient must have __________. | a physician-certified terminal illness |
| To prevent denials, coding personnel are advised to use the most specific diagnosis codes and to ensure that the ______________________ is always listed as the principal diagnosis. | terminal diagnosis |
| Medicare has defined four general hospice care levels and has assigned different reimbursement rates to each. Which of the following is not a Medicare-defined hospice care level? | Continuous inpatient care |
| According to Medicare hospice regulations, which of the following groups of employee roles represents the makeup of the interdisciplinary group, that plans and provides or supervises the care and services provided to patients and families? | Doctor of medicine or osteopathy, registered nurse, social worker, pastoral or other counselor |
| In hospices, Medicare requires that _________________ be used in administrative or direct patient care roles, such as providing services and support to the patient, family, or significant other. | volunteers |
| Bereavement counseling services are often provided to the family and caregivers after a patient’s death. Which of the following is not among the factors that determine what counseling services are provided? | The length of the patient’s hospice care |
| To be considered “continuous” by Medicare, home care must be provided for at least _________________, and care must be predominantly skilled-nursing care. | 12 hours in one 24-hour period |
| Medicare reimburses all home health agencies (HHAs) under a ___________________________________ system | prospective payment |
| To be eligible for Medicare-reimbursed home healthcare, a Medicare beneficiary must meet which of the following conditions? | A, B, and C |
| To be considered "homebound" by the Centers for Medicare and Medicaid Services (CMS), the patient must be bedridden. | false |
| Using the ___________________________ to document data from home care record reviews and patient visits, Medicare home care surveyors use medical, nursing, and rehabilitative care indicators to determine the quality of a patient’s care and the scope of th | CMS Home Health Functional Assessment |
| Which of the following is not a function of the plan of care documentation? | Give a clear picture of the patient’s status before the onset of the acute illness |
| How often must homecare agencies electronically report all OASIS data collected on all applicable patients in a format that meets Centers for Medicare and Medicaid Services (CMS) electronic data and editing | Every month |
| Health records should be reviewed on admission, on discharge, and on a regular basis every _________________. | 30 to 60 days |
| Which of the following issues is not among the most important legal concerns in home care and hospice? | Family rights |
| ________________________________________ requires organizations receiving Medicare and Medicaid funds to document that home care and hospice patients are informed of their rights and that they agree to their care plans. | The Omnibus Budget Reconciliation Act of 1987 (OBRA) |
| __________________ are instruments patients can use to clarify treatment choices in the event that they are no longer capable of doing so. | Advance directives |
| In hospice care cases, routine-care-only orders (or consent for care that indicates routine care only) do not substitute for a specific DNR order. | true |
Created by:
msbailey142001