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Stack #615300
| Question | Answer |
|---|---|
| A health record is considered | C. Both A and B |
| A medical report is a | D. Both A and C |
| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | B. supporting documentation in the health record |
| The chronologic recording of pertinent facts and observations about the patient's health is known as | C. Documentation |
| Reasons for documentation are | C. Both A and B |
| The SOAP in patient medical record charting may be defined as | B. Subjective, Objective,Assessment, Plan |
| When a patient fails to return for needed treatment, documentation should be made | D. All of the above |
| How should an entry in a patient's medical record be corrected? | A. Cross out the incorrect entry, substitute the correct information, date and initial the entry |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommeneded return, or other factor that is the reason for the encounter is abbreviated as? | A. CC |
| Levels of evaluation and management services are based on types of physical examination that may be | C. Problem focused |
| An expanded problem-focused examination is a/an | C. limited examination of the affected body area |
| The official American Hospital Association policy states that abbreviations should be totally eliminated from the more vital sections of the record, such as the | D. All of the above |
| A diseased condition or state is known as | B. Morbidity |
| What does comorbidity mean? | C. Underlying disease or other conditions present at the time of visit. |
| A new patient is one who? | C. Has not received any professional services from the physician within the past 3 yrs |
| An established patient is one who? | B. Has previously recieved professional services from a physician or another physcian of the same specialty within the last 3 years |
| In dealing with managed care plans, a referral is? | D. Both B and C |
| Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered? | B. Critical Care |
| When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered? | C. counseling |
| Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the? | C. right lower quadrant |
| Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as? | C. Intermediate |
| The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | A. simple |
| A review of patient records done before billing is submitted is called? | B. prospective |
| Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime. | A. exclusion from program participation is mandatory |
| Which of the following cases should not use fax transmission? | D. All of the above |
| Who may accept a subpoena? | C. Both A and B |
| Preservation of health records is governed by? | Both B and C |
| Records that must be retained indefinitely include | C. patient's medical records, x-ray films, and inactive patient's medical records |
| Social changes as well as medical specialization have altered what needs to be done with patient's medical records. | A. True |
| The acronym HIPAA stands for? | D. health Insurance Portability and Accountability Act |
| In 2000 congress appropiated 50 million to ---- to support a variety of efforts targeted at reducing medical errors | A. AHRQ |
| As many as ___ people die in hospitals each year as a result of medical errors that could have been prevented | D. 98,000 |
| CPOE is an acronym for | B. computerized physician Order entry |
| SOAP is an acronym for | D. subjective, objective, assessment, plan |
| The concept of computerizing a patient's medical record has been around for? | A. 30 years |
| A study by the Center for Information Technology Leadership found more than 130,000 life threatening situations caused by adverse drug reactions | A. True |
| The IOM put forth a set of___ core functions that an EHR should be capable of performing | A. 8 |
| A laboratory requisition records information about the patient, the clinician, and the___ | B. test to be performed |
| IOM stands for? | A. Institute of Medicine of the National Academies |
| DAW is a pharmacy acronym for? | D. dispense as written |
| The simplest example of health maintenance is a card or letter remindind the patient that it is time for a check up | A. True |
| EHR is an acronym for electronic Health record | A. True |
| ___are used to look up drugs by names or therapeutic classes | A. Drug formularies |
| The goal of the EHR is not to eliminate paper charts, but rather to eliminate paper charts being the only form of chart used | A. True |
| A non-profit org, that developed and maintains the leading messaging standard used to exchange clinical and administrative data between different health care computer systems is | D. health level seven |
| Which of the following is not one of the core functions of the EHR set by the IOM? | C. paper support |
| The father of the problem-oriented chart was? | C. Dr. Lawrence Weed |
| Drawbacks to paper records includ the fact that they are? | D. B and C |
| AHRQ is an acronym for | A. Agency for healthcare research and quality |
| Which of the following is not one of the three key criteria identified by the computer-based patient record institute? | C. institute universal abbreviations |
| The new position established in an Executive Order signed by President Bush in 2004 was____ | A. National Coordinator for Health Information Technology |
| The IOM study focused on medical erors occurring is hospitals, but other studies showed an even larger number of medical errors occurring in___ | C. outpatient facilities |
| AHRQ is an acronym for | A. Agency for healthcare Research and quality |
| CPRI stands for___ | A. computer-based Patient Record Institute |
| DUR is an acronym for? | C. Drug utilization review |
| HIPAA was passed by congress in___? | A. 1996 |
| A new staff position that some clinics may choose to utilize with the use of EHR is? | C. Medical Scribe |
| A(n)___is a term used in an EHR for a message or reminder that is automatically generated from the data | A. alert |
| Medical vocabulary used in an EHR should be codified because there are so many | B. words that mean the same thing |
| MRI is an acronym for medical record initiative | B False |
| HIT is an acronym for? | B. Health information Technology |
| the concept of computerizing a patient's medical record has been around for about 50 yrs | B. False |
| EHR is an acronym for ? | B. Electronic health Record |
| NOC is an acronym for? | D. Nursing Outcomes Classification |
| The newest revision of the ICD-9 is the ICD-10 and it was released by the WHO in 1992 | A. True |
| Which volume of the ICD-9 is used to bill for hospital procedures? | C. 3 |
| What way of storing information is the most common way to store in the EHR system and is fast, efficient, and uses very little storage space? | C. fielded data |
| Current Procedural Terminology was created in? | A. 1968 |
| EHR users tend to locate findings by the ___, not the code | C. description |
| PCDS has more components than the Omaha System? | A. True |
| The ICD-9CM currently is published in___volumes | C.3 |
| What is the code set designed for documenting nursing interventions in any clinical setting? | D. Nursing Interventions Classification |
| NIC stands for nursing interventions classification and is a code set designed for documenting nursing interventions in? | D. any clinical setting |
| ___provides a universal coding system for mapping laboratory tests and results to a common terminology in the EHR | A. LOINC |
| Which of the following is not one of the ways that patient records can be stored? | A. protected data |
| NOC can be used to measure? | D. All of the above |
| The FDA began maintaining a list of all drugs prepared or sold by registered drug companies in___ | A. 1973 |
| CMS is an acronym for? | D. centers for medicare and Medicaid Services |
| Each drug product listed by the FDA is assigned a unique___digit number | C. 10 |
| Which of the following is not a domain in the system of nursing interventions classifications? | A. education |
| PCDS stands for Patient Care Data Set and was developed by physicians at Harvard | B. False |
| Health and human services and the dept of defense and vetrens affairs agreed to endorse a set of standards in? | d. 2004 |
| The largest number of LOINC codes are in the ___section | a. LABORATORY |
| To bill for a patient who is not sick, the ICD-9 code would start with the letter? | c. v |
| NANDA states that "A clinical judgement about individual, family, or community response to actual or potential health problems/life processes is a(n) | A. nursing diagnosis |
| When a code is stored in the medical record in addition to thee text description, the record is considered codified | A. True |
| HCPCS codes were created for billing | B. supplies, injectable medications, and blood products |
| CPT codes were created by the American Medical Association | A. True |
| How many standards are recognized by the north american nursing diagnosis association for use in the assessment, diagnosis, interventions, and outcomes of nursing care? | C. 13 |
| Nomenclature is from a latin term and means? | C. a list of names |
| ICD-10PCS has been proposed to replace | B. ICD-9 volume 3 |
| A code set designed specifically to record medical observations is often referred to as a clinical | D. nomenclature |
| ___ in the EHR are automatic messages to the clinician or other staff person | D. Alerts |
| International classification of disease codes are maintained by the | C. World Health Organization |
| The Omaha system is made up of ___components | C. 3 |
| FDA is an acronym for | C. Food and Drug Administration |
| Which of the following is not a category of medcin? | A. prognosis |
| CPT-4 codes were adopted by the government in? | C. 1983 |
| Lab tests are a good example of codified data | A. true |
| What are the three portions of LOINC? | A. laboratory, clinical, and HIPAA |
| EHR nomenclatures need to have alot more codes to describe the details of the exam, for this reason they are said to be | B. granular |
| The standard identifier for human drugs is? | C. NDC |
| There are___different code sets offically recognized by the american nurse association | D. 13 |
| A nomenclature is a system of names used in a field of science, typically created by a recongnized group or authority | A. True |
| SNOMED is an acronym for Selected Nomenclature of medicine | B. false |
| In medicine there is only one way to describe a symptom, condition, or observation | B. False |
| Which is not one of the components of the Omaha system? | B. problem updating area |
| The omaha system is a standardized terminology recognized by the american nurses association | A. true |
| Health and human services and the dept of defense and veterans affairs agreed to endorse a set of ___ standards | D. 20 |
| In the term rheumatoid, the root rheumat means? | A. discharge |
| In the term phosphorus, the root phos means? | A. light |
| A sutural or__ bone is found between the flat bones of the skull? | A. wormian |
| The process of bending a limb is called? | A. flexion |
| In the term arthroscope, the suffix-scope means? | D. instrument |
| A condition that is characterized by the progressive loss of bone density and thinning of bone tissue is called | B. osteoporosis |
| A lateral curvature of the spine is known as? | C. scoliosis |
| The prefix dis- means | C. apart |
| In the term cartilage, the root cartil means | C. gristle |
| In the term chondrocostal, the root cost means | B. rib |
| In the term meniscus, the root menisc means | D. cresent |
| In the term cartilage, the suffi-age means? | A. related to |
| All of the following are classified as long bones except? | B. vertebrae |
| All of the following are functions of the skeletal system except? | A. acid-base balance |
| The membrane that forms the covering of bones except at their articular surfaces is called? | A. periosteum |
| A disease that involves inflammation of the joints is called? | A. arthritis |
| What structure is narrow passageway about as big around as ones thumb and located on the palm side of the wrist? | C. Carpal tunnel |
| The medical word for pertaining to the lower jawbone? | C. mandibular |
| The medical word for pertaining to the elbow is? | D. olecranal |
| The medical term for the big toe is | D. Hallux |
| A___fracture occurs at the ankle and affects both bones of the lower leg | A. Potts |
| Inflammation of the bone and joint is | B. osteoarthritis |
| The medical term for the heel bone is | A. calcaneus |
| the medical term for a fingerprint is? | B. dactylogram |
| Which bone is not located in the upper extremity? | D. femur |
| The medical term for knock-knee | D. gene valgum |
| Abnormal anterior curvature of the spine is called | D. lordosis |
| The ____ is the shaft of long bone | C. diaphysis |
| An opening in the bone for blood vessels, ligaments, and nerves is called | C. forearm |
| Bending a limb is called? | D. flexion |
| Lying with the face upward is called? | D. supination |
| An open fracture is called | B. compound |
| A condition of stiffening of ajoint is? | A. ankylosis |
| The bones of the wrist are called? | C. carpals |
| A diagnostic examination of a joint whee air and then a radiopaque contrast medium are injected into the joint space | C. arthrography |
| The process of recording heat patterns of the body's surface is called? | C. thermography |
| Which substance is increased i gout, arthritis, myeloma,rheumatism | C. uric acid |
| the ___ level in the blood may be increase in osteomalacia and fracture healing | C. alkaline phoshatase |
| which substance/s is/are present in a variety of immunologic diseases? | A. uric acid |
| Swayback is another word for? | D. lordosis |
| The solid matter in bone is known as | C. osseous tissue |
| All of the following are functions of bone except | D. hormone production |
| An articulation refers to a(n)? | D. joint |
| A rounded process that enters into the formation of a joint is | B. condyle |
| Synarthrosis is a type of joint | C. does not permit movement |
| Example of an amphiarthrosis joint is the | B. vertebrae |
| The process of moving a baody part away from the middle is | B. abduction |
| The suffix in flexion means | C. process |
| The cervical curve consists of ___ vertebrae? | B) 7 |
| the center for longitudinal bone growth in childern is | D. Epiphyseal plate |
| The daily recommeneded amount of calcium for age 12 is | A. 1300 mg |
| Women build bone until about age? | D. 35 |
| A term to describe loss of bone mass is | B.osteoporosis |
| The combining form in achondroplasis means? | C. cartliage |
| The term ankylosis means? | A. condition of stiffening of a joint |
| The combining form in calcaneal means? | D. heel bone |
| A term that means humpback is? | C. kyphosis |
| The suffix in lumbodyynia means? | D. pain |
| The term myelopoiesis means? | B. formation of bone marrow |
| The term used to describe softening of the bone is? | B. osteomalacia |
| The combining form in rachigraph means? | C. Spine |
| Drugs that can be used for skeletal system diseases and disorders include | D. all of the above |
| An abnormal lateral curvature of the spine is? | D. scoliosis |
| A___fracture usuallyoccurs in childern? | B. greenstick |
| Which fracture occurs at ankle and affects both bones of the lower leg? | B. Pott's |
| The surgical puncture of a joint for removal of fluid is? | C. arthrocentesis |
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