FINAL EXAM
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| All of the patient’s diagnosis data is organized together, such as diagnosis pertaining to appendicitis, or the patient’s heart problem. Which of the following data organization is this called? | Problem-Oriented Record
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| True or False: A form is developed to ensure that complete data is collected according to the clinical guidelines of the facility and of the profession and according to regulations. | True
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| Which of the following is the organization that regulates workplace health and safety? | OSHA
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| Which of the following is the patient’s demographic information? | Address
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| An acute care facility is which of the following? | Hospital
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| True or False: An integrated record is more complicated to file. | False
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| Which of the following physicians deals with disorders of the mind? | Psychiatrist
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| True or False: The fundamental difference between ambulatory care and acute care is the patient’s length of stay. | True
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| Which of the following is a clinical professional? | Medical Assistant
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| Give an example of an Ambulatory Care Facility. | Doctor’s office
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| Which of the following is the patient’s clinical information? | Medications
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| Which of the following best describes Long-Term Care Facilities? | Residents
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| True or False: The process of sending a patient to another physician is called a referral. | True
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| Which of the following organizations set standards to reflect optimum industry practice and defines how the health care facilities should operate in terms of patient care, the clinical flow of data, and the documental standards? | Joint Commission on Accreditation of Healthcare
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| Which of the following is not part of the SOAP note in a physician’s examination? | Preparing drug and dosage
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| Which of the following facilities would you go for palliative care? | Hospice Facility
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| Which of the following organizations adopted the Code of Ethics? | American Health Information Management Association
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| True or False: Allied Health Professionals cannot be both clinical and non-clinical professionals who provide services to patients. | False
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| Which of the following data organization group together labs, radiology, office visits, hospitalizations, etc.? | Source-Oriented Record
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| Which of the following patient’s health information is collected by the Medical Assistant? | Blood Pressure
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| True or False: A cardiologist treats the disease of the muscles and bones. | False
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| Which of the following is a federally funded health care insurance plan for the elderly and certain categories of chronically ill patients? | Medicare
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| Which of the following physicians treat diseases of the digestive system? | Gastroenterologist
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| Which of the following facilities would a patient go for a colonoscopy? | Ambulatory Surgery Facility
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| True or False: The integral part of a Problem-Oriented Record is the Problem Summary Sheet. | True
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| Which of the following is not included under Patient’s Registration tab? | Medication data
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| True or False: The Soap note data is the provider’s notes of each encounter with the patient, found inside paper file on top. | True
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| Which of the following is not a data element paper based health record required to maintain data quality? | Preventive controls
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| In paper-based medical record errors should never be erased; an error should be corrected by drawing a line through the erroneous data and writing the correct data near it with which of the following? | Date and initial
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| Which of the following is included in an Ambulatory Care Data Set? | Encounter Data Items, Provider Data Items, Patient Data Items (all of the above)
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| True or False: For information to be useful it must be accurate. | True
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| Which of the following is a system that helps HIM to keep track of paper-based records removed from its usual location? | Outguide
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| True or False: Paper-based record moves physically every time an individual touches it, so keeping track of it requires less control procedures. | False
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| Which of the following is included in a hospice care data collection set? | Continuous care, Care intended to soothe, Reduce symptoms (all of the above)
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| Which of the following computer data controls help to ensure errors do not occur? | Preventative Controls
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| Besides the patient’s information, which of the following best describes a Radiology and Laboratory Data Set? | Fluid samples
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| Give an example of what’s inside Ambulatory Care Health Record. | Married/single, Race, Sex
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| True or False: “Resident” health care charts can generate volumes because of the long-term health care. | True
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| Which of the following is not part of Home Health Care Data Collection? | Resident
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| Which of the following qualifies a patient for hospice? | Terminally ill
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| Which of the following health facilities use free text and are not required to use a data collection set? | Behavioral Health Care
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| Describe the person who is responsible for storage and retention of a health record. | HIM
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| True or False: Completeness refers to the collection or recording of data in their entirety. | True
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| Describe one of the three elements in a Quantitative Analysis. | Existence – does the data exist
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| Which of the following helps in the discovery of errors that have been made? | Detective Control
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| Which of the following must be included in an operative report? | Preoperative diagnosis, Description of procedure, Assisting physician (all of the above)
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| Which of the following is proof that a physician has reviewed a patient’s faxed consultation report? | A physician’s signature
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| True or False: Fluid samples and original films must be filed in the patient’s medical health record to maintain completeness. | False
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| Describe what is included in a Medical Assistant’s data collection set. | Vital signs
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| True or False: Soap format is an acronym that describes the medical decision making process and also refers to the way physicians organize their progress notes. | True
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| What is the key to locating a health record and a primary tool for identifying each file for all patients who have been seen at a facility? | MPI
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| True or False: Open shelves allow access to only one drawer of records at a time. | False
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| In a _____ filing identification system, a patient receives the same medical record number for each encounter to the facility. | unit
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| Retention Schedule: Birth, death, surgical procedure registers. | permanently
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| Retention Schedule: X-ray films – | 5 years
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| Retention Schedule: Employee health records – | 30 years
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| True or False: Middle-digit filing is easy to learn and does not require additional cross-reference to identify a file number. | False
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| Name and describe one alternative storage method. | Microfilm – a reproduction of the original paper record, miniaturized, onto plastic film, reels, or sheets
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| Which of the following best describes an MPI? | Rolodex file to look up a patient by name
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| Which of the following six digit ID number is based on Terminal-digit Filing if the patient’s medical number is 245468? | 685424
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| True or False: The biggest advantage of an off-site storage method is the health records are no longer under the direct control of the facility’s HIM. | False
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| True or False: An audit trail is an important role in the paper health record environment for tracking the use of a patient’s health record and information. | False
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| A _____ file identification system that assigns the same number to an entire family, uniquely identifying each member with a modifier. | family unit
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| Secondary data – | data taken for use elsewhere
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| Research awareness – | investigation into a matter to obtain and increase knowledge
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| Litigation – | to support or prove a fact in a lawsuit
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| Education – | health information used for instruction and examples
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| Patient Care Improvement – | to improve quality care provided to patients
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| Community Awareness – | to educate the public on healthcare issues and promote
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| Marketing – | promoting products/services of a facility
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| Primary data – | data taken when the nurse talks to the patient to obtain his/her health information
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| Define mortality - | refers to death.
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| Define morbidity - | refers to disease
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| If the patient’s medical record number is 489763, what is the Middle-digit filing number? | 974863
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| True or False: In 1984 JCAHO standards outlined specific instructions requiring each department in the health care facility to develop a monitoring and evaluation program. | True
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| Which of the following is the reason for coding personnel to review the patient’s health record? | Identify the correct diagnosis and procedures
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| True or False: Accreditation by JCAHO requires that a facility review specific cases of patient care in the areas of surgery, medication usage, and blood and tissue usage. | True
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| In health care, a payer is the person or party responsible for the bill. Who is the third party payer. | Insurance
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| A survey is a set of questions designed to gather information about a specific topic or issue. Why are surveys so important in the health care facility? | To improve healthcare quality
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| Which of the following mandates an aisle at least 3 feet wide between filing units or shelves and the amount of space between the top shelf and the ceiling of the file room? | OSHA
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| ______ is to ask questions of the data base for information or a report. | Query
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| True or False: A co-payment is a type of cost-sharing in which the insured pays out-of-pocket a fixed amount for health care services. | True
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| Which of the following is not the correct way to display patient information? | Lying on the front desk
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| Which of the following organizations contracts with a network of health care providers who then agree to certain reimbursement rates? | PPO
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| Which of the following is a request for payment by the insured or the provider for services covered? | Claim
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| Which of the following ways can only the patient waive the physician-patient privileged confidentiality? | In writing
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| True or False: Beneficiary is one who is eligible to receive or is receiving benefits from an insurance policy or managed care program. | True
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| Which of the following are specific conditions or hazards for which a health care policy will not grant benefit payment? | Exclusion
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| True or False: Health care professionals must continuously weigh the need for confidentiality versus access to patient information. | True
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| True or False: A fiscal intermediary is a specific condition or hazard for which a health care policy will not grant benefit payments. | False
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| Confidentiality - | “keeping a secret” discretion regarding disclosure of information
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| Privacy – | the right of an individual to control access to medical information
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| Which of the following best describes the amount of cost that the beneficiary must incur before the insurance will assume liability for the remaining cost? | Deductible
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| Which of the following best describes informed consent? | Permission given by a competent individual, Permission given by an individual of legal age, Permission given with full knowledge (all of the above)
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| Which of the following best describes payment made by a flat rate to the provider, whether or not services are rendered? | Capitation
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| Which of the following notations are allowed on the outside of the medical folder? | Allergies
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| Which of the following is not a reason to access a patient medical record? | A friend of yours
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| Which of the following best describes prospective consent? | Authorizing the release of medical information before the information has been generated
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| Which of the following consents is permission that is given after the event to which the permission applies? | Retrospective consent
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| True or False: Inappropriate access to a record is not illegal and should not be punished. | False
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| Describe why HIPAA is important to health care. | Patient confidentiality
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| Which of the following is a payment of a flat rate, based on diagnoses, procedures, or combination of the two? | Prospective payment
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| Give an example of why a patient would waive his/her right to confidentiality? | To get the bill paid, Insurance
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| True or False: When a patient makes an appointment with a physician to get a flu shot, consent to have the shot is implied because they showed up for the appointment. | True
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| Which of the following best describes the legal foundation of confidentiality? | Physician-patient privilege
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| Name two major types of sensitive records? | Employee medical files and litigation
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| Which of the following is the only place to discuss patient information? | With patient present
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| Which of the following are instances in which reporting may not occur without a patient’s consent? | Litigation
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| True or False: A 16 year old female patient presents for treatment of stomach pain. She is conscious, alert, and oriented, which gives her the legal right to sign the consent for treatment. | False
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| True or False: Confidentiality is discretion regarding disclosure of information. | True
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| Which of the following elements are causes for a defective release? | If it is known that it was revoked
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| Which of the following best describes litigation? | Process by which one party sues another in a court of law.
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