In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the:

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the:

A. general appearance as assessed by the physician.
B. chief complaint.
C. family history as related by the patient.
D. subjective review of systems.

Answer: A

An example of a primary data source for health care statistics is the

An example of a primary data source for health care statistics is the 

A. disease index.
B. accession register.
C. MPI.
D. hospital census.

Answer: D

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing:

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing:

A. quantitative record review.
B. clinical pertinence review.
C. concurrent record analysis.
D. point-of-care documentation.

Answer: D

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement? 

A. Yes, within 8 hours postsurgery
B. No, as long as it is done ASAP
C. Yes, prior to surgery
D. Yes, within 24 hours postsurgery

Answer: C

A Clinical Documentation Specialist performs many duties. These include reviewing the data,and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)

A Clinical Documentation Specialist performs many duties. These include reviewing the data,and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) 

A. reviewer
B. analyst.
C. educator.
D. ambassador.

Answer: B

Based on the following documentation in an acute care record, where would you expect this excerpt to appear?

Based on the following documentation in an acute care record, where would you expect this excerpt to appear?

"With the patient in the supine position, the right side of the neck was appropriately prepped with
betadine solution and draped. I was able to pass the central line, which was taped to skin and
used for administration of drugs during resuscitation."


A. physician progress notes
B. operative record
C. nursing progress notes
D. physical examination

Answer: B

You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

A. 12 hours after admission.
B. 24 hours after admission.
C. 12 hours after admission or prior to surgery.
D. 24 hours after admission or prior to surgery.

Answer: D

A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to a large percentage of the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n)

A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to a large percentage of the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n) 

A. reviewer.
B. Analyst
C. educator.
D. ambassador

Answer: C

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) will be added to his health record.

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) will be added to his health record.

A. interval summary
B. consultation report
C. advance directive
D. interdisciplinary care plan

Answer: B

As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the:

As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the: 

A. facility's data dictionary.
B. MDS.
C. glossary of health care terms.
D. UHDDS.

Answer: A

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the:

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the:

A. UHDDS.
B. MDS.
C. Uniform Clinical Data Set.
D. Uniform Ambulatory Core Data.

Answer: B

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

A. sciatica unimproved with hot pack therapy
B. patient moving about very cautiously, appears to be in pain
C. adjust pain medication; begin physical therapy tomorrow
D. patient states low back pain is as severe as it was on admission

Answer: D

According to the following table, the most serious record delinquency problem occurred in which of the following months?

According to the following table, the most serious record delinquency problem occurred in which of the following months?

Record delinquency for 2nd quarter
April 70% May 88% June 79%
Percentage incomplete records
April 51% May 43% June 61%
Percentage delinquent due to missing H&P
April 3% May 1.4% June 0.5%


A. April
B. May
C. June
D. Cannot determine from these data

Answer: A

Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?

Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital? 

A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital
B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court
C. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record
D. when the record is taken to a physician's private office for a follow-up patient visit post-discharge

Answer: B

In creating a new form or computer view, the designer should be most driven by:

In creating a new form or computer view, the designer should be most driven by:

A. QIO standards.
C. needs of the users.
B. medical staff bylaws.
D. flow of data on the page or screen.

Answer: C

You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and will end in 2014. You remind him that by 2015, sanctions for noncompliance will appear in the form of:

You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and will end in 2014. You remind him that by 2015, sanctions for noncompliance will appear in the form of:

A. Downward adjustments to Medicare reimbursement.
B. The withdrawal of permission to treat Medicare and Medicaid patients
C. A mandatory action plan for implementing a meaningful use EHR.
D. Monetary fines up to $100,000

Answer: A

A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be

A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be 

A. chief complaint.
B. condition on discharge.
C. time and means of arrival.
D. growth and development record.

Answer: D

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the 

A. physical findings.
B. lab and diagnostic test results.
C. time and means of arrival.
D. instructions for follow-up care.

Answer: C

When developing a data collection template, the most effective approach first considers:

When developing a data collection template, the most effective approach first considers: 

A. the end user's needs.
B. applicable accreditation standards.
C. hardware requirements.
D. facility preference.

Answer: A

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's 

A. EDMS system.
B. CPOE.
C. expert system.
D. RHIO.

Answer: D

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? 

A. Minimum Data Set
B. Uniform Hospital Discharge Data Set
C. Conditions of Participation
D. Federal Register

Answer: B

In an acute care hospital, a complete history and physical may not be required for a new admission when

In an acute care hospital, a complete history and physical may not be required for a new admission when

A. the patient is readmitted for a similar problem within 1 year.
B. the patient's stay is less than 24 hours.
C. the patient has an uneventful course in the hospital.
D. a legible copy of a current H&P performed in the attending physician's office is available.

Answer: D

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the 

A. CARF manual.
B. hospital bylaws.
C. Joint Commission accreditation manual.
D. Federal Register.

Answer: D

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data 

A. reliability.
B. timeliness.
C. precision.
D. validity

Answer: C

The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is

The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is 

A. 15-0000/00.
B. 15-0000/01.
C. 15-0001/00.
D. 15-0001/01

Answer: C

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case? 

A. data comprehensiveness
B. data granularity
C. data precision
D. data accuracy

Answer: D

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? 

A. pharmacy consultation
B. medical consultation
C. physical exam
D. emergency record

Answer: A

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

A. placement of hospital logo.
B. signature line for authentication.
C. use of box design.
D. bar code placement.

Answer: D

The best example of point-of-care service and documentation is:

The best example of point-of-care service and documentation is:

A. using an automated tracking system to locate a record.
B. using occurrence screens to identify adverse events.
C. doctors using voice recognition systems to dictate radiology reports.
D. nurses using bedside terminals to record vital signs.

Answer: D

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? 

A. disease index
B. physician index
C. master patient index
D. operation index

Answer: D

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to:

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to: 

A. require written authorization from a custodial parent before disclosing proof of the child's immunization to the school.
B. Allow the minor to authorize the disclosure of the proof of immunization to the school.
C. Simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school
D. allow school officials to authorize immunization disclosures on behalf of a child attending their school

Answer: A

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates:

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates:

A. Noncompliance with Joint Commission standards
B. Compliance with Joint Commission standards
C. Compliance with Medicare regulations
D. Compliance with Joint Commission standards for nonsurgical patients

Answer: A

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that healthcare organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would not be a considered part of a preoperative verification process?

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that healthcare organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would not be a considered part of a preoperative verification process?

A. Confirm the patient's true identity
B. Mark the surgical site.
C. Review the medical records and/or imaging studies.
D. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated



Answer: D

One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with:

One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with: 

A. Joint Commission standards
B. The HIPAA privacy rule
C. Conditions of Coverage rules
D. Meaningful use requirements

Answer: D

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for:

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for:

A. Including the primary caregiver in surgery consults. B. Including the surgeon in the pre-anesthesia assessment
C. Marking the surgical site
D. Apprising the patient of all complications that might occur

Answer: C

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental:

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental:

A. ONC
B. CMS
C. OSHA
D. CDC

Answer: A

The foundation for communicating all patient care goals in long-term care settings is the:

The foundation for communicating all patient care goals in long-term care settings is the:

A. legal assessment
B. Medical history
C. Interdisciplinary plan of care
D. Uniform Hospital Discharge Data Set

Answer: C

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the:

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the:

A. UHDDS
B. MDS
C. OASIS
D. DEEDS

Answer: B

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the:

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the:

A. Chief of staff
B. Attending physician
C. HIM director
D. Risk manager

Answer: B

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate:

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate:

A. Quality of care through the use of pre-established criteria.
B. Adverse effects and contraindications of drugs utilized during hospitalization.
C. Potentially compensable events.
D. The overall quality of documentation in the record

Answer: D

Discharge summary documentation must include

Discharge summary documentation must include 

A. A detailed history of the patient
B. A note from social services or discharge planning
C. Significant findings during hospitalization
D. Correct codes for significant procedures

Answer: C

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to:

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to:

A. Reduce clinical denials for medical necessity
B. Decrease medication errors through CPOE systems
C. Increase patient engagement through patient portals
D. Report sentinel events to the Joint Commission

Answer: A

The minimum length of time for retaining original medical records is primarily governed by:

The minimum length of time for retaining original medical records is primarily governed by:

A. Joint Commission
B. Medical staff
C. State law
D. Readmission rates

Answer: C

Joint Commission requires the attending physician to countersign health record documentation that is entered by:

Joint Commission requires the attending physician to countersign health record documentation that is entered by:

A. Interns or medical students
B. Business associates
C. Consulting physicians
D. Physicians partners

Answer: A

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's:

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's:

A. Disease index
B. Number control index
C. Physician's index
D. Patient index

Answer: A

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman:

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman:

A. A new H&P is required for every inpatient admission. B. That you apologize for not noticing the H&P she provided
C. The H&P copy is acceptable as long as she documents any interval changes
D. Joint Commission standards do not allow copies of any kind in the original record

Answer: C

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the:

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the:

A. Prenatal record
B. Labor and delivery record
C. Postpartum record
D. Discharge summary

Answer: A

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that 

A. It is too easy to delegate use of computer passwords
B. Evidence cannot be provided that the physician actually reviewed and approved each report
C. Electronic signatures are not acceptable in every state.
D. Tampering too often occurs with this method of authentication

Answer: B

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the:

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the:

A. interdisciplinary patient care plan
B. Discharge summary
C. Transer record
D. Problem list

Answer: D

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the:

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the:

A. Doctor's progress notes
B. Integrated progress notes
C. Incident report
D. Nurse's notes

Answer: C

Engaging patients and their families in health care decisions is one of the core objectives for A. achieving meaningful use of EHRs. B. the Joint Commission's National Patient Safety goals

Engaging patients and their families in health care decisions is one of the core objectives for A. achieving meaningful use of EHRs. B. the Joint Commission's National Patient Safety goals 

A. Achieving meaningful use of EHRs
B. The Joint Commission's National Patient Safety goals
C. HIPAA 5010 regulations
D. establishing flexible clinical pathways

Answer: A

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the:

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the:

A. prohibited use of any abbreviations.
B. flagrant use of specialty-specific abbreviations
C. use of prohibited or "dangerous" abbreviations
D. use of abbreviations in the final diagnosis

Answer: C

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be:

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be:

A. personal identification.
B. cognitive patterns.
C. procedures and dates.
D. principal diagnosis

Answer: B

Prepping for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is:

Prepping for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is:

A. recovery room record.
B. pathology report.
C. operative report.
D. discharge summary

Answer: B