Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be:

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be:

A. written within 24 hours of the patient's admission.
B. accepted by charge nurses only.
C. cosigned by the attending physician within 4 hours of giving the order.
D. recorded by persons authorized by hospital regulations and procedures.


Answer: D. recorded by persons authorized by hospital regulations and procedures.

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data:

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data:

A. reliability.
B. accessibility .
C. legibility.
D. completeness.


Answer: A. reliability.

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the:

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the:

A. peer review organization.
B. National Practitioner Data Bank.
C. risk manager.
D. Health Plan Employer Data and Information Set.


Answer: B. National Practitioner Data Bank.

The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an)

The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an) 

A. Joint Commission-approved system.
B. Certified EHR.
C. Functional EMR.
D. AMA-approved product.


Answer: B. Certified EHR.

A primary focus of screen format design in a health record computer application should be to ensure that:

A primary focus of screen format design in a health record computer application should be to ensure that:

A. programmers develop standard screen formats for all hospitals.
B. the user is capturing essential data elements.
C. paper forms are easily converted to computer forms.
D. data fields can be randomly accessed.


Answer: B. the user is capturing essential data elements.

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show:

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show:

A. missing signatures on progress notes.
B. missing discharge summaries.
C. absence of SOAP format in progress notes
D. missing operative reports


Answer: D. missing operative reports