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AHIMA RHIA Exam Prep (7th Edition)
Questions And Answers
- A patient requests copies of her medical records in an electronic format. The hospital maintains a portion of the designated record set in a paper format and a portion of the designated record set in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically - ANSWER-c. Provide the patient with both paper and electronic copies of the record The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be delivered electronically (Thomason 2013, 102).
- For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - ANSWER-If an EHR is to provide clinical decision support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364).
- Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN - ANSWER-c. Password and swipe card
The three methods of two-factor authentication are something you know, such as a password or PIN; something you have, such as an ATM card, token, or swipe/smart card; and something you are, such as a biometric fingerprint, voice scan, iris, or retinal scan (Sayles and Trawick 2014, 219). Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems - ANSWER-Each Resource-Based Relative Value Scale (RBRVS) comprises three elements: physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register (Casto and Forrestal 2015, 150).
- The predefined process icon is used in flowcharting to indicate: a. A process in which actions are being performed by humans b. A point in the process at which participants must evaluate the status of the process c. Formal procedures that participants are expected to carry out the same way every time d. A point in the process at which the participants must record data in paper-based or computer- based formats - ANSWER-The rectangle with double lines on the side in a flowchart is a predefined process icon. This symbol represents the formal procedure that participants are expected to carry out the same way every time (Shaw and Carter 2015, 198). . A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? a. Content analysis b. Effect size review c. Psychometric assay d. Secondary analysis - ANSWER-Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586). In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results
the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and Forrestal 2015, 253). Which health record format is arranged in chronological order with documentation from various sources intermingled? a. Electronic b. Source-oriented c. Problem-oriented d. Integrated - ANSWER-The integrated health record is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse-chronological order. The advantage of the integrated format is that it is easy for caregivers to follow the course of the patient's diagnosis and treatment (Russo 2013b, 305). The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and that only the number be announced. - ANSWER-The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is not to interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure and, therefore, allowed in the Privacy Rule (Thomason 2013, 37).
- Which of the following is a graphical display of the relationships between tables in a database? a. RDMS b. SQL c. ERD d. SAS - ANSWER-An entity relationship diagram (ERD) is used to describe how the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool (White 2016a, 46).
What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? a. Core measures b. Enhanced discharge planning c. Data mining d. Clinical practice guidelines - ANSWER-Clinicians use health record information to develop clinical pathways and other clinical practice guidelines, which help clinicians make knowledge- and experience-based decisions on medical treatment. These guidelines make it easier to coordinate multidisciplinary care and services (Fahrenholz 2013b, 78). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - ANSWER-Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). Which of the following is a kind of technology that focuses on data security? a. Clinical decision support b. Bitmapped data c. Firewalls d. Smart cards - ANSWER-Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders (Sandefer 2016a, 366).
- What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts approved by Medicare, amount Medicare paid, and amount the patient must pay? a. EOB b. MSN c. EOMB d. ABN - ANSWER-Correct Answer: B For Medicare patients, the fiscal intermediary and carriers prepare Medicare summary notices or MSNs. The MSN details amounts billed by the provider, amounts approved by Medicare, how much Medicare reimbursed the provider, and what the patient must pay the provider by way of deductible and copayments (Casto and Forrestal 2015, 256).
- Secondary data sources provide information that is ________ available by looking at individual health records. a. not easily b. easily
b. Medical staff c. Newly hired coding personnel d. Nursing staff - ANSWER-Correct Answer: D In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff. Coding is based primarily on physician documentation, so nursing staff would not be included in the education process (Hunt 2016, 288). 18 5 Correct Wrong Unanswered
- A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a: a. Problem-oriented health record b. Patient-centric record c. Longitudinal health record d. Health record - ANSWER-Correct Answer: C A longitudinal health record maintains information throughout the lifespan of the patient, ideally from birth to death (Fahrenholz 2013a, 45).
- In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. This data is called a(n): a. Indicator b. Measurement c. Assessment d. Outcome - ANSWER-Correct Answer: A An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2015, 153). The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action.
d. Place all offending physicians on suspension if the documentation issues continue. - ANSWER-Correct Answer: B The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Hunt 2016, 275). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - ANSWER-Correct Answer: B Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). For a contract to be valid, it must include three elements. Which of the following is one of those elements? a. Assumption of risk b. Consideration c. Statute of limitations d. Notice of liability - ANSWER-Correct Answer: B The elements of a contract must be stated clearly and specifically. A contract cannot exist unless all the following elements exist: there must be an agreement between two or more persons or entities and the agreement must include a valid offer, acceptance, and exchange of consideration (Rinehart-Thompson 2016, 56). For Medicare patients, how often must the home health agency's assessment and care plan be updated? a. At least every 60 days or as often as the severity of the patient's condition requires b. Every 30 days c. As often as the severity of the patient's condition requires d. Every 60 days - ANSWER-Correct Answer: A Home health agencies are expected to conduct an assessment that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires (White 2013, 558). Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: a. Never allowed
Healthcare organizations need to be very clear about which abbreviations are not acceptable to use when writing or communicating medication orders. The organization's policy should also define whether or when the diagnosis, condition, or indication for use is included on a medication order (Shaw and Carter 2015, 248-249). Which of the following is true of the median? a. It is a measure of variability. b. It is difficult to calculate. c. It is based on the whole distribution. d. It is sensitive to extreme values. - ANSWER-Correct Answer: C The median offers the following three advantages: relatively easy to calculate; based on the whole distribution and not just a portion of it, as is the case with the mode; and unlike the mean, it is not influenced by extreme values or unusual outliers in the frequency distribution (Horton 2016, 222).
- This type of data display tool is a plotted chart of data that shows the progress of a process over time. a. Bar graph b. Histogram c. Pie chart d. Line graph or plot - ANSWER-Correct Answer: D A line graph or plot may be used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the values of the variable being plotted (Marc 2016, 546). Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given: a. No information due to the highly sensitive nature of his illness b. Admission date and location in the facility c. General condition and acknowledgment of admission d. Location in the facility and diagnosis - ANSWER-Correct Answer: C A facility may maintain a facility directory of patients being treated. HIPAA's Privacy Rule permits the facility to maintain in its directory the following information about an individual if the individual has not objected: name, location in the facility, and condition described in general terms. This information may be disclosed to persons who ask for the individual by name (Rinehart-Thompson 2017d, 227).
- If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? a. Survey sampling b. Systematic sampling c. Cluster sampling d. Stratified sampling - ANSWER-Correct Answer: B A systematic random sample is a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure
that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample (White 2016a, 140).
. If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: a. Release the information to the health insurance provider b. Get special patient consent to release the information c. Comply with the patient's request and keep the information private d. Request permission from HHS to release the information - ANSWER-Correct Answer: C The 2013 HIPAA Omnibus Rule finalized regulations give patients the right to request that their PHI not be disclosed to a health plan if they pay out of pocket in full for the services or items. A provider who accepts the payment and provides the service is compelled to abide by this request (Rinehart-Thompson 2017d, 220-221). Which of the following would be the best approach in starting a data governance program? a. Focus on one or a few small business imperatives b. Begin with developing policies and procedures c. Identify HIPAA requirements d. Establish success metrics - ANSWER-Correct Answer: A Data governance is an iterative process. It initially prioritizes initiatives and focuses on small select business imperatives that quickly deliver value and expand as the program matures (Johns 2016, 88). 18 5 Correct Wrong Unanswered Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Utilization management b. Patient access c. Health information management d. Patient accounts - ANSWER-Correct Answer: C Resolving failed edits is one of many duties of the health information management (HIM) department. Various medical departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Schraffenberger and Kuehn 2011, 237-238). The legal health record for disclosure consists of: a. Any and all protected health information data collected or used by a healthcare entity when delivering care b. Only the protected health information requested by an attorney for a legal proceeding
. The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called: a. Environmental assessment b. Operations improvement planning c. Strategic management d. Employment assessment - ANSWER-Correct Answer: A Knowledge of the internal and external environment is essential to vision and strategy formulation. An environmental assessment is defined as a thorough review of the internal and external conditions in which an organization operates. This data-intensive process is the continuous process of gathering and analyzing intelligence about trends that are—or may be—affecting an organization and industry. IBM did not see the market demands and change in the personal home computing environment quickly enough, so their competitors were out to market ahead of them (McClernon 2016, 933).
- Ensuring that data have been accessed or modified only by those authorized to do so is a function of: a. Data integrity b. Data quality c. Data granularity d. Logging functions - ANSWER-Correct Answer: A Data integrity means that data should be complete, accurate, consistent and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules (Johns 2015, 211)
- Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a: a. Case mix index b. Master patient index c. Health record matrix d. Retention program - ANSWER-Correct Answer: D The health information management (HIM) director is generally responsible for implementing the retention program; however, other individuals may be charged with the shared responsibility of implementing the program in some facilities. Some facilities establish a task force to oversee the record retention program, and this is sometimes chaired by the HIM professional. The steps in developing a record retention program include: conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a retention period, and destroying records that are no longer needed (Reynolds and Sharp 2016, 133-135). 15 8 Correct Wrong Unanswered
What must be in place to enhance the retrieval process for scanned documents? a. Electronic signature b. Indexing system c. RFID device d. Table of contents - ANSWER-Correct Answer: B To enhance retrieval of scanned documents, some form of indexing needs to take place in order to organize the documents. Ideally, each form that is scanned or otherwise created should have a bar code or some other forms recognition feature, or features, associated with it (Amatayakul 2017, 285).
- Which of the following statements is most accurate regarding effective communication? a. Use passive listening b. Monitor others' nonverbal behaviors for cues that they are following or confused c. Make sure all parties are distracted to better communicate your message d. Message content is more important than how it is delivered - ANSWER-Correct Answer: B To communicate effectively, managers must pay just as much attention to how their message is received and interpreted as they do to its content. In order to enhance the accuracy and acceptance of communication, the communicator needs to monitor others' nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties would not enhance effective communication (Kelly and Greenstone 2016, 36). A visitor walks through the work area and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? a. Device and media controls b. Facility access controls c. Workstation use controls d. Workstation security controls - ANSWER-Correct Answer: B Facility access controls include establishing safeguards to prohibit the physical hardware and computer system itself from unauthorized access while ensuring that proper authorized access is allowed (Reynolds and Brodnik 2017a, 275-276) In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed? a. Initial study b. Design c. Testing d. Operation - ANSWER-Correct Answer: C Running a mock query would be part of application testing that ensures every function of the new computer system works. Application testing also ensures the system meets
c. When demographic and financial information is used to acquire medical services d. When demographic information is used to purchase nonmedical items - ANSWER- Correct Answer: C Medical identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits. Most often this is done so a person can receive medical care with an insurance benefit and pay less or nothing for the care he or she receives (Rinehart-Thompson 2016, 71). Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical? a. When the patient is readmitted a second time for the same condition b. When the patient is readmitted within 30 days of the initial treatment for a different condition c. When the patient is readmitted a third time for the same condition d. When the patient is readmitted within 30 days of the initial treatment for the same condition - ANSWER-Correct Answer: D An interval note may be used for the patient's history and physical when the patient is readmitted within 30 days of the initial treatment for the same condition (Russo 2013a, 207).
- In which of the following examples does the gender of the patient constitute information rather than a data element? a. As an entry to be completed on the face sheet of the health record b. In the note "50-year-old white male" in the patient history c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females d. In a study of the age distribution of lung cancer patients - ANSWER-Correct Answer: C Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combined to produce value) and enhance that information with experience and trial-and-errors that produce knowledge. In this example, the gender is tied to race in the data collection that constitutes information and not a data element (Amatayakul 2017, 284).
- Code the following scenario: Patient admitted with major depression, recurrent, severe. F32.9 Major depressive disorder, single episode, unspecified F33.2 Major depressive disorder, recurrent, severe, without psychotic features F33.3 Major depressive disorder, recurrent, severe, with psychotic symptoms F33.9 Major depressive disorder, recurrent, unspecified a. F33. b. F33. c. F32. d. F33.9 - ANSWER-Correct Answer: B
Main term: Depression, subterm: recurrent; see Disorder, depressive, recurrent. Follow the cross reference to Disorder, depressive, recurrent, severe F33.2 (Schraffenberger and Palkie 2017, 34). Which of the following keywords precedes the listing of variables to be returned from an SQL query? a. SELECT b. SET c. DATA d. BY - ANSWER-Correct Answer: A A simple query statement using the data manipulation language has three parts. The "select" statement is always first. This determines the label, or field name, of the data that is being retrieved (White 2016a, 48). The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan? a. Traditional retrospective b. Capitated rate c. Relative value d. Discounted fee schedule - ANSWER-Correct Answer: B Capitated rate is a method of payment for health services in which the third-party payer reimburses providers a fixed, per capita amount for a period. Per capita means per head or per person. A common phrase in capitated contracts is per member per month (PMPM). The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs (Casto and Forrestal 2015, 11). Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room. a. Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule. b. Sally owns the information in her record, so she must be granted her request. c. Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record. d. Patients should never be given access to their actual medical records. - ANSWER- Correct Answer: C The covered entity may require the individual to make an amendment request in writing and provide a rationale for it. Such a process must be communicated in advance to the individual through the organization's notice of privacy practices. Therefore, an individual cannot review his or her physical record without an authorized HIM staff member present to maintain the integrity of the record (Rinehart-Thompson 2017e, 245-246). The Security Incident Procedures Standard has one required implementation specification centered on: a. Performing the Security Risk Analysis
d. Write off the failed charges to bad debt and bill Medicare for the clean charges - ANSWER-Correct Answer: D The Integrated Outpatient Code Editor (IOCE) is a predefined set of edits created by Medicare to check outpatient claims for compliance with the Medicare outpatient prospective payment system (OPPS). The IOCE will review a coded claim for accuracy and send back an edit flag if an error has been detected in the claim. Most organizations run all their claims through the IOCE prior to sending out to any payer to look for errors, correct them, and then send out a clean claim. A portion of the NCCI edits are embedded in the IOCE edits (Schraffenberger and Kuehn 2011, 465). An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LMRP). Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims-processing contractors. The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: a. Unbundling b. Billing for services not provided c. Medically unnecessary services d. Upcoding - ANSWER-Correct Answer: D Upcoding is the practice of using a code that results in a higher payment to the provider that actually reflects the service or item provided (Hunt 2016, 286).
- An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s). a. A list of newborns to the local newspaper for publication in the birth announcements section b. Data about cancer patients to the state health department cancer surveillance program c. Birth information to the country registrar d. Information about patients with sexually transmitted infections to the county health department - ANSWER-Correct Answer: A The Privacy Rule provides patients an opportunity to agree or object to specific types of disclosure. These do not require a written authorization; verbal authorization is acceptable. However, communication with the patient regarding these types of disclosures and the patient's decision should be documented in the health record or other appropriate manner of documentation (Brinda and Watters 2016, 317).
- Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?
a. X12N b. LOINC c. RxNorm d. DICOM - ANSWER-Correct Answer: B LOINC is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results (Palkie 2016a, 155). According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary - ANSWER-Correct Answer: C Except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed (Russo 2013a, 238). A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena? a. Inform defense and plaintiff lawyers that the records no longer exist b. Submit a certification of destruction in response to the subpoena c. Refuse the subpoena since no records exist d. Contact the clerk of the court and explain the situation - ANSWER-Correct Answer: B Those who choose to destroy the original health record may do so within weeks, months, or years of scanning. If the record was destroyed according to guidelines for destruction and no scanned record exists, the certificate of destruction should be presented in lieu of the record (Reynolds and Sharp 2016, 137).
. Who is responsible for the content, quality, and signing of the discharge summary? a. Attending physician b. Head nurse c. Consulting physician d. Admitting nurse - ANSWER-Correct Answer: A The physician principally responsible for the patient's hospital care generally dictates the discharge summary. However, a resident, physician assistant, or nurse practitioner who is being supervised by the attending physician may complete this task. Regardless of who documents it, the attending physician is responsible for the content and quality of the summary and must date and sign it (Russo 2013a, 284).
- What is the process of finding, soliciting, and attracting new employees called? a. Recruitment b. Retention
