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Authorizations are always required for the use or disclosure of psychotherapy notes except in which of the following situations:
- employee and employment-related activities
- health insurance carrier
- media-related activities
- carry out payment, treatment and operations - ✔✔carry out payment, treatment and operations Steve has submitted a written authorization to request a copy of his medical chart. However, Steve's psychiatrist has determined that access to his PHI might endanger his life or safety. What should the covered entity do concerning the request?
- release requested information to Steve's legal guardian
- confirm the psychiatrist decision and deny the request
- release requested information to Steve
- provide an appeals process to Steve for the denial - ✔✔-provide an appeals process to Steve for the denial A health information technician wants to obtain a chronological list of all patients admitted to the facility during the third quarter with a diagnosis of appendicitis. Which database should the technician utilize? accession register (is a unique and irreplaceable official administrative document that establishes the museum's legal right of ownership) disease index (an alphabetical list of diseases with information about each condition, such as the CDC's Diseases & Conditions A-Z Index.)
master patient index ( is a patient database used by healthcare organizations to maintain accurate medical data across its various departments.) patient register (is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, c - ✔✔patient register Which of the following organizations is responsible for developing standards and conducting investigations to determine compliance in matters related to occupational safety and health? COBRA (Consolidated Omnibus Budget Reconciliation Act. It gives employees the right to pay premiums for and keep the group health insurance) CMS DHHS ( a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services.) OSHA ( Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.) - ✔✔OSHA Warren, a 12 year old Boy Scout breaks his leg while hiking with the troop. Which type of facility might Warren's Boy Scout leader take him to for emergent treatment? Ambulatory care clinic (is an outpatient facility for medical, surgical and diagnostic procedures) non emergent situations Surgicenter General hospital Specialty hospital - ✔✔General hospital
As director of health information of a newly established acute-care facility, where would you expect to find directives concerning the minimum health record contents?
- Benchmarks from area acute-care facilities
- Medical record committee meeting minutes
- The Joint Commission
- Credential committee meeting minutes - ✔✔The Joint Commission Upon discharge analysis of a patient's record, the analyst does not see a discharge order written by the physician. What can the analyst assume? the family members requested hospice care the patient left against medical advice the patient will continue treatment on an outpatient basis the patient died prior to discharge - ✔✔the patient left against medical advice The Hill-Burton Act of 1946: assured the provision of health care for the indigent. (ACA) provided health care to Americans 65 years of age and older (Medicare)
enacted legislation funding the construction of hospitals and other healthcare facilities. established the retrospective payment system. - ✔✔enacted legislation funding the construction of hospitals and other healthcare facilities. Dr. Thomas made an error in recording the progress notes in a patient's medical record. What is the first thing he should do to correct the error? draw a single line through the error obliterate the error and enter correct entry remove the page on which he made the error tell the nursing staff to ignore the statement - ✔✔draw a single line through the error A patient is hospitalized for less than 48 hours. Which of the following is permissible in lieu of a discharge summary? final diagnosis discharge order final progress note discharge diagnosis - ✔✔final progress note Who is responsible for developing bylaws governing physicians' completion of medical records? chief executive officer governing board chief of medicine medical staff - ✔✔medical staff Which system avoids assigning a new number for each patient encounter?
speed at which individual sheets can be located - ✔✔speed at which individual sheets can be located Which of the following would be most beneficial in locating a charged out medical record? master patient index requisition slip ( lists the items to be picked from inventory and used in the production process or in the provision of a service to a customer, Charge-out procedures should be followed regardless of who removes the medical record from the files, for what reason, or for how long. ) transfer notice outguide - ✔✔requisition slip Which of the following filing systems would be most affected in the event of a divorce? family serial serial-unit unit - ✔✔Family filing system A patient had an appendectomy due to appendicitis. This operative report must be completed when? within 15 days of discharge within 24 hours of surgery immediately after surgery within 48 hours of surgery - ✔✔immediately after surgery A post-anesthesia note is required when?
within 15 days of discharge within 24 hours of surgery within 48 hours of surgery immediately after surgery - ✔✔within 24 hours of surgery A discharge summary: is not required when death occurs within 48 hours or less may be completed in lieu of a clinical resume is not required for a stay of 48 hours or less must be dictated and typed for ease of readability - ✔✔is not required for a stay of 48 hours or less (CSR&I 108) A PEG tube would most likely be done to facilitate eating breathing urination none of the above - ✔✔eating (CSR&I 11) A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are: congestive heart failure and diabetes mellitus. The code should query the physician about adding the diagnosis of laryngitis bronchitis
The transcription are has an opening for a transcriptionist with demonstrated skill in medical and surgical reports. Which of the following types of tests should be administered? aptitude ( determine a person's ability in a particular skill or field of knowledge) performance (skill) intelligence stress - ✔✔performance (CSR&I 5) A patient who is taking the drug Antivert may have a diagnosis of arthritis dizziness (treats Vertigo) urinary tract infection congestive heart failure - ✔✔dizziness (CSR&I 56) A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a master patient index disease index admissions register disease registry - ✔✔disease registry (CSR&I 6) Which of the following is NOT included as a part of the minimum data maintained in the MPI? full name (last, first, and middle) patient medical record number date of birth
principal diagnosis - ✔✔principal diagnosis (HDC 10) As a new CTR you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility's patient's index physician's index disease index number control index - ✔✔disease index (HDC 11) Joint Commission requires the attending physician to countersign health record documentation that is entered by consulting physicians midwives interns or medical students physician partners - ✔✔interns or medical students (HDC 3) A good first step toward protecting the security of data contained in a health information computer system would be to establish a good record tracking system define levels of security for different types of information, depending on sensitivity provide internet access to facility records
National Practitioner Data Bank - ✔✔National Practitioner Data Bank Rules and principles determined by legislative bodies constitute which type of law? case law (the law as established by the outcome of former cases.) common law (derived from custom and judicial precedent rather than statutes) administrative law (law that regulates the operation and procedures of government agencies.) statutory law (written laws, usually enacted by a legislative body. ) - ✔✔statutory law Your job description states that as Assistant Director of the Health Information Management Department, you will supervise day-to-day operations for the transcription, release of information, and coding areas. What principle of management is described? span of control delegation specialization centralized authority (organizational management structure where most of the major decision-making power and authority rests in the hands of a concentrated group of leaders) - ✔✔span of control Gary's primary concern is providing food and housing for his large family. What level of Maslow's hierarchy of needs does Gary operate from? self-actualization ("the full realization of one's potential", and of one's "true self")
physiological (survival needs like need for sleep, food, air, and reproduction.) esteem (needs refer to the need for respect, self-esteem, and self-confidence.) safety (need for security and protection) - ✔✔physiological Under the ADA, prior to employment it is illegal to require a math aptitude test coding proficiency test typing skill test pre-employment physical exam - ✔✔pre-employment physical exam Jason, an HIM director, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. He will describe which of the following? Wagner Act (stablished the National Labor Relations Board and addressed relations between unions and employers in the private sector.) Labor Management Relations Act ( United States federal law that restricts the activities and power of labor unions.) AKA Taft hartley act Taft-Hartley Law OSHA - ✔✔OSHA Color coding of record folders is used to assist in the control of misfiles
If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? 2.4% (3545/150,000*100) 3.5% 5.1% 4.6% - ✔✔2.4% in a terminal digit filing system, what would be the record number immediately in front of number 01- 06 - 26? 03 - 06 - 26 00 - 06 - 26 99 - 99 - 25 02 - 06 - 26 - ✔✔ 00 - 06 - 26 (IR&A 91) According to AHIMA's recommended retention standards, which one of the following types of health information does NOT need to be retained permanently? physician index register of surgical procedures register of births register of deaths - ✔✔physician index (MB&RS 12) A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n) case-mix analyzer DRG creeper encoder grouper - ✔✔grouper
(MB&RS 16) Currently, payment to the physician for outpatient surgery performed on a Medicare patient is based upon which prospective payment system? MS-DRGs ASCs APGs RBRVS - ✔✔ASCs How to calculate case mix index - ✔✔Acute Inpatient PPS. This file contains hospitals case mix indexes (CMI) for discharges. A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. (MB&RS 24) All of the following elements are found in the charge description master, EXCEPT for narrative description HCPCS/CPT code ICD- 9 - CM code charge - ✔✔ICD- 9 - CM code (MB&RS 3) __________ indicates that the claim has been released as complete for submission to the insurer for payment. Bill hold Accounts receivables Bill drop Concurrent review - ✔✔ (MB&RS 4) All of the following items are packaged under the Medicare outpatient prospective payment system, EXCEPT for recovery room anesthesia
Each of the following pertains to COPD EXCEPT chronic bronchitis pneumonia smoking emphysema - ✔✔ A diagnostic test for meningitis usually involves stool C&S testing urine cerebrospinal fluid analysis blood cultures - ✔✔cerebrospinal fluid analysis (O&M 11) In a filing system containing a total of 1,255 records, 48 records are identified as misfiles. What is the percentage of filing accuracy for this area? 26.14% 3.82% 96% 74% - ✔✔96% (O&M 16) Anna Claire is attending budget training for new supervisors. The representative from Finance explains that ________ costs will vary in direct proportion to changes in the volume of care provided. variable periodic semi-variable fixed - ✔✔fixed (O&M 2) Strong lateral relationships within a facility are most likely when individual departments cooperate together to achieve organizational goals individual departments are only interested in their internal goals
individual departments avoid one another vertical relationships are less than adequate - ✔✔individual departments cooperate together to achieve organizational goals (O&M 32) In preparing a capital budget request, the first priority will be to document the cost of the new equipment where the new equipment will be located the specific type of equipment requested the need for the new equipment - ✔✔ (O&M 37) The most important consideration in planning the office layout for a HIS department is the types of furniture to be purchased workflow cost the number of employees - ✔✔ O&M 8) A rule is helpful to both managers and the employees in the decision-making process. A rule requires interpretation allows judgments to be made pre-decides issues provides the necessary details - ✔✔
