health records

Most inpatient hospital admissions begin in:

Question 1 options:

	the emergency department.
	an ambulatory care facility.
	the registration department.
	the billing department.

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Question 2 (1 point)

The first step in an inpatient admission and discharge is:

Question 2 options:

	an attending physician is assigned.
	procedures are ordered by a physician.
	patient care is provided by the nursing staff.
	patient demographic and insurance information is collected.

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Question 3 (1 point)

The American Health Information Management Association was previously known as the:

Question 3 options:

	American Association of Record Librarians.
	American Medical Record Association.
	Association of Record Librarians of North America.
	All of the above

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Question 4 (1 point)

The process of standardizing forms by using certain forms for specific purposes is called:

Question 4 options:

	forms control.
	documentation control.
	standardized record control.
	hospital paperwork control.

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Question 5 (1 point)

Which of the following positions is responsible for both the health information management department and the information technology department?

Question 5 options:

	Hospital administrator
	Chief information officer
	Health information manager
	Risk manager

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Question 6 (1 point)

Reports such as discharge summaries, history and physicals, and operative reports are created by listening to a dictated report by which of the following positions?

Question 6 options:

	Optical imaging coordinator
	Clinical analyst
	Medical transcriptionist
	Clinical vocabulary manager

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Question 7 (1 point)

This position ensures that healthcare data used for coding and reimbursement, records, and documentation is accurate and consistent.

Question 7 options:

	Data resource administrator
	Data quality manager
	Clinical applications coordinator
	APC coordinator

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Question 8 (1 point)

The American Health Information Management Association offers which of the following credentials by a certification exam?

Question 8 options:

	Certified Coding Specialist
	Registered Health Information Technician
	Registered Health Information Administrator
	All of the above

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Question 9 (1 point)

Which of the following is NOT a responsibility of the data quality manager?

Question 9 options:

	Audit the quality of data
	Ensure documentation is consistent
	Optimize reimbursement
	Review the data entry process
	Ensure documentation is accurate

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Question 10 (1 point)

The responsibility of the IT (information technology) manager includes:

Question 10 options:

	strategic planning.
	development of new information systems.
	supervising the computer network.
	All of the above

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Question 11 (1 point)

A coding specialist is also sometimes called a(n):

Question 11 options:

	reimbursement specialist.
	insurance specialist.
	payment specialist.
	billing department specialist.

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Question 12 (1 point)

A ________ management specialist helps increase patient safety by analyzing risk, educating patients, and educating employees.

Question 12 options:

	coding
	safety
	risk
	data

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Question 13 (1 point)

Healthy Heart Hospital has a position open in which the primary responsibility is to develop policies and procedures to ensure compliance with contractual obligations, regulations, and ethics. They are looking to hire a:

Question 13 options:

	compliance officer.
	project manager.
	risk management specialist.
	privacy officer.

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Question 14 (1 point)

All of the following are responsibilities of the health information manager EXCEPT:

Question 14 options:

	enforcing confidentiality.
	managing health information management systems.
	implementing policies and procedures.
	assigning standard codes for patient diagnoses.

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Question 15 (1 point)

The American Health Information Management Association has a code of ethics that is followed by:

Question 15 options:

	all AHIMA members.
	credentialed nonmembers.
	most health information management departments.
	All of the above

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Question 16 (1 point)

________ allied health positions do NOT involve direct patient care but do manage and protect patient medical information.

Question 16 options:

	Nonclinical
	Clinical
	Supportive
	Clerical

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Question 17 (1 point)

The word data refers to:

Question 17 options:

	records of facts.
	computer information.
	patient information.
	presentation of information.

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Question 18 (1 point)

Which of the following refers to the presentation of patient information in a useful form and the association of other relevant details with it?

Question 18 options:

	Computer data
	Health information
	Patient data
	Health data

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Question 19 (1 point)

All of the following statements are true of the patient health record EXCEPT:

Question 19 options:

	it is not used for billing and reimbursement.
	it provides information about the patient’s treatment.
	it is the primary communication document for those who care for the patient.
	medical bills will not be paid if the patient record does not contain necessary documentation.

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Question 20 (1 point)

Records gathered directly from the patient and his or her providers that document the patient’s history and state of health are:

Question 20 options:

	secondary records.
	research records.
	data records.
	primary records.

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Question 21 (1 point)

Records that are created by abstracting and summarizing information from primary records are:

Question 21 options:

	primary records.
	secondary records.
	compiled records.
	research records.

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Question 22 (1 point)

All of the following are examples of secondary health records EXCEPT:

Question 22 options:

	master patient indexes.
	reports from other providers.
	health insurance claims.
	aggregate data.

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Question 23 (1 point)

Which of the following are standardized codes for reporting medical services, procedures, and treatments performed for patients by the medical staff?

Question 23 options:

	ICD-9-CM
	CPT-4
	HCPCS II
	ABC

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Question 24 (1 point)

HCPCS II codes were created for billing:

Question 24 options:

	surgical procedures.
	outpatient services.
	inpatient treatments.
	supplies, injectable medications, and blood products.

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Question 25 (1 point)

An ICD-9-CM V code is used to code a(n):

Question 25 options:

	non-illness condition.
	accident.
	medication error.
	disease.

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Question 26 (1 point)

All of the following statements are true of ICD-10-CM EXCEPT:

Question 26 options:

	HHS has proposed that the ICD-10 code sets be used for billing 01/01/10.
	it is used broadly in Europe and Canada.
	transition to ICD-10 will require significant time and effort.
	it is used in the United States for reporting the cause of death on death certificates.

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Question 27 (1 point)

Hospital billing includes which of the following codes?

Question 27 options:

	ICD-9-CM codes
	HCPCS codes
	Principle diagnosis codes
	All of the above

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Question 28 (1 point)

Inpatient acute care hospitals are reimbursed a single total payment for each patient discharge based on a(n) ________ code, which assumes that patients with the same sort of diagnoses require about the same length of stay and use approximately the same amount of resources.

Question 28 options:

	ICD-9-CM
	HCPCS
	CPT-4
	DRG

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Question 29 (1 point)

The reason (after study) that the patient was admitted to the hospital is called the:

Question 29 options:

	principle diagnosis.
	discharge diagnosis.
	final diagnosis.
	Both A and B

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Question 30 (1 point)

All of the following are an unethical and/or illegal practice EXCEPT:

Question 30 options:

	upcoding.
	unbundling.
	billing for services provided.
	billing for levels of service not supported by documentation.