HSMA 3045 Final Exam With 100% Correct And Verified Answers 2024, Exams of Advanced Education

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HSMA 3045 Final Exam With 100%

Correct And Verified Answers 2024

True/false: When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care - Correct Answer-True True/false: The drug utilization review committee is responsible for maintaining the hospital formulary. - Correct Answer-True True/false: An imaging center is a freestanding facility that provides radiographic, magnetic resonance imaging (MRI), and positron-emission tomography (PET) services to ambulatory patients. - Correct Answer-True True/false: Many medical transcriptionists work at home using the Internet. - Correct Answer-True True/False: An initial plan describes the actions that will be taken to evaluate, treat, and educate the patient about his or her current condition. - Correct Answer-True True/false: Administrative data includes demographic, socioeconomic, and financial information. - Correct Answer-True True/false: A neighborhood health clinic is usually a hospital-based outpatient department - Correct Answer-False True/false: demographic data is documented on the face sheet of a manual patient record - Correct Answer-True True/false: A medical nomenclature organizes disease and procedures into numeric and alphabetic characters - Correct Answer-False True/false: The preparation of a final meeting agenda is the joint responsibility of the committee chairperson and secretary. - Correct Answer-True True/false: Crisis services consist of a team of specially trained staff who visit patients in their homes. - Correct Answer-False True/false: since the early 1980s, the provision of outpatient services has decreased - Correct Answer-False True/false: Respite care offers relief and rest to primary caregivers of patients - Correct Answer-True

True/false: demographic data is a type of clinical data that identifies a patient's medical condition - Correct Answer-False True/false: the primary purpose of the patient record is to provide continuity of care - Correct Answer-True True/false: The medical record is the property of the provider - Correct Answer-True True/false: health care providers are responsible for documenting care and treatment to prove that patient care was provided - Correct Answer-True Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his inpatient admission. An incident report was completed at the time of the fall. Smith is suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should not have occurred. A. The incident report was filed in the risk management office. B. A note was entered in the patient record stating that an incident report was completed. C. A copy of the incident report was filed in the patient's record. D. Defense attorneys for the health care facility reviewed the incident report to prepare for the case. - Correct Answer-D. B and C Sally Jones is responsible for analyzing, organizing, and presenting information based on patient records. This is a function of: - Correct Answer-b. report generation Which organization was founded to improve the quality of care for surgical patients by establishing standards for surgical education and practice? - Correct Answer-c. American College of Surgeons The agency known as the premier medical research organization in the United States that supports research projects nationwide is called the: - Correct Answer-National Institutes of Health True/false: Civil law deals with relationships between individuals and government - Correct Answer-False Sally works in a pathology laboratory, gathering information for staff pathologists. Which nomenclature does she use in her job? - Correct Answer-SNOMED

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion. - Correct Answer-objective Patients that undergo procedures that can be performed on an outpatient basis are categorized as - Correct Answer-ambulatory surgery patients The American Hospital Association recommends that patient records be retained for: - Correct Answer-five years Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record. - Correct Answer-socioeconomic A patient who receives diagnostic or therapeutic care in an outpatient department because such care is unavailable in a primary care provider's office is a(n): - Correct Answer-referred outpatient AHIMA requires RHITs and RHIAs to submit proof of continuing education every: - Correct Answer-two years Tom Black falls while transferring from his bed to a wheelchair. This would be documented on a(n): - Correct Answer-incident report A hospital that provides emergency care, performs surgery, and admits patients for a range of problems is a ____ hospital. - Correct Answer-general To calculate the delinquent record rate, divide the total number of delinquent records by the: - Correct Answer-total number of discharges in the period Dan Smith has recently moved to a new town. He calls Dr. Jones' office to make an appointment for an annual history and physical. It is the policy of Dr. Jones' office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan's medical information, which includes treatment for alcohol abuse, depression, and documentation of therapy and treatment. This information would most accurately be referred to as: - Correct Answer-behavioral health information Polly's job responsibilities include collecting outcome and assessment information set (OASIS) data and entering the data set into Home Assessment Validation Entry (HAVEN) data-entry software. She most likely works at a: - Correct Answer-home health agency

Which of the following agencies supports research designed to improve the outcomes and quality of health care, reduce costs, address patient safety and medical errors, and broaden access to effective services? - Correct Answer-AHRQ Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries. - Correct Answer-signature legend Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical? - Correct Answer-Dr. Johns must sign the report first and then Dr. Blake must countersign Which filing order saves time in processing discharged records? - Correct Answer- universal chart order National Drug Codes are managed by the: - Correct Answer-Food and Drug Administration The primary reason for completing medical records in a fashion consistent with medical staff policies and procedures is to: - Correct Answer-Provide continuity of care to patients Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions? - Correct Answer- audit trail The physicians at Sunny Valley Hospital have requested that all progress notes be organized with the most current progress note filed first, a type of filing order known as:

• Correct Answer-reverse chronological date order The Joint Commission requires patient records to be completed ____ days after a patient is discharged. - Correct Answer- Which is an example of clinical data? - Correct Answer-diagnosis A nursing home administrator places the following advertisement in a local newspaper: "Seeking a health care professional who has the ability to coordinate a program to ensure superior patient care, monitor and improve patient outcomes, monitor facility compliance with accreditation and regulatory standards, and coordinate preparation for surveys." The job title for this professional would be - Correct Answer-quality manager

Suzy Staff's job responsibilites include coordinating patient care to ensure that patients receive timely discharge or transfer. Her job title is: - Correct Answer-utilization manager A candidate for hospice care would be a patient who: - Correct Answer-was diagnosed with cancer Critical access hospitals (CAHs) are located at a distance of ____ miles from any hospital or another CAH. - Correct Answer- Which is a freestanding facility that provides radiographic services such as MRI and PET? - Correct Answer-imaging center Ambulatory surgery, also called _________________________ or _________________________, is elective surgery that is performed on patients who are admitted and discharged on the same day. - Correct Answer-short-stay, one-day surgery The primary function of hospitals is to provide _________________________, nursing, and other health-related services to patients for surgical and _________________________ conditions. - Correct Answer-inpatient medical, nonsurgical Health care is provided in ______________________________ to economically disadvantaged patients; treatment is family centered. - Correct Answer-neighborhood health centers Documents of clinical findings, such as X-rays, operative reports, and vital sign sheets, are considered ____________________ sources of patient information. - Correct Answer-primary All entries made in a patient's record must be ____________________, which means that the entry is signed by the author. - Correct Answer-authenticated The collection of cancer data from a variety of sources and the reporting of cancer statistics to government and health care agencies, is performed by a(n) _________________________. - Correct Answer-cancer register At times it is necessary for a provider to amend an entry that was made in a patient record by adding a(n) ____________________. - Correct Answer-addendum During the professional practice experience, students receive ____________ experience prior to graduation - Correct Answer-on-the-job Louis Pasteur and Robert Koch established the microbial, or ____________________, theory of disease. - Correct Answer-germ

Lister believed that germs caused many surgical deaths, and he began using carbolic acid to ____________________ surgical wounds. - Correct Answer-sterilize Long and Morton discovered that ether gas could be used during surgery as a(n) ____________________ to put patients to sleep. - Correct Answer-anesthetic A universal chart is created when inpatient and ____________________ patient records are organized in the same order. - Correct Answer-discharged A ____________________ ensures an appropriate response to internal and external disasters. - Correct Answer-disaster recovery plan Compare the job functions of a privacy officer and a quality manager. - Correct Answer- A privacy officer oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization's policies and procedures covering privacy of and access to patient health information in compliance with federal and state laws and the health care organization's information privacy practices. A quality manager coordinates a health care facility's quality improvement program to ensure quality patient care, improve patient outcomes, confirm accreditation/regulatory compliance, and prepare for surveys.. Explain the goal of hospice care. - Correct Answer-to provide palliative care, or comfort care, rather than curative care Describe the areas in which a health information management consultant might specialize, and list tasks they might perform. - Correct Answer-A health information management consultant could specialize in ares such as data or information technology. As a data manager, they could be responsible for coding medical procedures. As an information technologist, they could be in charge of analyzing patient data to report trends to the quality management department. Explain the Joint Commission standard that addresses countersignatures. - Correct Answer-Assures quality in authenticity of the signatures that were given by providers of the medical treatment Record circulation includes the retrieval of patient records. Describe the reasons records are retrieved. - Correct Answer-Records will be retrieved if a patient is readmitted to the facility or requests their records to either relocate or move. Define the role of the health services manager. - Correct Answer-Works with the governing board and medical staff to oversee daily operations and assure that quality measures have been met Explain the term quaternary care - Correct Answer-Quaternary care is considered an extension of tertiary care and includes advanced levels of medicine that are highly

specialized, not widely used, and very costly. It can include types of experimental medicine Discuss the responsibilities of a hospital governing board. - Correct Answer-Members of a business committee that serves without pay to uphold the organization's mission. Explain the purpose of the Privacy Act of 1974 - Correct Answer-The Privacy Act of 1974 was implemented to protect the privacy of individuals identified in information systems maintained by federal government hospitals, and to provide access to records concerning these persons. True/false: A licensed nurse is required to have a public license to deliver care to patients. - Correct Answer-true Ms. HIM files the following records: 223345, 223346, 223347, 223348, and 223349. Which system is being used? - Correct Answer-straight numeric filing The process of advising a patient about treatment options is known as: - Correct Answer-informed consent true/false: A discharge progress note can be documented in a patient record instead of a discharge summary if a patient had an uncomplicated hospital stay of less than 48 hours. - Correct Answer-true true/false: Every report in the patient record must contain patient identification data. - Correct Answer-true true/false: Soundex is a methodology used to file patient records. - Correct Answer-false true/false: Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical activity of the brain. - Correct Answer-false true/false: Master patient index cards are filed by patient number. - Correct Answer- false At the time of admission, the patient is usually asked to sign a consent to admission, also called the ______________________________, which is a generalized consent that documents a patient's consent to receive treatment. - Correct Answer-conditions of admission Additional diagnoses that describe conditions that arise after the beginning of the hospital observation and treatment are called ____________________. - Correct Answer-complications Sunny View Hospital is part of a large university hospital with a very active and congested file area. Records are filed and refiled throughout the day. Which filing

system should be used to distribute the records equally in the file area? - Correct Answer-terminal digit true/false: In serial numbering, a patient receives a new number each time he or she is admitted. - Correct Answer-true The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as the day of discharge. This information can be located on the: - Correct Answer-graphic record Terrace View Hospital is located in a community that has a large population of Hispanic and foreign patients. Which system can help facilitate the organization of the master patient index? - Correct Answer-Soundex true/false: Third-party payer information is classified as financial data, and it is obtained from the patient at admission. - Correct Answer-true true/false: All orders must be authenticated by the responsible provider. - Correct Answer-true true/false: In family numbering, the head of household's patient number ends with the digits 00. - Correct Answer-false true/false: In a family numbering system, each family member is given a two-digit modifier that serves as a prefix (or suffix) to the household patient number. - Correct Answer-true true/false: The death certificate is usually filed with a state department of health's office of vital statistics within five days. - Correct Answer-true Hillcrest Hospital is converting from a serial to unit numbering system. Which of the following will decrease? - Correct Answer-number of file folders used If a shelving unit has eight shelves with 20 inches of storage on each shelf, how many inches of filing can the unit hold? - Correct Answer-160 inches Dr. Jones completes an admission history and physical on Bob Lot, who states, "When I walk up stairs, I have difficulty breathing." This statement is known as the patient's: - Correct Answer-chief complaint true/false: The appearance of an outpatient to a hospital department is called an encounter. - Correct Answer-false true/false: Persons under 18 years of age must have their parents' or guardian's consent to donate organs. - Correct Answer-true

true/false: Terminal digit filing divides a nine-digit patient number into three parts. - Correct Answer-false Which of the following would not be documented on a medication administration record?

• Correct Answer-provisional diagnosis Which of the following is true with regard to terminal digit filing? - Correct Answer-it provides a high degree of record security true/false: Social Security numbering systems are used in Veteran Affairs medical centers. - Correct Answer-true A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a: - Correct Answer-comorbidity Dr. Cook records the following as part of a history and physical examination: "Patient presents with abdominal pain of seven days' duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon." The diagnoses recorded are: - Correct Answer-differential diagnosis Arrange the following numbers in middle-digit order: 01-30-49, 01-31-40, 02-30-49, 02- 36-40, 20-39-50, 03-40-50. - Correct Answer-01-30-49, 02-30-49, 01-31-40, 02-36-40, 20-39-50, 03-40- true/false: Progress notes facilitate health care team communication, which is crucial to quality care. - Correct Answer-true A blend of the serial and unit numbering systems is known as ____________________.
• Correct Answer-serial-unit numbering system Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered: - Correct Answer-administrative data All patient information must be secured in a locked file or ____________________. - Correct Answer-locked room Birth certificate information is usually submitted to the ____ within 10 days of birth. - Correct Answer-state departments of health offices of vital statistics Many facilities have ____________________ quality reviews of scanned documents. - Correct Answer-two

Select the correct sequence of the following names: A. Chris Batts, Andrew C. Batts Sr., Adam Charles Batts, Sister Anne Batts, Andrew C. Batts Jr., A. Douglas Batts. - Correct Answer-A. Chris Batts, Adam Charles Batts, A. Douglas Batts, Andrew C. Batts Sr., Andrew C. Batts Jr., Sister Anne Batts true/false: Health information personnel who abstract records assign ICD-9-CM/ICD-10- CM codes to diagnoses and procedures. - Correct Answer-false true/false: The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients age 21 and over that they have the right to have an advance directive.

• Correct Answer-false The CEO of Sunny Valley Hospital has made the following statement: "I want to decide on an electronic record system and implement the system in the next four months." Assume that you are the HIM director and have to respond to the CEOs statement. Defend your response. - Correct Answer-An electronic record system could not be implemented in such a short period of time. Many processes have to be analyzed before implementation can occur. Transitioning to electronic record systems can take years to accomplish and must be planned by numerous departments within the organization. Sunny Valley Hospital has adopted the following patient record documentation guidelines:

1. All entries should be documented and signed by the author.
2. Complete only necessary entries on preprinted forms. Leave others blank.
3. If other patient(s) are referenced in the record, document their name(s).
4. All documentation should be entered in permanent black ink.
5. Be sure to document specific information and to avoid vague entries. - Correct Answer-2 and 3 true/false: Color coding allows misfiles to be easily identified. - Correct Answer-true The tissue report or _________________________ records the analysis of tissue removed surgically or diagnostically. - Correct Answer-pathology report true/false: Only authorized personnel should have access to file areas, and the file area should be secured when a file staff member is not in the file area. - Correct Answer-true The content of a legal medical record must be defined in facility ____________________ and standards for maintaining the security and integrity of the information. - Correct Answer-policy

true/false: A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day. - Correct Answer-false true/false: The Health Care Financing Administration is now called the Centers for Medicare and Medicaid Services. - Correct Answer-true Explain the content and purpose of progress notes. - Correct Answer-progress notes are used to document a patient's current condition, any changes in their condition, and any procedures that have to be preformed during the stay. Progress notes contain all relevant patient information from the departments they were seen at (laboratory, nuclear medicine, etc.) and they contain the patient's identification information Arrange the following numbers in terminal digit order: 01-30-49, 01-31-40, 02-30-49, 02- 36-40, 20-39-50, 03-40-50. - Correct Answer-01-31-40, 02-36-40, 01-30-49, 02-30-49, 20-39-50, 03-40- Dr. Jones reviews the following information located in the patient record. In which report is the information documented? - Correct Answer-vital signs record Ms. RHIT is analyzing and assembling a patient's record and notices that a copy of a history and physical from the attending physician's office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 (this year), and the patient was admitted to the hospital on January 5 (this year); the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is: - Correct Answer-acceptable, as the H&P for this admission because it was completed no more than seven days prior to admission true/false: In a unit numbering system, each time a patient is admitted, he or she is assigned a new patient number, but the record is always filed under the original patient number assigned. - Correct Answer-false The term ____________________ was used in the period 1970-1980 to describe the early medical record automation attempt. - Correct Answer-computerized medical records A filing unit has six shelves and holds 180 inches of filing. How many inches of filing does each shelf hold? - Correct Answer-30 inches Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the: - Correct Answer-forms committee Review the following patient record entry, and determine in which report it would be documented:

Skin- no jaundice, reveals pale, cool, moist surface chest- respirations needed lungs- clear on inspection, percussion, and ascultation Abdomen- no tenderness, guarding, or rigidity Extremities- no significant findings Genitalia- normal Rectal- deferred - Correct Answer-Physical examination Hillcrest Hospital uses a unit numbering system. Patient Tom Jones, admitted on January 4, was assigned patient record number 456789. Patient Mary Black, the next patient admitted, had a previous admission to the facility and at that time was assigned patient number 422223. On this admission, Mary should be assigned record number: - Correct Answer- true/false: In a unit numbering system, each time the patient is registered, a new patient number is assigned. - Correct Answer-false List two functions that are included in a pharmacy application. Briefly discuss the advantage of a pharmacy application. - Correct Answer-pharmacy applications include medications that a patient is being treated with and the possible side effects of the medications. the advantage of a pharmacy application is that doctors and/or nurses can use them to better treat their patients, by knowing which medications may cause adverse effects and which medications should not be given in addition to others. Physician orders preapproved by the medical staff, which are preprinted and placed on a patient's record, are called ____________________. - Correct Answer-standing orders Dr. Health sees Jack in her office to monitor his blood chemistry. She completes an examination and orders blood tests. Her medical assistant completes the venipuncture. Charges for these services would be recorded on a(n): - Correct Answer-encounter form true/false: Alphabetic filing systems are easy to learn, and staff can be trained quickly. - Correct Answer-true true/false: HL7 is a standards development organization that develops electronic health record (EHR) standards. - Correct Answer-true

There should be 18 to 20 inches of clearance between the ______________________________ in the file area - Correct Answer-top shelf and ceiling Which of the following statements would be found as part of a preanesthesia note?

1. The patient denies any previous reactions to anesthesia.
2. General anesthesia is to be used.
3. The patient had no reaction to current surgery.
4. The patient is at risk due to smoking history. - Correct Answer-1, 2, and 4 With alphabetic filing, which name is filed first? - Correct Answer-(B. Kim) Sally Jones is a 74-year-old inpatient at Sunny View Hospital. During the night her temperature rose, and she is currently not responding to the nurses. Nurse Smith informed the attending physician and called the family. Discuss the information that should be recorded in a progress note. - Correct Answer-Nurse Smith should include the rise in temperature and what time it was recorded. She should also include subsequent temperatures recorded during the remainder of her shift to show that Ms. Jones was unresponsive to treatment. Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Which of the following statements is true, based on Joint Commission standards? - Correct Answer-The record is not in compliance, as the H&P needs to be completed within 24 hours. Additional conditions for which the patient receives treatment or which impact inpatient care are called _________________________. - Correct Answer-secondary diagnosis