ACRONYMS

CMS

DRGs

CPT

OIG

Centers for Medicare and Medicaid Services

Diagnosis Related Groups

Current Procedural Terminology

Office of the Inspector General

The state approves the number of beds a hospital is allowed to have as part of its:

Licensure

Accreditation

Registration

Certification

Licensure

The 82 year old patient presented in the physician's office for a routine physical examination. He gave the receptionist two cards, evidencing his primary governmen-funded insurance plan that pays for most of the bill and an additional, private plan that covers the remaining charges. The patient's primary insurance is most likely: 

Discounted fee for service

Wraparoud plan

Medicare

Capitation

Medicare

The Community Care Center has 200 beds. It has an average length of stay of 2 1/2 years. Most of the patients are elderly, but there are some younger patients with serious chronic illnesses. Community Care Center is most likely a(n) ___________ facility. 

Acute Care
Behavioral Health
Long Term Care
Rehabilitation

Which of the following qualifies an acute care facility for deemed status?

State Licensure

CARF accreditation

Joint Commission Accreditation

Compliance with COP

Joint Commission

Which of the following is an example of a diagnosis?

Tonsilitis

Appendectomy

Chest X-ray

Physical Therapy

A facility is reviewing its policies and procedures to ensure that they comply with Joint Commission standards. The facility is concerned about its:

Accreditation

Certification 

Licensure

Registration

Accreditation

The patient was admittted to the hospital on Tues morning and died Tuesday evening. The patient is classified as a(n):

Inpatient

Outpatient

Both a and b 

None of the above

Inpatient

A synonym for a "vocational nurse" is:

Registered nurse

Licensed Practical nurse

Nurse Practitioner

Advanced Practical nurse

Licensed Practical Nurse

A patient is most likely to undergo surgery at a(n)

Acute Care

Long-term Care

Rehabilitation

Hospice

Acute Care

An organization that insures covered lives as well as owns (exerts employer control over) the health care providers is a(n)

Health Maintenance Organization

Preferred Provider Organization

Indemnity company

Blue Cross Organization

Health Maintenance Organization

Define and discuss the differences between the following:

Health Maintenance Organization

Preferred Provider Organization

Indemnity company

Blue Cross Organization

An HMO contracted with a group of physicians to provide health care services to its members. This is characteristic of a(n)_____model HMO.

Staff

Group Practice

Independent Practice Association 

All of the above

Group Practice

Clinical pathways are based on all of the following EXCEPT:

Experience

Reimbursement method

Research

Successful outcomes

Reimbursement Method

The ability of a patiet to see a physician without an appointment is called:

Appointment-free

Open-access

Free scheduling

Open appointments

Open Access

Of the following workers n a physician's office, who is the most likely one to collect the patient's blood pressure?

Physician 

Nurse

Medical Secretary

Health Information Technician

Nurse

If a patient's insurance company has reimbursed the physician for the appropriate amount and there is still a balance due in this paient's account, the physician must apply next for payment to the:

Guarantor

State government

Medicaid

Patient's parents

Guarantor

Which of the following is an example of the possible contents of a field?

F

Fl

Florida

All of the above

All of the above

The student of health trends or patterns is called:

Demographic data

Epidemiology

Health data

Health Information

Epidemiology

The individual or organization that is ultimately responsible for paying a hospital billis called the:

Employer

Guarantor

Patient 

Spouse

Guarantor

"Patient complains of dizziness and shortness of breath" is an example of which of the following components of medical decision making?

Subjective

Objective

Assessment

Plan

Subjective

"Pupils equal, round, and reactive to light and accomodation" is an example of which of the following components of medical decision making?

Subjective

Objective

Assessment

Plan

Subjective

"Rule out Congestive Heart Failure versus Cerebrovascular Accident" is an example of which of the following components of medical decision making?

Subjective

Objective

Assessment

Plan

Assessment

"Chest x-ray to rule out CHF" is an example of which of the following components of medical decision making?

Subjective

Objective

Assessment

Plan

Plan

Which of the following is NOT a benefit of a problem list?

Reduces the amount of documentation in a record

Facilitates management of the patient's care

Improves communicaton among caregivers

Creates an index to the patient's record

Reduces the amount of documentation in a record

Al of the following are components of a problem list EXCEPT:

Diagnoses

Date of initial diagnosis

Procedures

Discharge date

Discharge date

SOAP notes are examples of ____ data.

Demographic

Socioeconomic

Financial

Clinical

Clinical

A synonym for an integrated record is:

Date-oriented

Sequential
Source oriented

Both a and b 

Both a and b

Which of the following is an element of an acute care admission record?

Patient's previous operations

Type of dwelling in which the patient lives

Name of the patient's employer

Patient's height and weight

Name of the patient's employer

If a hospital wanted to correspond with a patient after discharge, the appropriate source of the patient's current address would be the:

Discharge summary

Attending physician's office record

History and Physical

Latest admission records

Latest admission records

Which of the following is an example of the "O" in SOAP?

Pancreatitis versus hiatal hernia versus gastritis

Patient reports continued pain in the abdomen, particularly after eating

Patient's abdomen is tender to palpation in the epigastric region

Schedule barium swallow

Patient's abdomen is tender to palpation in the epigastric region

Define and give an example of each of the components of SOAP

TBD

The nursing department  in your facility has submitted a form to the forms committee for approval. The form is printed on dark gold paper so that it will stand out in the chart. You recommend a light yellow paper instead, because it photocopies/scans better than the gold. This is an example of taking into consideration:

Te purpose of the data collection device

The needs of all users of the device

An understanding of the technlogy used 

Simplicity

The needs of all users of the device

???should this be C???

The purpose of instructions on a data collection device is to:

Ensure that the correct form is used

Help users with complicated dated collection

Help ensure the consistency of data collection

Sequence the data collection correctly

Help ensure the consistency of data collection

The extent and complexity of a history and physical is dictated by: 

Joint Cmmission guidelines

Department of Health guidelines

Data needed to evaluate the patient's problem 

All of the above

Data needed to evaluate the patient's problem

All of the following are always elements of a physicians order EXCEPT:

Date 

Physician's signature

Initials/signature of individual executing the order

Reason/rationale for the order

Reason/rationale for the order

The best place to look to determine what medications a patient has received is the: 

Physician's orders

Physician's progress notes

Nursing Medication Admnistration Record

Discharge Summary

Nursing Medication Administration Record

The physician's operative record must be completed:

Prior to the procedure

During the procedure

Immediately after the procedure

Within 30 days of the patient's discharge from the hospital 

Immediately after the procedure

The process of recording data into an information system is called:

Data entry

Utilization review

Detective control

Collection

Data entry

Which of the following cannot take place retrospectively?

Corrective

Detective

Preventive

All of the above

Preventive

The health information management department can verify which patient records are available for processig by referring to the: 

Admission register

Audit trail 

Discharge register

Exception list

Discharge register

All of the following are routinely identified during quantitative analysis EXCEPT for:

Missing signature on a physician progress note

Discharge report has not been dictated

Requested cardiology consultation was not performed

H&P was dictated and transcribed on the third day of admission

H&P was dictated and transcribed on the third day of admission

The coding system used to tract diagnoses and procedures in an acute care setting is:

ICD-9-CM

ICD-O

DSM-IV

CPT-4

ICD-9-CM

Which of the following is an example of a nomenclature?

ICD-9-CM

ICD-O

CPT-4

DRG

CPT-4

All of the following are steps in post discharge processing EXCEPT:

Coding 

Abstracting

Chart retrieval 

Concurrent analysis

Concurrent analysis

Which of the following is a preventive control?

A nurse alerts a physician that a patient is allergic to an ordered medication

The nursing supervisor reviews a chart to ensure that medications were administered on a timely basis 

The HIM department sends a physician a list of her incomplete charts

A coder reviews a record in order to assign a clinical code

A nurse alerts a physician that a patient is allergic to an ordered medication

Community Hospital, an acute care facility, is preparing for a Joint Commissio survey. The Chief Operating Officer is reviewing the following data from the HIM department:

538

1000

1100

1200

1100

research this answer

Control over records in process can be maintained using:

Batch control record and deficiency sheets

Central staging area and deficiency sheets

Batch control record and central staging area

Deficiency sheets and loose sheets

Batch control record and central staging area

Complete each statement: ________provides care to patients at all or most points along the continuum of care.

A hospital or acute care hospital

Care for the terminally ill is the focus of _______ care.

hospice

Health care professional's must adhere to their discipline's __________.

code of ethics

Appendicitis is an example of a ______________.

diagnosis

When one physician asks another physician for an opinion regarding the care of the patient, the first physician is asking for a ________________.

consultation

A federally mandated database collected on all inpatients discharged from a hospital is the:

MPI

UHDCS

UHDDS

UACDS

UHDDS

The CEO requests information on the number of arthroscopies performed annually. What information should be requested from the database to be included on the report so that individual cases can be reviewed, if necessary?

Patient name only

Patient name, MR#, ICD-9-CM procedure code, discharge date, surgeon

Patient name, procedure description, surgery date

Surgeon

Patient name, MR#, ICD-9-CM procedure code, discharge date, surgeon

Identify the statement below that requests aggregate health information.

Request for report on all DRG 127 for the month of June

Request for patient information, MR# 02-34-65, DRG 127

Request for the first case of CHF for the third quarter

Request for record of patient #197808, under the cae of Dr. S.S. Schoner

Request for report on all DRG 127 for the month of June

Given a request for the number of Medicare CHF cases for the month of April, how would you query the database to sort the report?

Patient gender 

Patient age

Financial class

Diagnosis

Diagnosis

The database mandated for collection on outpatients is:

MPI

UHDCS

UHDDS

UACDS

UACDS

Birth certificates, completed by the health care facility, are registered with the Department of:

Motor Vehicles 

Live Births

Complete Statistics

Vital Records

Vital Records

Which of the following graphs would best illustrate the following information: of the 440 discharges for the month of June, 340 were Medicare, 60 were Medicaid, 20 were insurance, 20 were private pay?

Pie chart

Line chart

Brainstorming

Decision matrix

Pie Chart

Which statement best describes the patient abstract?

Patient database

Summary of the patient's stay

Summary of the patient's medical history

Patient demographics

Summary of the patient's stay

A sample is a small group within a:

Data set

Database

Aggregate group

Population

Population

The patient abstract is an example of ______ data.

Demographic

Primary

Secondary

Tertiary

Secondary

DOMAIN 1 What term is used in reference to objective descriptions of processes, procedures, people and other observable objects and activities?

a. Information b. Data c. Knowledge d. Notices