which one of the following action would NOT be included in the professional obligations of the health information practitioner that lead to responsible handling of patient health information?
Take a compromising position toward optimal interpretation of nonnsp0ecific regulations and laws.
If there is more than one patient with the identical last name , first name, and middle initial , the master patient index entries are then arranged according to the
Date of birth.
Which one of the following is NOT a step in developing a health record retention schedule?
Assigning all records the same retention period.
What type of filing system is being used if records are filed in the following order:12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79?
Straight numeric
If there are 150,000 records and the HIM department receives 3545 requests for records within a given period of time, what is the request rate?
2.4%
Which of the following is NOT an advantage of a centralized filing system?
There is less transportation time and effort when a facility operates from several sites.
In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26
00-06-26
The HIM Departement at General Hospital has been experiencing an average 30-minutes delay in the retrieval of records requested by the emergency Departement . Which of the following corrective actions would be most effective in reducing the delay in retri
Review and possibly reegineer the retrival process to decrease retrieval time.
Which one of the following is NOT an advantage of a computerized master patient index?
Duplicate of patient registration can never occur.
Color coding of record folders is used to asist in the control of
Misfiles.
Which of the following would not be considered secondary data?
Health record
Under the patient Self-Determination Act of 1990, evidence of advance directives
Are required to be documentated in the health record.
A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number?
12
A 200- bed acute care hospital currently has 15 years of paper health records and filling space is limited. What action should be taken?
Destroy inactive records that exceed the statute of limitations.
Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital?
Straight numeric
What is the chief criterion for determining record inactivity?
Amount of space available for storage of newer records.
Out of 2,543 records requested from the HINM Department, 2,375 were located. What is the filing accuracy rate?
93%
Which set of records filed consecutively on a shelf displays terminal digit filing order?
57-78-00, 57-78-01, 56-78-99
In the master patient index, which is filed by last name, Jill Thomas-Jones would be
Thomas, Jill, Jones
According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30
00-00-31
How many years does the CMS regulations require that health records be maintained?Medicare's C
ondition of Participation for Hospitals requires that patient health records be retained for at least __________ years unless a longer period is required by sta
5 years
Your state regulations require heath records to be kept for a status of limitations period of 7 years. Federal Law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be
7 years.
Which of the following technologies works best with automated record-tracking systems to speed the data entry process?
Bar codes.
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf fiing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches s
14
Microfilmed records are considered
Acceptable as courtroom evidence.
A research request has been received by the HIM Department from the quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2014. Which of the following indices would be t
Disease index
How many inches are recommended for aisles between file units when using stationary open-shelf files?
36
In a manual record-tracking system, no record should be removed from the file without being replaced by a(n)
Outguide.
Which of the following should NOT be included in the documentation of record destruction?
Dates not covered in destruction.
f the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number?
8
Which of the following is NOT a consideation when implementing a disaster plan
Test the disaster plan only once.
Which of the following, lists is in correct alphabetical order?
Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo,Joshua Philip
Many schnering was admitted to Community Hospital on 10/3/14 and assigned a record number of 54-47-53. The patient was later admitted on 1/14/15 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/ f
Serial-Unit.
Capital Health Center is moving to a new facility in december 2015. The CEO is projecting a conversion to an electronic health record system by then. This new facility will not include space for the filing of paper-based health records. Which of the follo
Relationship with the microfilm vendor.
What microform shoul the HIM practitioner select if the records must be unitizer and color-coded for filing purposes?
Jacket microfilm.
In retrieval of optical image files, cache memory
Decreases access time for all users on the system.
At Community Hospital the average admission will create a file that will take up 0.25 inch of file space. Each new ER record requires 0.125 inch of file space. Approximately 25000 new patients are admitted per year and 15,000 ER patients are treated per y
$8,531.25
On his 12/23/14 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous record number asigned to Mr. Robinson during a 9/1/14 admission was07-10-47. In a serial numbering/filing system, how would th
Each admission is filed under its own number.
The same patient was admitted on three diffeernt occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be used given the following information?
Void the last two numbers and file all admissions under 23-33-56
The health care providers in an acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the director of the HIM Department should
Staff the department with personnel 24 hours a day.
AS a prerequisite to phasing in a new imaging system, what process would facilitate automatic indexing?
Redesigning forms to include bar codes
Which of the following is NOT a safety hazard in the HIM department?
Stepladders that are fully open and locked in place.
A HIM Department wants to buy new open -shelf filing units for its file expansion . Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average records is 1 -inch thick. How man
6
Which of the following microform types is the least expensive to prepare and results in the greatest storage density?
Roll microfilm
Brian Hill was discharged from the hospital after a 3-day hospitalization and instructed to return to the outpatient department for follow-up care. On his visit as on outpatient, a new record was created and he was assigned a new record number. Following
Decentralized
The master patient index must , at a minimum, include sufficient information to
Uniquely identify the patient
Dr. Gray has applied for medical staff privileges at your hospital. What databes would you research to determine if he has been denied medical staff privileges at another hospital?
National Practitioner Data Bank.
Which type of patient information system does the Joint Commission suggest that hospital use?
Any one of the above.
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?
Department staffing
Which of the following is NOT a benefit of the electronic document management system in the HIM department?
Decreased use of computer technology.
Which one of the following is an advantage of straight numeric filing over terminal digit filing?
All sections of the file expand uniformly
Which one of the following is NOT an electronic document management system component?
Reader-printer.
which of the following items is the Health Information Manager primarily concerned with when purchasing file guides?
Durability and visibility
Palm Beach Healthcare Center has been in operation for 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admissions per year from now on. There are 2,500 linear feet of filing space available and half is bei
4,340
As Director of HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to
Install a computerized access control panel.
What technical security controls do electronic health record systems employ that are different from paper-based health record systems?
-Audit trails
_ Data encryption protocols
-User-based access controls
All of the above
The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information?
Operation index.
A major consideration in a hospital or facility closure is to
Ensure that authorized parties have access to the information as provided by law.
What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program?
90%
In negotiating a contract with a commercial storage company for forage of inactive records, what would be the most important issue to clarify in writing?
Confidentiality policies and liability concerns.
Which index is used by the HIM department to link the patient's name and number in relation to access and retention of the clinical record?
Master patient index
Unless state or federal laws require longer periods, AHIMA recommends that patient health information for minors be retained for at least how long?
Age of majority plus statute of limitation.
A health care facility has a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?
Magnetic degaussing
Which of the following statements would be found in the laboratory report section of the health record?
BUN reported as 20mg.
Which of the following is a disadvantage of terminal digit filing as compared to straight numeric filing?
The training period is slightly longer
The main advantage of phonetic filing is?
Names that sound alike are filed together.
Electronic health record built-in tools that can make data capture easier include all but which one of the following?
Flow process charts.
If the department staff are having trouble locating the terminal digit sections quickly , the supervisor could add more
File guides.
The HIM Department receives a request for a certified copy of a bird certificate on a patient born in the hospital 30 years ago . The department should
Direct the request to the state's office of vital records.
A surgeon requests the name of a patient he admitted on January 11, 2013. Which of the following would be used to retrieve this information?
Admission register
Which of the following is NOT a consideration in file folder size and design?
Vendor location.
Where in the Health record would the following statement be located?
" Microscopic Diagnosis: Liver(needle biopsy), metastatic adenocarcinoma
Pathology report.
The HIM department is located in a hospital that provides health record access 24 hours a day, 7 days a week. To secure the file area and continue to maintain accessibility, the department director should
Staff the file area with file clerks on all three shifts.
A file area has limited space, medium file activity , and two file clerks. The HIM department would benefit from choosing which of storage equipment?
Compressible filing units.
When evaluating an outside contract microfilm company, all but which of the following are important factors to rate?
Cache memory.
Under the HIPAA Private Rule, when destruction services are outsources to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include which of the following element
-Method of destruction or disposal
-Time that will elapse between acquisition and destruction or disposal
-Safeguards against breaches
-All of the above
The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the lab
Access.
When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow?
Security training is provided to all levels of staff.
Which one the following features should NOT be considered when designing screens to capture quality health data?
Left to right and bottom to top formatting
When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT
Communities of practice requirements.
Case finding methods for patients with diabetes include a review of all but which one of the following?
CPT diagnostic codes
What type of plan is a joint Commission- accredited facility required to maintain to protect health information from catastrophes such as fire, flooding , bomb threats, and theft?
Disaster
Which of the following is NOT an alternative storage method for paper-based records?
Outguide
Which of the following issues would be of LEAST concern when storing health records in off-site storage?
Filing order of the records.
The HIM Department maintains 500,000 records and responds to 5,000 request for records in a given period of time. What is the record usage rate?
1%
Which one of the following is NOT a data retrieval tool?
Point-and- click fields.
When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract?
Type of reader or printer needed to view the microfilm
What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital?
Scanning all 250,000 records for a cost of $195,000
The total number of records filed during the month is 2,500 and , upon completion of filing accuracy study, 90 records were not found. What is the accuracy rate for
filing?
96%
A quality control measure that should be established for the filing , storage, and retrieval of health records includes criteria for the
Inclusion of late reports.
According to AHIMA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently?
Physician index.
For a health care facility to meet its document destruction needs, the certificate of destruction should include all BUT which of the following elements?
Patient notification.
The steps in developing a record retention program include all but which of the following?
Notifying the courts of the destruction
A health care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past years and subsequent years. Given that each of the data sources cited below contains the necessary
Birth defects registry.
An example of primary data source is the
Health record.
Which of the following is NOT considered a challenge in the adoption of an electronic health record system?
Contribution to the quality of patient care
Fetal monitoring strips are part of the ________ record and should be maintained_____
Mother's ; according to the length of time require for a minor's records.
Which one of the following would NOT be a strategy when purchasing an electronic health record system?
Braden the vendor field and select several vendors of choice.
How many years does the Food and Drugs Administration require research records pertaining to cancer patients be maintained?
30 Years.
What data cannot be retrieved from the MEDPAR?
Non- Medicare patient data.
As the record retention supervisor , you are evaluating storage devices for a new health information management system. Which one of the following would you NOT consider as an option for storing health information?
Light Pen.
General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for the activity?
Database management system.
The director of health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Direc
Elimination of the need for expensive desktop computers
The assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed?
Test the software prior to purchase.
Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate
-Security controls and access privileges of staff.
-Policies and procedures developed to safeguard privacy and security.
-Use of a back-up system.
-ALL OF THE ABOVE
Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months . IT is ready to start retrieving data from the database to improve clinical services. Which tool should be used?
SQL
The assistant Director of HIM is evaluating that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What department function is this most useful for?
Chart tracking
The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?
Executive information system
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. which one of the following is the medical staff using?
Clinical information system
The HIM practitioner's duty to retain health information by archiving and storage of health data includes
-Strategies that consider accessibility , natural disasters, and innovations in storage technology.
-Strategies ensuring that inactive records are as secure as active records.
-A retention plan for multiple volumes of records.
ALL OF THE ABOVE
As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following security measures can be implemented to prevent privacy violations in this computer system?
-Authentication
-Encryption
-Disaster recovery plan
ALL OF THEABOVE
Health informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information system that are designed to share data without human or technical intervention. This is a (an)
Interfaced system.
The function of a (an) _________ is limited to data retrieval.
Clinical data repository.
The director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. which of the following would be the key advantage in using this type of data entry?
Enhanced databases will provide information for improved clinical care.
University Hospital , a 900-bed tertiary health care organization , is undergoing an information systems development. What system would best meet its needs?
Application service provider model.
A 16- years- old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would
Be filed in the mother's record.
Which of the following is a major management challenge in the storage and retention of electronic health record systems?
-Following state and federal laws and accreditation requirements when developing retention and destruction policies.
-Keeping technology updated in order to retrieve data.
-Ensuring that health information can be retrieved in a timely manner.
-ALL OF THE
When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?
Access control.
Which of the following is NOT a factor to consider when developing a record retention program?
Reimbursement guidelines.
Of 750 records filed during the week, 75 were not located. What is the filling error rate?
10%
Which of the following is NOT a document input device in the electronic document management system?
Printer.
which of the following statements is false when addressing characteristic of the legal health record in an electronic document management system?
Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate data from these ancillary systems.
which of the following is NOT a data retrieval tool?
Light pen.
Messenger, pneumatic tube, dumbwaiter, and conveyor belt are all examples of
Record circulation systems.
Which item is collected and maintained in the transplant registry?
Histocompatibility information