Exam 1: Registered Health Information Administrator

Established 42-year-old patient comes into your office to obtain vaccines required for his trip to Sri Lanka. The nurse injects intramuscularly the following vaccines: hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As the coding specialist, what would you report on the CMS 1500 form?

Patient presents with a traumatic partial amputation of the second, third, and fourth fingers on the right hand. Patient was taken to the operating room where completion of the amputation of three fingers was performed with direct closure.

Ralph has asked for a list of disclosures of his medical record. He seems surprised not to see his physician, Dr. Emory, on it. What do you tell him?

Decrease in blood pressure, salivation, and heart rate are examples of

Neonatal jaundice in preterm infant born in hospital. Phototherapy done to treat jaundice.

Your job description states that as Assistant Director of the Health Information Management Department, you will supervise day-to-day operations for the record processing, transcription, and release of information areas. What principle of management is described?

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

Pain in hip due to displaced hip prosthesis. Patient is admitted and undergoes revision of hip prosthesis.

In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent?

Total shoulder replacement

Nurse Jones suffers a needle stick and presents for HIV testing. She sees her physician for the test results and counseling.

You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time?

A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records would be

A HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is

James is admitted to the hospital for severe anemia that is a result of the chemotherapy treatments he is receiving for metastatic prostate cancer to bone. James receives blood transfusions and is discharged home.

Patient has been followed by his primary care physician for elevated PSA . Patient underwet prostate needle biopsy in the physician office 2 weeks ago and final pathology was positive 10 carcinoma. Patient is admitted for prostatectomy. Frozen section of the prostate and one lymp node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectom became a radical perineal with bilateral pelvic lymphadenectomy.

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

When a healthcare facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the healthcare facility can be held liable under

You have just constructed the chart displayed below: The names of the hospital services are hard to read. The best way to deal with this problem would be to

Which of the following BEST summarizes the current treatment of cervical cancer?