Question 1

Under which of the following conditions can an original patient health record by physically removed from the hospital?

Accepted Answer

A)  when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital 
B)  when the directory of health records is acting in response to a subpoena duces tecum and takes the health record to court 
C)  when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record 
D)  when the record is taken to a physician's private office for a follow-up patient visit postdischarge

Question 2

Bayside Hospital has 275 adult beds, 30 pediatric beds, and 40 bassinets. In a nonleap year, inpatient service days were 75,860 for adults, 7,100 for pediatrics, and 11,800 for newborns. What was the average daily census for the year?

Accepted Answer

A)  227 
B)  208 
C)  207 
D)  259

Question 3

Laparoscopic retroperitoneal lymph node biopsy

Accepted Answer

A)  38570 
B)  38780 
C)  49323 
D)  38589

Question 4

In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to

Accepted Answer

A)  reliability. 
B)  validity. 
C)  completeness. 
D)  timeliness.

Question 5

The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that

Accepted Answer

A)  the IRB focuses on patient care only, and the Ethics Committee addresses both patient care and business practices. 
B)  the Ethics Committee reviews ethics complaints, and the IRB focuses on developing policies and procedures. 
C)  the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. 
D)  the IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary.

Question 6

The data in the column on the far right were collected when the coders traded records for recoding. This is a common practice used to check The coding supervisor at Bayside Hospital regularly has her coders recode records from the previous week in an effort to improve and monitor coding consistency. The supervisor has collected the data displayed below on four coders.

Accepted Answer

A)  interrater reliability. 
B)  intrarater reliability. 
C)  interrater validity. 
D)  intrarater validity.

Question 7

The most common blood borne infection in the United States is

Accepted Answer

A)  Helicobacter pylori. 
B)  hepatitis A 
C)  hepatitis C 
D)  hemophilia.

Question 8

The best place to ascertain the size of an excised lesion for accurate CPT coding is the

Accepted Answer

A)  discharge summary. 
B)  pathology report. 
C)  operative report. 
D)  anesthesia record.

Question 9

As an HIM supervisor at Bayview Hospital, you supervise five employees. One of y employees reports that a co-worker has returned from lunch on numerous occasions with smell of alcohol on his breath. What is the best approach in handling this problem?

Accepted Answer

A)  Confront the employee and place him on suspension for 1 week. 
B)  Terminate the employee immediately. 
C)  Ignore the report because it is hearsay. 
D)  Handle the situation the same as you would any other disease that affects an employee' work.

Question 10

Which one of the following is NOT a pathophysiological factor in anemia?

Accepted Answer

A)  excessive RBC breakdown. 
B)  lack of RBC maturation 
C)  loss of bone marrow function 
D)  loss of spleen function

Question 11

A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the

Accepted Answer

A)  physical findings. 
B)  lab and diagnostic test results. 
C)  time and means of arrival. 
D)  instructions for follow-up care.

Question 12

A 4-year-old had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition.

Accepted Answer

A)  49553 
B)  49496 
C)  49521 
D)  49501

Question 13

You point out to your administrator that the study model generally accepted to be the best method to determine the magnitude of risk in the population with the characteristic or suspected risk factor is the

Accepted Answer

A)  descriptive study design. 
B)  analytic study design. 
C)  prospective study design. 
D)  case control study design.

Question 14

Which one of the following is NOT a data retrieval technology?

Accepted Answer

A)  color 
B)  sound 
C)  point and click fields 
D)  icons

Question 15

An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient's last three glucose tests. The patient is still running above normal glucose levels, so the physician decides to adjust the patient's insulin. An expanded history was taken and a physical examination was performed.

Accepted Answer

A)  99213 
B)  99232 
C)  99202 
D)  99214

Question 16

Gas exchange in the lungs takes place at the

Accepted Answer

A)  alveoli. 
B)  bronchi 
C)  bronchioles 
D)  trachea

Question 17

Dr. Smith wants to see the latest test results first. Dr. Brown wants to see the nurse's notes first. The different user views can be available by use of by a

Accepted Answer

A)  subschema. 
B)  schema. 
C)  data dictionary. 
D)  GUI

Question 18

Malignant melanoma, skin of back. Patient undergoes a radical excision of the melanoma with full-thickness skin graft.

Accepted Answer

A)  173.5, 86.4, 86.63 
B)  172.5, 86.4, 86.63 
C)  173.5, 86.3, 86.63 
D)  172.5, 86.3, 86.63

Question 19

The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of

Accepted Answer

A)  fingerprint signatures. 
B)  voice recognition systems. 
C)  expert systems. 
D)  electronic signatures.

Question 20

IV infusion of chemotherapy for 3 hours

Accepted Answer

A)  96422, 96423, 96423 
B)  96409, 96411 
C)  96413, 96415, 96415 
D)  96413, 96413, 96413

Exam 1: Registered Health Information Administrator