Question 1

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitits secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

Accepted Answer

A)  alcoholism. 
B)  abdominal pain. 
C)  cholecystitis. 
D)  acute pancreatitis.

Question 2

When a record custodian brings the medical record to court in response to a subpoena duces tecum, it is her responsibility to

Accepted Answer

A)  identify the record in her official capacity as custodian. 
B)  present the case favorably for the patient involved. 
C)  leave the original record in the possession of the plaintiff's attorney. 
D)  explain details of the medical treatment given to the patient.

Question 3

The table above presents an example of

Accepted Answer

A)  the systems standards. 
B)  a RFI 
C)  the functional specifications. 
D)  a systems design.

Question 4

+In order to prevent the accidental introduction of a virus into your facility's local area network, your facility has a policy that strictly prohibits

Accepted Answer

A)  doing personal work on the computer system, even during personal time. 
B)  sharing disks from one workstation to another within the facility. 
C)  downloading executable files from electronic bulletin boards. 
D)  sending or receiving e-mail from addresses that have not been authorized.

Question 5

Administration has asked the clinical provider order-entry task force to select the method implementation that will reduce risk to the hospital. What method should they choose?

Accepted Answer

A)  Implement all modules across the entire organization. 
B)  Implement one module in one unit while running the current system in parallel. 
C)  Implement all modules across the entire organization while running the current system parallel. 
D)  Implement one module in one unit while shutting down the existing system.

Question 6

What action(s) would assist the manager of a medical record department in improving customer perception of the quality of services provided by the department?

Accepted Answer

A)  Establish a 2-week turnaround time for all dictated reports. 
B)  Refuse to fax patient information to protect confidentiality. 
C)  Have physicians and hospital staff retrieve their own medical records. 
D)  Identify specific customer needs in order to design value-added services.

Question 7

Lucy Ann manages a claims review unit for an insurance company. Her staff keys a high volume of data daily. She scheduled a staff PT to do the annual ergonomics presentation to help prevent repetitive strain injuries. All of the following would be included EXCEPT

Accepted Answer

A)  using a footrest. 
B)  wrists should be elevated. 
C)  monitor placed directly in front and elevated. 
D)  lumbar support provided.

Question 8

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

Accepted Answer

A)  interdisciplinary patient care plan. 
B)  discharge summary. 
C)  transfer record. 
D)  problem list.

Question 9

The transcriptionists have collected data on the number and types of problems with the dictation equipment. The best tool to display the data they collected is a

Accepted Answer

A)  flowchart. 
B)  Pareto chart. 
C)  Gantt chart. 
D)  PERT chart.

Question 10

In the master patient index, which is filed by last name, Jill Thomas-Jones would be

Accepted Answer

A)  J-I-L-L-T-H-O-M-A-S-J-O-N-E-S 
B)  T-H-O-M-A-S,J-I-L-L-J-O-N-E-S 
C)  T-H-O-M-A-S-J-O-N-E-S,J-I-L-L 
D)  J-O-N-E-S,J-I-L-L-T-HJ-O-M-A-S

Question 11

Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of

Accepted Answer

A)  retrospective deficiency analysis. 
B)  special study audits. 
C)  concurrent chart review. 
D)  occurrence screening.

Question 12

Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5.0 cm and 2.7 cm.

Accepted Answer

A)  11406; 11403 
B)  12034 
C)  12032; 12031 
D)  12032

Question 13

Bleeding esophageal varices with alcoholic liver cirrhosis and portal hypertension. Patient is alcohol dependent. Esophagogastroduodenoscopy for control of hemorrhage.

Accepted Answer

A)  456.20, 571.2, 303.90, 42.33 
B)  571.2, 456.20, 303.90, 280.0, 42.33 
C)  572.3, 571.2, 303.90, 456.20, 42.33 
D)  303.90, 456.20, 303.90, 42.33

Question 14

When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?

Accepted Answer

A)  certificate of authentication 
B)  consent from the patient 
C)  consent from the hospital administrator 
D)  correspondence from the attending physician

Question 15

Patient has recurrent spontaneous pneumothorax which has resulted in a chemical pleurodesis by thoracoscopy.

Accepted Answer

A)  32650 
B)  32310; 32601 
C)  32605 
D)  32960

Question 16

Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT

Accepted Answer

A)  the patient has a total of 60 lifetime reserve days. 
B)  lifetime reserve days are usually reserved for use during the patient's final terminal hospital stay. 
C)  lifetime reserve days are paid under Medicare Part B. 
D)  lifetime reserve days are not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges.

Question 17

Cardioversion of cardiac arrhythmia by external forces

Accepted Answer

A)  92961 
B)  92950 
C)  92960 
D)  92970

Question 18

Henry experienced sudden sharp chest pain that he described as heavy and crushing. His paint and past medical history cause Dr. James to suspect that Henry was having a myocardial infarction. Which of the following tests is a more specific marker for a mi?

Accepted Answer

A)  AST 
B)  CK-MB 
C)  LHI 
D)  troponin I

Question 19

Acute and chronic maxillary sinusitis. Maxillary sinusectomy performed.

Accepted Answer

A)  461.0, 22.62 
B)  473.0, 22.62 
C)  461.0, 473.0, 22.62 
D)  461.2, 22.62

Question 20

You are conducting a patient satisfaction survey in your outpatient clinic using interviewers administer a questionnaire. Because you typically see about 300 people per day in the clinic, decide to have the interviewers administer the questionnaire on every tenth patient. You using

Accepted Answer

A)  systematic sampling. 
B)  stratified sampling. 
C)  variable sampling. 
D)  convenience sampling.

Exam 1: Registered Health Information Administrator