Question 1

In the ICD-9-CM classification system, severe shock due to third-degree burns sustained in an industrial accident would be coded as a(n)

Accepted Answer

A)  current injury. 
B)  late effect. 
C)  mechanical complication of an internal prosthetic device. 
D)  abnormal reaction of the body to the presence of an internal prosthetic device.

Question 2

As head of the Performance Improvement Department, you are asked to evaluate pati satisfaction and offer recommendations for action. The following performance tool is used graphically display the results. What is the name of this chart?

Accepted Answer

A)  Pareto chart 
B)  line chart 
C)  bar chart 
D)  run chart

Question 3

Liveborn infant, born in hospital, cleft palate and lip

Accepted Answer

A)  749.00, 749.10 
B)  749.20 
C)  V30.00, 749.20 
D)  V30.00, 749.00, 749.10

Question 4

Virginia is the Record Processing Coordinator, which is a lead position. She has an excellent w record and is able to assist in most work areas of the department. She knows that she could e get another job within the hospital for the asking. Recently she has been arriving late and has uncooperative in dealing with others. As her immediate supervisor, what is the BEST first step dealing with this situation?

Accepted Answer

A)  Institute progressive discipline. 
B)  Ignore the situation and hope she will improve because she is a good employee. 
C)  Counsel her by encouraging self-analysis and problem-solving processes. 
D)  Suggest that she transfer to another department.

Question 5

Cindy, Tiffany, and LaShaundra are all nurses at Desert Sands Health Care. They all have access to the same functions in the information system. It is likely that this facility is using

Accepted Answer

A)  user-based access. 
B)  role-based access. 
C)  DAC. 
D)  MAC.

Question 6

Referring again to the data collected on scanning errors, if you want to work on the type of material with the highest volume, you will work on problems with

Accepted Answer

A)  consultation reports. 
B)  lab slips. 
C)  correspondence. 
D)  other.

Question 7

Which of the following is least likely to be identified by the deficiency analysis clerk?

Accepted Answer

A)  missing discharge summary 
B)  needs for physician authentication of two verbal orders 
C)  discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist 
D)  x-ray report charted on the wrong record

Question 8

The graph below can best be described as

Accepted Answer

A)  sequential. 
B)  multimodal. 
C)  substitutional 
D)  erratic.

Question 9

10 sq cm epidermal autograft to the face from the back

Accepted Answer

A)  15110 
B)  15115 
C)  15110,15115 
D)  15120

Question 10

What advice should be given to a physician who has just informed you that she just discovered that a significant portion of a discharge summary she dictated last month was left out?

Accepted Answer

A)  Squeeze in the information omitted by writing in available spaces such as the top, bottom, and side margins. 
B)  Dictate the portion omitted with the heading "Discharge Summary-Addendum" and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., "9/1 /08-See Addendum to Discharge Summary"- Signature). 
C)  Redictate the discharge summary and replace the old one with the new one. 
D)  Inform the physician that nothing can be done about the situation.

Question 11

Which of the following is a true statement regarding psychotherapy notes?

Accepted Answer

A)  Patients have open access to psychotherapy notes. 
B)  Psychotherapy notes are never intended to be shared with anyone. 
C)  Psychotherapy notes cannot be used in defending oneself in a court case. 
D)  Psychotherapy notes are to be destroyed after one year because of their confidential nature

Question 12

You stop by an office to meet a friend for lunch. Looking on the desk, you see the grid below: Your friend is trying to

Accepted Answer

A)  plan a conversion. 
B)  design a system. 
C)  analyze a workflow. 
D)  make a decision.

Question 13

A patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of

Accepted Answer

A)  45 days. 
B)  46 days. 
C)  47 days. 
D)  48 days.

Question 14

The minimum length of time for retaining original medical records is primarily governed by

Accepted Answer

A)  Joint Commission. 
B)  medical staff. 
C)  state law. 
D)  readmission rates.

Question 15

A 19-year-old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the Army. The release of information clerk should

Accepted Answer

A)  send the records as requested. 
B)  inform the young man that specific reports must be identified in his request. 
C)  send a letter informing him that faxed requests are not accepted. 
D)  deny the request.

Question 16

Case study #6 You are helping the Nursing Department to write indicators, to determine appropriate formulas ratios and to determine data collection time frames. One important aspect of care is documentation of education of patients. More specifically, the nursing department would like assess its documentation of education on colostomy care for patients with new colostomies. Referring to Case Study #6, which of the following ratios would you recommend?

Accepted Answer

A)  number of records with documentation of colostomy-care teaching total number of patients on surgery unit 
B)  number of records with documentation of teaching total number of discharges 
C)  number of records with documentation of colostomy-care teaching total number of patients with new colostomy 
D)  number of records reviewed with documentation of colostomy-care teaching total number of records reviewed

Question 17

ORYX is a program that was developed by

Accepted Answer

A)  CMS to track Medicare costs. 
B)  Joint Commission to link patient outcomes to accreditation. 
C)  NIH to track communicable diseases. 
D)  AMA to allow for rapid CPT updates

Question 18

When billing for the admitting physician for a patient that is admitted to the hospital as an inpatient, one must use a CPT Evaluation and Management code based upon the level of care provided. These are the codes to be selected from for initial hospital care.99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components. a detailed or comprehensive history a detailed or comprehensive examination and -medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components. a comprehensive history a comprehensive examination and -medical decision making of moderate complexity 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components. -medical decision making of high complexity The following statement is true.

Accepted Answer

A)  This code can be used only once per hospitalization. 
B)  This code can be used by the admitting physician or consulting physician. 
C)  This code can be used for patients admitted to observation status. 
D)  This code can be used by the hospital to bill for facility services.

Question 19

Evidence-based management and decision-making is an emerging model now used to make more informed decisions. The primise of this model is

Accepted Answer

A)  using intuition based on previous experience. 
B)  using a decision tree that branches to alternatives. 
C)  using the best clinical and research practices available. 
D)  using an alternative that meets minimum requirements.

Question 20

Patient presents to the outpatient department for a chest x-ray. Physician order lists the following reasons for the chest x-ray: fever and cough, rule out pneumonia. Radiologist reports the chest x-ray is positive for pneumonia.

Accepted Answer

A)  486 
B)  486, 780.61, 786.2, V72.5 
C)  780.61, 786.2 
D)  V72.5, 780.60, 786.2

Exam 1: Registered Health Information Administrator