Question 1

Housekeeping is notified to clean the room

Accepted Answer

Housekeeping is typically notified to clean a room after a patient is discharged to prepare it for the next patient.

Question 2

The set of procedures by which paper portions of the record are ordered for scanning or further processing is

Accepted Answer

Assembly refers to the process of organizing paper documents before they are scanned or processed further, ensuring that the records are complete and in the correct order for digitization or review.

Question 3

Using _____________, many paper documents are digitized at once, after which software sorts the documents into the correct record by bar code.

Accepted Answer

Batch scanning is the process used to digitize many paper documents at once, where software can then sort these documents into the correct records, often using identifiers like bar codes.

Question 4

What is another term that refers to the period postdischarge?

Accepted Answer

The term "retrospective" refers to looking back on or dealing with past events or situations, which aligns with the concept of a period postdischarge, where analysis or review is conducted after the event has occurred.

Question 5

Documents entered into the health record as images must be ___________ for identification and future retrieval.

Accepted Answer

Indexing documents is essential for their identification and future retrieval, especially when they are entered into the health record as images. This process involves assigning a specific code or keyword to a document, making it easier to locate among many others.

Question 6

Which patient would be found on a discharge register for May 1st?

Accepted Answer

A discharge register records patients who are discharged from the hospital. The patient admitted on April 30 and discharged on May 1st would be the one recorded on the discharge register for May 1st.

Question 7

Quantitative analysis is usually performed by a(n)

Accepted Answer

Quantitative analysis in the context of healthcare often refers to the review and analysis of medical records to ensure they contain all the necessary components, data accuracy, and completeness. Health Information Management (HIM) professionals are specifically trained in managing patient health information and medical records, making them the most suitable for performing quantitative analysis.

Question 8

Each element of the record must be properly dated, timed, and ______________ in accordance with the rules and regulations of state or accrediting agencies that apply to the facility, with the authors clearly identified.

Accepted Answer

Authenticated is the correct term as it implies that the record must be verified or signed off by the author, ensuring that the information is accurate and reliable, in line with regulatory requirements.

Question 9

Which is NOT identified during quantitative analysis?

Accepted Answer

Quantitative analysis typically involves checking for the presence or absence of required documentation, such as signatures or reports, rather than evaluating whether specific medical actions, like consultations, were performed.

Question 10

The assignment of physicians to cases-attending, consultants, and surgeons-is called _____________.

Accepted Answer

Attribution is the process of assigning physicians to specific roles or cases, such as attending physicians, consultants, and surgeons, in a healthcare setting.

Question 11

The Joint Commission (TJC) considers incomplete acute care records delinquent

Accepted Answer

The Joint Commission (TJC) considers incomplete acute care records delinquent if they are not completed within 30 days after discharge.

Question 12

When a patient is being admitted for a health-related issue, the physician must state the patient's ___________.

Accepted Answer

The answer of When a patient is being admitted for...

Question 13

Community Hospital, an acute care facility, is preparing for TJC survey. The Chief Operating Officer is reviewing the following data from the HIM department:
 Using the information above, at the end of April, is Community Hospital in compliance with TJC rules regarding the number of delinquent records permitted?

Accepted Answer

The answer of Community Hospital, an acute care facility, is...

Question 14

__________________ specialists assist physicians in achieving the best possible documentation of their medical decision-making process.

Accepted Answer

Clinical documentation improvement (CDI) specialists work closely with healthcare providers to ensure accurate and comprehensive documentation in patient records. Their role is crucial in capturing patient care details, which supports the medical decision-making process.

Question 15

Why is concurrent coding beneficial?

Accepted Answer

The answer of Why is concurrent coding beneficial?
...

Question 16

Which describes computer-assisted coding (CAC)?

Accepted Answer

Computer-assisted coding (CAC) involves software that analyzes healthcare documents and assigns appropriate medical codes based on the content of the documents.

Question 17

At registration, the patient access clerk searches the ____________ history files to determine whether the patient has been treated at the facility on a previous occasion.

Accepted Answer

The Master Patient Index (MPI) is the correct answer because it is a database that maintains a unique index (or identifier) for every patient registered at a healthcare facility. It is used to track patients' records over time and across different departments, ensuring that patient information is organized and accessible for future visits.

Question 18

Why do HIM professionals look for duplicate medical record numbers of the same patient and merge them?

Accepted Answer

Duplicate medical record numbers for the same patient can lead to fragmented care information, making it difficult to provide coordinated and safe care. Merging them ensures all patient information is consolidated in a single record, facilitating continuity of care.

Question 19

A summary of the patient's record is created during the ___________ step of postdischarge processing.

Accepted Answer

Abstracting involves summarizing the patient's record, which is a key step in postdischarge processing to ensure that essential information is easily accessible for future reference or analysis.

Question 20

Patient records are sometimes abstracted for __________, collections of data specific to a disease, diagnosis, or procedure.

Accepted Answer

Patient records are often abstracted for registries, which are collections of data specific to a disease, diagnosis, or procedure. Registries are used to track outcomes, prevalence, and treatment effectiveness for specific conditions.

Quiz 4: Data Quality and Management