Question 1

Which of the following is NOT an example of clinical data?

Accepted Answer

B

Question 2

"Rule out Congestive Heart Failure versus Cerebrovascular Accident" is an example of which of the following components of medical decision making?

Accepted Answer

This statement is part of the assessment component of medical decision making, as it involves weighing different diagnoses and ruling out others to arrive at a final diagnosis. The other components of medical decision making are subjective (such as gathering patient history and symptoms), objective (such as conducting a physical exam), and planning (such as deciding on a treatment plan or further diagnostic tests).

Question 3

Dr. Smith is a physician in general, or family, practice. He and his partner, Dr. Wong, are evaluating the way they organize their paper record documentation. They have a large number of patients, many of whom have multiple, chronic illnesses. The doctors would like to organize their records to make it easier to see what has been done with respect to each patient's illness. As their office manager, what do you recommend?

Accepted Answer

The problem-oriented record (POR) is a documentation system that is organized by problem, making it easier to see what has been done with respect to each patient's illness. This system includes a database that contains information on each of the patient's problems and is organized by problem, including the Patient's medical history, physical exam findings, treatments, and progress notes. POR is commonly used in family medicine practices, where many patients have multiple chronic diseases. POR enables providers to efficiently manage complicated and long-standing health problems by providing an efficient way of organizing the medical history and treatment plan of each patient's problem.

Question 4

All of the following are examples of demographic data EXCEPT:

Accepted Answer

The answer of All of the following are examples of...

Question 5

"Pupils equal, round, and reactive to light and accommodation" is an example of which of the following components of medical decision making?

Accepted Answer

This statement describes an objective finding related to the patient's physical exam, specifically their pupillary response to light and accommodation. Therefore, it pertains to the objective component of medical decision making, which involves collecting and analyzing clinical data.

Question 6

In creating a data collection device, which of the following is the most important consideration?

Accepted Answer

The purpose of the form should be the most important consideration when creating a data collection device. This will guide the design of the form and ensure that the data collected is pertinent to the research question or objective. The size of the paper or computer screen and the number of fields on the page can be important design considerations, but they should not take precedence over the purpose of the form. Joint commission rules regarding forms creation may be important for certain contexts, but they are not universally applicable.

Question 7

Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?

Accepted Answer

CIn a source-oriented medical record, documentation is organized by the source of the documentation, meaning each healthcare professional or department documents in a separate section. Therefore, B is correct because it emphasizes the separation of documentation between physicians and nurses, aligning with the source-oriented approach. C is also correct because the way clinicians document (the content and style of their notes) does not need to change for the implementation of a source-oriented record system; what changes is how the documentation is organized post-discharge, not the documentation process itself.

Question 8

Which of the following is NOT a benefit of a problem list?

Accepted Answer

A problem list does not reduce the amount of documentation in the record. In fact, it adds to the documentation by providing a comprehensive list of the patient's active and resolved medical issues.

Question 9

A patient presented in the emergency department with unusual lesions on the skin, a fever, and dehydration. Of the following types of data, which will be most helpful to the physician in developing a list of potential diagnoses?

Accepted Answer

The answer of A patient presented in the emergency department...

Question 10

The individual or organization that is ultimately responsible for paying a hospital bill is called the:

Accepted Answer

The guarantor is the person or entity responsible for paying the hospital bill. This can be the patient, their spouse, or even their employer in some cases. Therefore, the correct answer is B.

Question 11

The study of health trends or patterns is called:

Accepted Answer

Epidemiology is the study of health trends and patterns, including the distribution, causes, and control of diseases and other health outcomes within populations. Demographic data refers specifically to information about the characteristics of a population, while health data and health information are broader terms that can encompass a range of information related to health and healthcare.

Question 12

"Chest x-ray to rule out CHF" is an example of which of the following components of medical decision making?

Accepted Answer

The phrase "Chest x-ray to rule out CHF" is part of the plan component, as it outlines a specific diagnostic test to be performed to confirm or rule out a condition.

Question 13

"Patient complains of dizziness and shortness of breath" is an example of which of the following components of medical decision making?

Accepted Answer

"Patient complains" indicates that this is subjective information provided by the patient regarding their symptoms.

Question 14

Which of the following is NOT an example of the possible contents of a 2 character state field?

Accepted Answer

A 2 character state field is designed to hold exactly 2 characters, representing state abbreviations. "F" is only one character and does not fit this criterion, whereas "FL", "DC", and "NM" are all valid 2 character state abbreviations.

Question 15

Data that have been processed into a useful frame of reference is called

Accepted Answer

Information refers to data that have been processed and organized into a meaningful context, making it useful for decision-making and analysis. Observations refer to the act of collecting data through observation, while a schedule is a plan on when to perform certain tasks. Assessment is the process of evaluating something based on a set of criteria or standards.

Question 16

If a patient's insurance company has reimbursed the physician for the appropriate amount and there is still a balance due in the patient's account, the physician must apply next for payment to the:

Accepted Answer

The guarantor (usually a family member or friend who agrees to pay the patient's medical bills if the patient cannot) is responsible for paying any balance not covered by insurance. The physician should attempt to collect from the guarantor before taking further action.

Question 17

The result of a plan of treatment is called the:

Accepted Answer

The result of a plan of treatment is called the outcome. It refers to the changes or improvements that occurred as a result of the treatment plan. The assessment is the evaluation of a patient's condition or situation, the diagnosis is the identification of a disease or condition, and the health record documents a patient's medical history and treatment.

Question 18

Which of the following is an example of demographic data?

Accepted Answer

The answer of Which of the following is an example...

Question 19

In which step of the medical decision-making process can the following statement be found? "Patient's BP 120/75, rule out hypertension"

Accepted Answer

The statement "Patient's BP 120/75, rule out hypertension" is part of the Assessment step, where the healthcare provider evaluates the patient's data and considers possible diagnoses.

Question 20

Another term for demographic data is:

Accepted Answer

"Indicative" means serving as a sign or indication, which is appropriate for demographic data as it provides an indication or representation of certain characteristics within a population. The other three options (explanatory, referral, and global) do not accurately describe demographic data.

Quiz 2: Collecting Health Care Data