HIT 120 Chapter 4 Review quiz
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SUNY Westchester Community College *
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Course
120
Subject
Health Science
Date
Dec 6, 2023
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docx
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6
Uploaded by ProfessorNarwhalMaster908
HIT 120 Chapter 4 Review Quiz
Instructions:
For each item, complete the statement correctly or choose the most appropriate answer.
1.
Complete and accurate health record information _________________.
a.
Increases healthcare costs
b.
Decreases coding accuracy
c.
Increases quality of treatment
d.
Has no impact on cost, coding accuracy, or quality of treatment
2.
The Healthcare Facilities Accreditation Program (HFAP) accredits_________.
a.
Only osteopathic facilities
b.
Only allopathic facilities
c.
Only ambulatory facilities
d.
All healthcare facilities
3.
The overall goal of documentation standards is to ______________.
a.
Ensure physicians have access to the health record information they need to care for the
patient
b.
Ensure that the healthcare provider organization is reimbursed appropriately by payers
c.
Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to
fine the healthcare provider organization
d.
Ensure what is documented in the health record is complete and accurately reflects
the treatment provided to the patient
4.
Identify the part of a medical history documents the nature and duration of the symptoms that
caused a patient to seek medical attention as stated in that patient’s own words.
a.
Chief complaint
b.
Social and personal history
c.
Past medical history
d.
Present illness
5.
Identify an example of administrative information.
a.
Admitting diagnosis
b.
Blood pressure records
c.
Medication records
d.
Patient’s address
6.
Home care records typically include:
a.
An individualized treatment plan
b.
Operative report
c.
Pathology report
d.
APGAR scores
7.
The federal Conditions of Participation apply to
a.
Organizations that are accredited
b.
Organizations that provide acute care services
c.
Organizations that treat Medicare or Medicaid patients
d.
Organizations that are subject to the Health Insurance Portability and Accountability Act
8.
Identify the documentation that tells the nurses and others what to do.
a.
Progress notes
b.
Diagnostic and therapeutic orders
c.
Discharge summary
d.
Consultation report
9.
The health record format that is most commonly used by healthcare settings as they transition to
electronic records is
a.
Integrated records
b.
Problem-oriented records
c.
Hybrid records
d.
Paper records
10.
A healthcare provider organization, when defining its legal health record must ___________.
a.
Assess the legal environment, system limitations, and HIE agreements
b.
Determine what other healthcare provider organizations are doing
c.
Determine if a legal health record is needed
d.
Only include the paper components of the health record
11.
Critique each statement to determine the true statement related to correcting errors in the paper-
based health record entries.
a.
Addendum should be backdated
b.
The reason for the change should be noted
c.
The incorrect information should be obliterated
d.
The phrase late entry should be noted on the entry
12.
The Medicare Access and CHIP Reauthorization Act (MACRA) is a(n)________.
a.
New privacy law
b.
Federal healthcare quality improvement initiative
c.
New federal insurance program
d.
Accrediting organization
13.
Justify the need for the discharge summary.
a.
Providing information about the patient’s insurance coverage
b.
Ensuring the other healthcare providers know what to do next while the patient is
hospitalized
c.
Providing information to support the activities of the medical staff review committee
d.
Documenting the patient’s health history in detail
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14.
A patient’s registration forms, personal property list, MDS and care plan and discharge or transfer
documentation would be found most frequently in the ___________ health record.
a.
Rehabilitative care
b.
Ambulatory care
c.
Behavioral health
d.
Long-term care
15.
The healthcare organization has decided to become accredited by an accreditation organization
that focuses on rehabilitation programs and services. The healthcare organization should select
_______ as their accrediting organization.
a.
HFAP
b.
Joint Commission
c.
AAAHC
d.
CARF
16.
Federal and state documentation initiatives as well as the subsequent reimbursement and payment
models are now focusing on ____________.
a.
the quantity of healthcare services provided
b.
the efficiency and value of the healthcare services provided
c.
the quality of the healthcare services provided
d.
the efficiency, quality, and value of healthcare services provided
17.
Which of the following is an example of clinical data?
a.
Patient consent
b.
Physician orders
c.
Patient registration
d.
Name of insurance company
18.
Documentation standards have become more detailed and have become focused on ________.
a.
EHR technology
b.
Licensure requirements
c.
Patient care quality
d.
Accreditation standards
19.
Written or spoken permission to proceed with care is classified as ___________.
a.
Expressed consent
b.
Acknowledgment
c.
Advance directive
d.
Implied consent
20.
The Joint Commission places emphasis on ________________.
a.
Appropriate and standardized health record documentation
b.
Electronic health record technologies used to support documentation
c.
Clinical and operational practices related to the health record
d.
Statutes at both the federal and state level
21.
An electronic record technological tool that allows a paper-based x-ray report to be accessed is
_____.
a.
Database management
b.
Documents imaging
c.
Text processing
d.
Vocabulary standards
22.
The Subjective, Objective, Assessment Plan (SOAP) came from the _____.
a.
Source-oriented health record
b.
Problem-oriented health record
c.
Hybrid health record
d.
Depends on facility policy
23.
What standard must a hospital that participates in the Medicare and Medicaid programs comply
with that hospitals who do not accept Medicare and Medicaid patients do not?
a.
Medical bylaws of the healthcare provider organization
b.
Conditions of Participation
c.
Accreditation organization
d.
Documentation standard
24.
The management of health information is a fundamental component of _____.
a.
The overall information governance model
b.
The EHR workflows
c.
The documentation standards
d.
Cloud Computing
25.
A chronological report of the patient’s condition and response to treatment during a hospital stay
is known as _____.
a.
Physical examination
b.
Progress notes
c.
Physician order
d.
Medical history
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