Understanding Healthcare Delivery Systems and Medicare Essentials

A healthcare organization that provides a full range of healthcare services along a continuum of care (for example, an organization that provides acute care services, long-term care services, and home health services) is called a(n) ____. Correct! a. integrated delivery system b. managed care system c. public health system d. hospital system Question 2 1 / 1 pts In a prospective payment system (PPS), the amount of reimbursement for healthcare services is _____. Correct! a. Predetermined using the diagnosis related group methodology b. Calculated at the time of discharge c. Determined by the provider based on aggregate charges d. Negotiated between provider and payer Question 3 1 / 1 pts The total number of inpatients that can potentially be treated in a hospital is determined by the _____. a. size of the medical staff b. number of clinical services c. complexity of care Correct! d. bed capacity Question 4 1 / 1 pts

Not-for-profit hospitals differ from for-profit hospitals because they _____. a. do not bill for services b. pay dividends to stockholders Correct! c. reinvest excess funds in services and education d. provide free medical education to medical students and residents Question 5 1 / 1 pts The _____ has the primary objective of providing high quality care to patients. a. CEO b. Board of directors Correct! c. Medical staff d. Medical director Question 6 1 / 1 pts Using a process that is known as _____, CMS and the Joint Commission both require that healthcare professionals assess the work of colleagues in the same profession. Correct! a. peer review b. utilization review c. workflow process d. mediation Question 7 1 / 1 pts The federal government is introducing ________ to advance value-based care.

a. Certification of hospitals b. Prospective payment Correct! c. Focus on population health d. Deemed status Question 8 1 / 1 pts What is the primary goal of integrated delivery systems (IDS)? a. To ensure that every hospital that is part of the IDS is equipped with state-of-the-art equipment and technology Correct! b. To ensure that patients receive high-quality, cost-effective care in the most appropriate setting c. To ensure that every American has equal access to healthcare services d. To ensure that healthcare-related information can be shared among all the facilities operating in the community Question 9 1 / 1 pts The development of managed care services in the United States is an indirect result of the federal government’s enactment of _____. a. The Social Security Act of 1935 Correct! b. Medicare/Medicaid legislation of 1965 c. HIPAA legislation of 1996 d. The Balanced Budget Amendment of 1997 Question 10 1 / 1 pts Medical staff bylaws are legally binding, and any changes must be approved by a vote of the _____.

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a. employees of the facility b. administrative team Correct! c. medical staff d. all of the above Question 11 1 / 1 pts As a result of the Flexner Report in the early part of the 20th century, which of the following occurred? a. Hospitals were established in most communities in the United States b. Nursing was recognized as a profession c. Hospital accreditation standards were established Correct! d. Standards were established for medical schools and medical education Question 12 1 / 1 pts The ______ developed the first hospital standardization program. a. Joint Commission b. American Osteopathic Association Correct! c. American College of Surgeons d. American Hospital Association Question 13 1 / 1 pts _____ can be defined as a voluntary system of institutional review by an independent external agency. a. Licensure b. Certification

Correct! c. Accreditation d. Credentialing Question 14 1 / 1 pts Which of the following statements most accurately describes the Medicare program? a. A state program that finances healthcare services for the elderly Correct! b. A federal program that finances healthcare services for the elderly c. A state program that finances healthcare services for low-income families d. A federal program that finances healthcare services for low-income families Question 15 1 / 1 pts The Patient Protection and Affordable Care Act of 2010 ______. Correct! a. Extended coverage for pre-existing conditions b. Established the National Practitioner Data Bank c. Required hospitals to conduct continued-stay reviews for Medicare and Medicaid patients d. Instituted the Agency for Health Care Policy and Research Question 16 1 / 1 pts ______ healthcare organizations pay out their excess revenues in the form of bonuses and dividends to owners, investors, and managers. a. Not-for-profit b. Voluntary c. Government

Correct! d. For-profit Question 17 1 / 1 pts How does licensure of a healthcare organization differ from accreditation? a. Deemed status applies Correct! b. Licensure is required c. The governing body is responsible d. Based on written standards Question 18 0 / 1 pts Determine which of the following statements is correct. Correct Answer a. Common law established in a state is effective only in that state. b. There is an extensive code of national common law. c. Common law supersedes all other laws. You Answered d. All court decisions are persuasive authority only. Rationale: National common law does not exist in a code (incorrect option b); common law does not supersede all other laws (incorrect option c); court decisions are binding or persuasive, depending on the jurisdiction in which they were rendered (incorrect option d). Option a is a correct statement (p. 43). Question 19 1 / 1 pts

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Analyze the following scenario: John filed a lawsuit against his neighbor. The matter has been adjudicated by the local trial court and the state appellate court having jurisdiction. What can occur next? a. There are no further appeals available to either party. b. The case can next go to the US Supreme Court. Correct! c. The case can next go to the state supreme court. d. The case can next go to a US Court of Appeals. Question 20 1 / 1 pts Ann-Marie has contacted an attorney regarding a potential medical malpractice action against her nephrologist for failure to perform the necessary tests that would have led to the diagnosis of a medical condition. Which of the following theories might Ann-Marie’s attorney use based on the facts of this scenario? a. Implied warranty b. Assumption of risk c. Charitable immunity Correct! d. Negligence Question 21 1 / 1 pts A patient visits his physician due to symptoms of concern. The physician fails to order the battery of tests that would lead to the correct diagnosis. The patient does not suffer any harm. Which of the following statements is correct? The patient most likely has a viable action for: a. Fraud Correct!

b. Breach of contract c. Negligence d. Duress Question 22 0 / 1 pts In a negligence case against Dr. Roberts, an expert witness for the plaintiff provided testimony that Dr. Roberts did not practice in a manner that other physicians with similar training and experience would have practiced. The judge allowed the expert witness’ testimony to be admitted because it demonstrated lack of adherence to what standard of care? a. Minimal You Answered b. Optimal c. Community Correct Answer d. Reasonable Rationale: The first two terms are not existing standards of care. Option c refers to the community standard, which courts do not rely on because the law relies on industry or national standards instead. Option d is the standard that is relied upon (p. 49). Question 23 1 / 1 pts Distinguish the following actions by two physicians on a hospital’s medical staff. Physician A performs a procedure but mistakenly uses the incorrect instrument, resulting in injury to the patient. Physician B inserts a prosthetic device into a patient that is known to be defective. The physician did not intend to harm the patient, but he did not want to wait for a device that was not defective. Which of the following statements is the most correct? a. Physician A committed malfeasance; Physician B committed misfeasance.

b. Physician A committed nonfeasance; Physician B committed malpractice Correct! c. Physician A committed misfeasance; Physician B committed malfeasance d. Physician A committed malpractice; Physician B committed nonfeasance Question 24 1 / 1 pts A plaintiff’s attorney has requested “any and all records” of his client, a former patient at General Hospital. The hospital may interpret this request to _____. Correct! a. Include e-mails messages between the patient and General Hospital providers b. Include only information maintained on paper c. Exclude text messages between the patient and General Hospital providers d. Exclude calendar files Question 25 1 / 1 pts A HIM professional who is designing a health record system for a healthcare facility should check which legal source to determine how long medical records should be retained by the facility? a. AHIMA record retention guidelines Correct! b. State law c. County or city codes d. Joint Commission accreditation standards Question 26 1 / 1 pts Dr. Smith performs an invasive, non-emergency surgical procedure on a patient without discussing the procedure with the patient or obtaining the patient’s consent. Dr. Smith is most likely to be liable under which of the following causes of action?

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a. Nonfeasance Correct! b. Negligence c. Battery d. Malfeasance Question 27 1 / 1 pts In a patient record, the physician notes that the patient is “morbidly obese.” The patient sees the notation and sues the physician. Which of the following best characterizes this situation? The physician: a. is liable for committing slander. b. is liable for committing libel. c. has a right to record his or her personal opinion of the patient. Correct! d. has a right to document pertinent clinical observations. Question 28 1 / 1 pts Bertha Jones, a patient at Mercy Health, fell out of bed. An incident report was created. Bertha’s attorney is now seeking all records relevant to Bertha’s fall. The incident report is least likely to be protected from discovery if it is maintained in a. The administrative files of chief nursing officer. Correct! b. Bertha’s medical record. c. The hospital attorney’s office. d. The hospital risk manager’s office.

Question 29 1 / 1 pts Distinguish facts about medical identity theft by determining the incorrect statement: a. Internal medical identity theft is more common than external medical identity theft Correct! b. The damage caused by internal medical identity theft is limited because access to information pertains to only small numbers of patients c. Medical identity theft can be committed to obtain medical services d. Medical identity theft can be committed to falsify claims for medical services to obtain money Question 30 1 / 1 pts Which one of the following facility types is required to release information under the Freedom of Information Act (FOIA)? a. Budget Health, a proprietary hospital Correct! b. A US Army medical facility c. Mercy Health, a non-profit hospital operated by the Carmelite Sisters d. A state-owned and operated mental health facility Question 31 1 / 1 pts Misty is a nurse who is employed by Nurses On The Go, a contract agency that provides nurse staffing to hospitals. While working at Major Hospital, Misty fails to administer medication to a patient, resulting in patient harm. The doctrine of respondeat superior _____. a. Protects Major Hospital from liability for Misty’s negligence b. Subjects Major Hospital to greater liability than the corporate negligence doctrine c. Protects Nurses On The Go from liability Correct! d. Will impose liability on Major Hospital if Misty is deemed to be its agent

Question 32 1 / 1 pts General Hospital conducted an extensive focused retrospective review of patient care provided by Dr. Wallace following the filing of lawsuits by three of Dr. Wallace’s patients. One of the patient’s attorneys successfully obtained the retrospective review via the discovery process and is now seeking to have it admitted into evidence as a business record, which is a hearsay exception. The judge will not permit it to be admitted as a business record, although she will permit the patient’s health record to be admitted as a business record. The judge determined this about the retrospective review, which distinguishes it from the patient’s health record. It _____. a. Is not reliable b. Is not truthful c. Was not kept in the normal course of business Correct! d. Was not made at or near the time of the matter recorded Question 33 1 / 1 pts The copy-paste function _____. a. Allows the reader to definitively identify when documentation was first created b. Allows the reader to definitively identify the author of documentation Correct! c. Often creates redundant information d. Ensures that documentation is concise Question 34 1 / 1 pts Maintenance of a legally defensible health record includes ensuring _____. Correct! a. Control over the printing function b. That only physicians document

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c. The record is not revised once documentation is completed d. The record is complete within 24 hours after a patient encounter is completed Question 35 1 / 1 pts EHR system reliability _____.: a. Only includes features that prohibit unauthorized user access b. Only includes features that promote authorized user access Correct! c. Includes the ability to track access by both authorized and unauthorized users d. Focuses primarily on compliance with the HIPAA Privacy Rule Question 36 1 / 1 pts Whitney is a new health information department employee. She is trained on the special procedures that must be followed prior to disclosure of health information that is deemed to be highly sensitive. Whitney knows that highly sensitive information receives special protections because it pertains to conditions that _____. a. are generally fatal. b. are untreatable. c. are highly contagious. Correct! d. Have a stigma or sensitivity associated with them Question 37 1 / 1 pts Spoliation:

a. is an expected process when health information is deemed outdated. Correct! b. may be inferred to have occurred as the result of a nefarious motive. c. is a natural consequence of health information system vulnerabilities.. d. is always presumed to have occurred without bad faith Question 38 1 / 1 pts Which of the following best describes data life cycle management? a. Governing the input and output of data b. Broad category of applications that manage data from capture to destruction c. Integrated set of specifications Correct! d. Functions that coordinate data from beginning through its end points Question 39 1 / 1 pts What is the primary importance of data architecture management? a. To identify security breaches Correct! b. To define data requirements and integrate and control organization data assets c. To determine what type of hardware are needed d. To describe a data warehouse Question 40 1 / 1 pts Why are metadata essential in information systems? Correct! a. They provide the means to locate, retrieve, use, and manage data

b. They identify the organization’s most important data assets c. They provide data safeguards d. They identify the disposition of data Question 41 1 / 1 pts Which of the following best describes a DG program? a. A group of data stewards and business analysts who set data policy b. A process whereby data accountabilities and decision rights are assigned Correct! c. The enterprise authority that ensures control and accountability for enterprise data d. A project whose purpose is to control the organization’s data assets Question 42 1 / 1 pts Which of the following is best describes the purpose of business intelligence? a. To store data in a data warehouse Correct! b. To provide access to data for better decision making c. To bring together an organization’s key data d. To implement better data security Question 43 1 / 1 pts Which of the following best describes structured data? a. Data that do not have a pre-defined data model b. Text data stored in document management systems Correct! c. Data stored in electronic databases

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d. Data about key business entities Question 44 1 / 1 pts Why is data governance of the content management function important? a. To make data modeling easier b. To provide decision rights to end users c. To develop data protection mechanisms Correct! d. To identify links and relationships among documents Question 45 1 / 1 pts Which of the following is a true statement about a DG program? a. DG is an information technology function Correct! b. DG applies to data in any format. c. DG policies and procedures apply only to non-structured data d. DG programs are usually the same among organizations. Question 46 1 / 1 pts Which of the following is a business role with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? a. Chief data officer Correct! b. Data definition stewards c. Data production stewards

d. Subject matter experts Question 47 1 / 1 pts Which of the following would be the best approach in starting a DG program? Correct! a. Focus on one or a few small business imperatives b. Begin with developing policies and procedures c. Identify HIPAA requirements d. Establish success metrics Question 48 1 / 1 pts Which of the following identifies the fundamental purpose and scope of the DG program? a. DG goals b. Key performance indicators (KPIs) Correct! c. Mission statement d. Vision statement Question 49 1 / 1 pts Which of the following provides the authorization for the DG program and establish the program’s mission? Correct! a. Data governance executive steering committee b. Data governance office c. Chief data officer d. Chief data steward

Question 50 1 / 1 pts An organization has established an information governance program and a data governance program. Which of the following problem areas should not be assigned to the data governance team? a. Inconsistent data element naming conventions Correct! b. Inconsistencies in legal hold policies c. Identification of master data d. Password control variations Question 51 1 / 1 pts To categorize unstructured data which of the following should be incorporated into the data governance content management function? a. Development of rules to place the data in transactional databases b. Development of guidelines to use the data warehouse to store the data Correct! c. Development of indexing and cataloging systems for the data d. Development of a data dictionary to describe each element Question 52 1 / 1 pts Which of the following best describes data about key business entities? Correct! a. Master data b. Metadata c. Structured data d. Unstructured data

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Question 53 1 / 1 pts Which of the following would be the best source for the foundation of an organization’s information governance mission statement? a. AHIMA Information Governance Mission Statement b. Comparison of various information governance mission statements Correct! c. An organization’s mission and overall strategy d. An organization’s reporting structure Question 54 1 / 1 pts Dr. Williams saw Jerry Rhodes on May 1st at the clinic. Dr. Williams decided to admit Jerry to Healthwise Hospital on May 18th. Can the history and physical document Dr. Williams completed on Jerry in the clinic be used for the May 18th admission? a. No, because a new history and physical must be completed for each new hospital admission b. No, because only a history and physical completed within the previous week can be used at the time of a hospital admission Correct! c. Yes, because the history and physical completed in the clinic was done within 30 days of the hospital admission d. Yes, but only if the patient signs a consent form to allow the history and physical from the clinic to be used towards the hospital admission documentation Question 55 1 / 1 pts Dr. Williams saw Jerry Rhodes on May 1st at the clinic. Dr. Williams decided to admit Jerry to Healthwise Hospital on May 18th. Dr. Williams discharged Jerry Rhodes to go home on May 19th. Is Dr. Williams required to dictate a full discharge summary detailing Jerry Rhodes hospital stay? Correct!

a. No, because Jerry Rhodes was in the hospital for less than 48 hours, so a final discharge progress note will suffice. b. No, because Jerry Rhodes was admitted and discharged from the hospital within the same month, so a final discharge progress note will suffice. c. Yes, because Dr. Williams must dictate a full discharge summary on every patient he admits to a hospital. d. Yes, because Dr. Williams must dictate a full discharge summary since Jerry Rhodes was in the hospital for at least 24 hours. Question 56 0 / 1 pts Dr. Smith, a surgeon at Memorial Hospital, removes Jane Berry’s appendix due to suspected appendicitis. How soon must Dr. Smith dictate the operative report? Correct Answer a. Immediately after the surgical procedure is completed You Answered b. Within 48 hours of the operation c. Before the pathology report is completed d. Before discharge or transferring the patient to a follow-up physician Rationale: The answer is a because the operative report must be documented either in writing or dictated immediately after surgery in case there are complications and the patient must be treated further (p. 115). Question 57 1 / 1 pts Danny, an HIM analyst for Memorial Hospital, is conducting a qualitative analysis of a discharged patient’s chart. His goal in this process is: Correct! a. Determining if the documentation includes all requirements set by CMS, the state, and accrediting bodies b. Identifying whether all lab orders have corresponding lab reports in the chart

c. Verifying that health professionals are providing appropriate care d. Checking to ensure that the hospital bill is correct Question 58 1 / 1 pts George Hines, the HIM director at Memorial Hospital has been asked to compose a record retention policy for the hospital. What should be his first consideration in determining how long paper and electronic records must be retained? a. The amount of space allocated for record filing and server set up b. The number of paper records currently filed and the number of electronic files added on a daily basis Correct! c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards d. The cost of filing space and equipment Question 59 1 / 1 pts Which method of documenting physician progress notes is not acceptable for meeting documentation standards? a. Narrative note b. Flowchart c. Computer input Correct! d. Charting by exception Question 60 1 / 1 pts Mary Smith delivers a stillborn infant at Medical Center Hospital. The appropriate method of documenting information about the infant is to _____. a. create a health record for the infant Correct!

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b. File all stillborn information in the mother’s record since it was not a live birth c. retain the infant’s information in a separate administrative file d. do not retain information about the infant in hospital records Question 61 1 / 1 pts Healthwise Hospital has a hybrid EHR system where paper records are scanned into the system upon patient discharge. What should the HIM department do with the paper records after the scanning process is complete? Correct! a. Paper records should be boxed up after all the paper is scanned, indexed and released to the system; stored for 6 months; and then destroyed. b. Paper records should be kept indefinitely because the EHR system may go down and the paper records will be needed. c. Paper records should be immediately shredded after they are scanned to reduce legal responsibility. d. Paper records should be kept for 5 years due to CMS regulations. Question 62 1 / 1 pts Which of the following care sites is required by Medicare to have extensive social services documentation? Correct! a. behavioral health b. long-term care c. hospitals d. rehabilitation hospitals Question 63 1 / 1 pts When records are received in the HIM department after discharge or conclusion of the visit, what is the first thing that should be done?

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a. The records should be assembled in the prescribed order. Correct! b. An HIM professional should check to ensure that all records have been received. c. Record numbers should be entered in a chart locator system. d. Physicians’ offices should be called for diagnoses. Question 64 1 / 1 pts A nurse practitioner documents the following on Missy Hamilton, a patient at Healthwise Hospital: S – Patient reports that “she feels nauseous and has a headache.” O – Patient is afebrile, BP 138/90, P 88, R 16 with no acute distress. A – Patient may have overheated after extended exercise in the morning. P – Patient is discharged home with instructions to limit activities and drink lots of fluids. Based on the above note, what additional information should be documented to validate the assessment and plan? a. The nurse practitioner should include a medication list in the plan. b. The nurse practitioner should take the patient’s temperature to determine if she has a fever. Correct! c. The nurse practitioner should include more information about what the patient did to become overheated in the subjective comments. d. The nurse practitioner should include more comments in the assessment on why that possible diagnosis was chosen and if others were considered.

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Question 65 1 / 1 pts The HIM director at Healthwise Hospital, Jan Hines, RHIA, has noticed that history and physicals and OP Reports are not being transcribed and returned by the transcription service within the negotiated timeframes. What should be her primary concern related to this issue? a. That the transcription service company will overcharge the hospital for reports that are delayed. b. That physicians will stop dictating reports and just include comments in the progress notes. Correct! c. That the Joint Commission will find that history and physicals are not being uploaded into the EHR system within the 24 hours required timeframe. d. That information is not being made available in the patient portal within the required timeframe. Question 66 1 / 1 pts Which of the following is not a critical factor in determining the length of time that medical records must be retained in a facility is _____. a. State law b. Accreditation standards c. Medicare requirements Correct! d. EMTALA Question 67 1 / 1 pts Barbara is admitted to Healthwise Hospital for a procedure. This is her first visit/admission to this facility. She is assigned a new health record number for this first visit. If she is admitted or is seen at this hospital again, she will be assigned a new health record number and her old record will be brought forward and filed under the new number. This method of numbering is called _____ numbering. a. serial b. unit

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Correct! c. serial-unit d. family Question 68 1 / 1 pts Healthwise Hospital wants to be able to offer services to Medicare patients. In order to do this, they must first achieve which of the following? Correct! a. Medicare certification and state licensure b. AHIMA designation and Bylaw approval c. State licensure and TJC Accreditation d. Commercial insurance reimbursement approval Question 69 1 / 1 pts Which of the following errors most likely results from a data entry error in the MPI? a. Paul Garrett was sent home with a prescription to continue 0.625 Digoxin instead of the 0.0625 dosage that he was initially prescribed. b. Paul Garrett was assigned to room 1203 instead of 1213. c. Paul Garrett was diagnosed with indigestion instead of appendicitis. Correct! d. Paul Garrett was entered into the system as a new patient and assigned a new medical record number instead of being matched to the Paul M. Garett that was already in the system and keeping his current medical record number. Question 70 1 / 1 pts Evaluate the following statements about advance directives and determine which is correct. Correct!

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a. Patients must be informed that they have the right to have an advance directive. b. Patients must sign an advance directive upon admission. c. Physicians only follow patient’s advance directive wishes that are written not ones that were made verbally. d. Physicians can only abide by advance directive stipulations once the patient dies. Question 71 1 / 1 pts Which of the following would not be included in the history and physical of a patient? a. Patient complains of abdominal pain and fever b. Patient indicates that he was diagnosed with diabetes 6 years ago Correct! c. Patient was diagnosed with appendicitis after a CT scan was done d. Patient weighs 180 pounds, presents with a temperature of 101 and a rash across the upper abdomen Question 72 1 / 1 pts Which of the following would not be an appropriate duty for an HIM professional? Correct! a. Documenting the history and physical of a patient while the physician enters orders for diagnostic tests in the EHR b. Interpreting documentation guidance in the Medicare Conditions of Participation to ensure compliance c. Providing a training session for clinicians on documentation requirements for History and Physicals, Discharge Summaries, and Physician Orders. d. Auditing the patient records of the last 100 patients admitted to the hospital to determine if history and physicals were placed on the chart within 24 hours of admission. Question 73 1 / 1 pts

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It was recently reported that a hospital employee posted a picture on Facebook that showed a nurse posing with a patient with the caption, “Thank you, Nancy, for letting us take care of you after your mastectomy!” How should an HIM professional react? a. Post a Facebook message to congratulate Nancy on her recovery from surgery. Correct! b. Ensure the hospital has a policy on managing social media, including disciplinary sanctions. c. Determine if the nurse got the patient’s approval to post the picture. d. Ensure the Facebook post is included in the patient’s medical record. Question 74 1 / 1 pts Dr. Williams operated on Jerry Rhodes to remove his appendix. There were no complications noted during the surgery, and Mr. Rhodes was discharged within 48 hours of admission. Which of the following documentation examples is in compliance with the Joint Commission standards for operative reports? Correct! a. Since a surgical operation was performed, Dr. Williams dictated a full operative report. b. Since there were no complications during the surgery, Dr. Williams only included a brief postoperative progress note in the record. c. Since Mr. Rhodes was discharged within 48 hours, Dr. Williams only included a brief operative note in the discharge summary. d. Since the appendix was removed, a pathology report was required instead of an operative report. Question 75 1 / 1 pts The new EHR vendor has a patient portal option, the HIM professionals are asked to comment on the implementation of the patient portal. Which of the following is the most appropriate response from the HIM team? a. agree to whatever the EHR vendor team suggests Correct! b. advocate for HIM professionals to lead the implementation c. suggest that risk management should be consulted d. suggest that patient portals not be implemented because of privacy concerns

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Quiz Score: 72 out of 75

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Test 1 Chapters 1-4

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