Medical Records Management Exam Review
Course Introduction
Medical Records Management is a comprehensive course designed to introduce students to the principles, practices, and technologies involved in the effective organization, maintenance, and security of patient health information. The course covers key topics such as health information systems, legal and ethical considerations, privacy and confidentiality regulations, electronic health records (EHR), data coding, and record retention policies. Emphasis is placed on the importance of accurate and thorough documentation for quality patient care, compliance with regulatory requirements, and support of healthcare operations. Through case studies and hands-on exercises, students will gain practical skills in managing medical records and ensuring the integrity and confidentiality of health data within healthcare organizations.
Recommended Textbook
Health Information Management of a Strategic Resource 4th Edition by
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17 Chapters
1064 Verified Questions
1064 Flashcards
Source URL: https://quizplus.com/study-set/1150
Page 2
Mervat Abdelhak
Chapter 1: Health Care Systems
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77 Verified Questions
77 Flashcards
Source URL: https://quizplus.com/quiz/22527
Sample Questions
Q1) Which type of health insurance program would a retired army general be eligible for?
A) Tricare
B) Medicaid
C) CHAMPUS
D) Merchant Seaman Healthcare
Answer: A
Q2) Of the following health care practitioners, which one is least likely to be eligible for medical staff membership?
A) Podiatrist
B) Doctor of osteopathy
C) Nurse midwife
D) Dietetic technician
Answer: D
Q3) A major change in _____ was influenced by the Flexner Report of 1910.
A) Health care reimbursement
B) Patient care documentation
C) Medical education
D) Health care utilization
Answer: C
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Page 3
Chapter 2: The Health Informatics and Information
Management Profession
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) In the 1920s, the patient record was a source of needed information for board certification by the American College of Surgeons.
A)True
B)False
Answer: True
Q2) The Registered Health Information Administrator (RHIA) and Registered Health Information Technician (RHIT) credentials are awarded by American Health Information Management Association on graduation from an approved education program.
A)True
B)False
Answer: False
Q3) All the following components were specified for a computerized patient record system by the Institute of Medicine Study of 1991 except:
A) Clinical support systems.
B) Communications systems.
C) Alerts.
D) Reminders.
Answer: B
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Chapter 3: Health Information Infrastructure and Systems
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53 Verified Questions
53 Flashcards
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Sample Questions
Q1) HEDIS data collection
A)Clinical
B)Administrative/financial
Answer: B
Q2) Develops message standards for health care
A)HL7
B)DICOM
C)NCPDP
D)IEEE 1073
E)CHI
F)RxNorm
G)SNOMED
H)ASTM 1384
I)LOINC
J)HIPAA transactions
Answer: A
Q3) Decision support system
A)Clinical
B)Administrative/financial
Answer: A
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Chapter 4: Health Data Concepts
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126 Verified Questions
126 Flashcards
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Sample Questions
Q1) All of the following are health care data sets <b>EXCEPT</b>:
A) MDS
B) NCDB
C) UADS
D) UHDDS
Q2) Define this quality factor in relation to health care data: organized data.
Q3) Describe three principles of computer view design.
Q4) When reference is made to health care data having integrity, it means that the data are complete and accurate.
A)True
B)False
Q5) Using the information in Question 9 above, which patients were admitted and discharged the same day?
Q6) Name a data element comprising clinical data.
Q7) Providers of care use clinical data for determining effective utilization of services.
A)True
B)False
Q8) Name a data element comprising socioeconomic data.
Q9) Distinguish between primary and secondary data.
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Chapter 5: Electronic Health Record Systems
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39 Verified Questions
39 Flashcards
Source URL: https://quizplus.com/quiz/22531
Sample Questions
Q1) Which of these standards is not related to the others?
A) HTML
B) LOINC
C) XML
D) XForms
Q2) Which of the following systems generate patient data at the point of service?
A) Picture archiving and communication system (PACS)
B) EIS
C) REG-ADT
D) Expert system
Q3) Expected electronic health record functions include:
A) 24/7 availability
B) Links to external databases
C) Computerized practitioner order entry
D) All of the above
Q4) Computerized health information systems have demonstrated a reduction in health care costs.
A)True
B)False
Q5) Contrast a decision-support and an executive information system.
Page 7
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Chapter 6: Classification Systems, Clinical Vocabularies, and Terminology
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59 Verified Questions
59 Flashcards
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Sample Questions
Q1) What is the purpose of using a naming nomenclature and standard document titles in an electronic health record system?
Q2) Variations in inpatient and outpatient coding rules do not affect the clinical usefulness of the data.
A)True
B)False
Q3) Medical Subject Headings (MeSH) is used to query the National Library of Medicine's database.
A)True
B)False
Q4) The International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) is used with Healthcare Common Procedure Coding System for coding in physician offices.
A)True
B)False
Q5) Clinical terminologies use the concept of recognized redundancies to store homonyms.
A)True B)False
Page 8
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Chapter 7: Technology, Applications, and Security
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65 Verified Questions
65 Flashcards
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Sample Questions
Q1) Which is a system designed to acquire, store, retrieve, and display digital images?
A) Registration/admission, discharge, transfer system
B) Database management system
C) Communications order entry system
D) Picture archiving and communication system
Q2) All the following are data input devices except:
A) Printer.
B) Light pen.
C) Handheld computer.
D) Keyboard.
Q3) Frames are required to be in each Web page containing health information.
A)True
B)False
Q4) In the relational model, a patient has two different patient identification numbers from different clinics within a health system. How would the relationship be defined for the patient's social security number and these patient identifiers?
Q5) What is the term given to the study of medical computing?
Q6) Explain the differences between a data mart and a data repository.
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Chapter 8: Information Systems Life Cycle and Project Management
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59 Verified Questions
59 Flashcards
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Sample Questions
Q1) In a data dictionary notation for a data element, the label describes which of the following?
A) The project
B) The data name
C) The data entry type
D) The data value or meaning
Q2) Windows and icons are interfacing elements for data displays in an information system.
A)True
B)False
Q3) The phases of development, growth, maturity, and deterioration are generally considered the:
A) Information systems life cycle.
B) System development life cycle.
C) General system life cycle.
D) Strategic plan.
Q4) An entity relationship is represented by a rectangle in an entity-relationship diagram (ERD).
A)True
B)False
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Chapter 9: Managing Electronic Health Record Systems:
Collaboration and Implementation
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58 Verified Questions
58 Flashcards
Source URL: https://quizplus.com/quiz/22535
Sample Questions
Q1) The user manual for purchased software is developed by the facility's information system's staff.
A)True
B)False
Q2) A stakeholder in a computerization project is an individual who controls all or a major portion of the project's funding.
A)True
B)False
Q3) List three examples of improvements that could be measured in an electronic health record (EHR) implementation.
Q4) Frequent users of an electronic health record system will likely get to know how to use the system better than information systems staff.
A)True
B)False
Q5) Users can be sophisticated partners in systems development. A)True
B)False
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Q6) How can baseline data collected at the beginning of a project help in the evaluation process?
Chapter 10: Statistics and Data Presentation
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55 Verified Questions
55 Flashcards
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Sample Questions
Q1) When should the standardized mortality ratio (SMR) be used?
A) When age-specific rates are available
B) When the number of deaths per age category is large
C) When age-specific rates are not available
D) All of the above
Q2) Ten patients were discharged from the obstetrical service on May 4 at Rocky Mountain Hospital. The day's stay for each patient was 3, 2, 1, 1, 6, 5, 1, 2, 2, and 4. What was the median day's stay for these patients?
A) 1
B) 2
C) 3
D) 4
Q3) The standard deviation is the most common measure of variation and is represented by the symbol S.
A)True
B)False
Q4) The number of medications a person is taking is an example of ordinal data.
A)True
B)False
Q5) A whole number divided in 100 parts is a ____________________.
Page 12
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Chapter 11: Research and Epidemiology
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75 Verified Questions
75 Flashcards
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Sample Questions
Q1) Ovarian cancer
A)Independent variable
B)Dependent variable
C)Institutional review board
D)Risk factors
E)Specificity
F)Confounding variables
G)Case
H)Control
I)Research question
J)Historical-prospective study
K)Recall bias
L)Interviewer bias
Q2) Research enables individuals to learn something new and valuable about their professions.
A)True
B)False
Q3) Sensitivity is the percentage of all true cases correctly identified.
A)True
B)False
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Chapter 12: Performance Management and Patient Safety
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46 Verified Questions
46 Flashcards
Source URL: https://quizplus.com/quiz/22538
Sample Questions
Q1) The six sigma approach was introduced by:
A) Honda.
B) Motorola.
C) Xerox.
D) Leapfrog Group.
Q2) Which of the following is not one of the core measure areas for the Joint Commission?
A) Acute myocardial infarction
B) Heart failure
C) Community-acquired pneumonia
D) Fractured hip
Q3) Which hospital department often is responsible for monitoring patient incident data?
A) Social services
B) Patient accounting
C) Infection control
D) Risk management
Q4) An adverse patient event is synonymous with a potentially compensable event.
A)True
B)False
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Chapter 13: Data Reporting, Interpretation, and Use
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59 Verified Questions
59 Flashcards
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Sample Questions
Q1) In the physician office the codes for reimbursement may be assigned by those who have not been trained in established coding rules. Because of this:
A) The resulting codes may be more accurate than inpatient codes.
B) The resulting codes will be of equal quality to those generated in the inpatient coding process.
C) The resulting codes will be of lower quality than those generated in the inpatient coding process.
D) The resulting codes will be exactly the same.
Q2) All of the following are designated categories of an approved hospital cancer program except:
A) Incident-oriented cancer program.
B) Teaching hospital cancer program.
C) Community hospital cancer program.
D) Free-standing cancer center program.
Q3) The reference date for a cancer registry is defined as the date the:
A) Registry is planned.
B) Data collection begins.
C) Cancer committee is formed.
D) Cancer program is approved.
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Page 15
Chapter 14: Privacy and Health Law
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65 Verified Questions
65 Flashcards
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Sample Questions
Q1) The principle of stare decisis is used in a judicial decision when:
A) Children are involved.
B) Societal values have changed.
C) Statutory law applies to the situation.
D) The facts of the case are similar to a case that has been decided previously.
Q2) A legal document requiring someone to come before the court and testify is called a ____________________.
Q3) Assume that an employee of a hospital's health information management department inappropriately releases confidential information to a patient's employer. The patient decides to sue for breach of confidentiality. All the following parties could be held liable for this breach except the:
A) Patient's employer.
B) Employee.
C) Supervisors/managers of employee.
D) Hospital.
Q4) A properly executed authorization to release alcohol-related treatment information must include a description of the information to be disclosed.
A)True
B)False
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Chapter 15: Human Resource Management
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65 Verified Questions
65 Flashcards
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Sample Questions
Q1) Why must every organization have a complaint or grievance procedure?
Q2) Delegation of authority is important because it expands the manager's ability and provides decision-making opportunities for employees.
A)True
B)False
Q3) Describe some activities conducive to developing and maintaining an effective health information management team.
Q4) Which of the following leadership styles identified in the Blake-Mouton Leadership Grid is most appropriate when the input of followers is critical to implementing the leader's decision AND the stakes and risks associated with the decision are high
A) Organization man management
B) Authority obedience
C) Country club
D) Team management
Q5) Job evaluation by use of a factor and point system provides an objective measure of the employee's performance in his or her job.
A)True
B)False
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Chapter 16: Operational Management
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) The color red has the effect of putting workers to sleep.
A)True
B)False
Q2) Improving work processes requires questioning the necessity of continuing to do all currently performed tasks.
A)True
B)False
Q3) The color red is rarely used in offices because it can cause headaches and increase blood pressure.
A)True
B)False
Q4) Work sampling using random observations is effective because:
A) Data are obtained with less time and expense.
B) The employee gets the manager's attention.
C) The manager can see whether work is distributed equitably.
D) It interrupts the normal work routine for shorter periods of time.
Q5) Effective strategic planning requires environmental forecasting.
A)True
B)False
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Chapter 17: Revenue Cycle and Financial Management
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85 Verified Questions
85 Flashcards
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Sample Questions
Q1) The monthly fee for leasing the van in the health information imaging service is considered a fixed cost.
A) Yes
B) No
Q2) One of the financial statements most useful to the Director of Health Information Management is the
Q3) ____________________ is an example of fixed costs.
Q4) Which of the following is a performance measure?
A) Operating margin ratio
B) Capitalization ratio
C) Accounts receivable turnover ratio
D) Total asset ratio
Q5) What is the fundamental accounting equation?
Q6) The amount of money received from a payer less the actual cost to provide the service represents the ____________________ gained by the transaction.
Q7) After the imaging proposal was approved, the health information manager was able to complete the operating budget for consolidation in the hospital's ____________________ budget.
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