Question 1 of 20
5.0 Points
Which department in a health care facility is responsible for the overall maintenance of medical records, including their organization, security, confidentiality, and responsible use in patient care?
A. Risk Management Department
B. Performance Improvement Department
C. Health Information Management Department
D. Infectious Disease Department
Question 2 of 20
5.0 Points
All of the following would likely be incorporated into the job description of an entry-level medical records clerk except:
A. maintaining the hospital cancer registry.
B. filing and retrieving medical records.
C. picking up records of discharged patients from nursing units.
D. working with physicians in the physician incomplete area.
Question 3 of 20
5.0 Points
Which of the following accurately describes the potential career ladder beyond an entry-level medical records clerk?
A. Coding specialist, senior records clerk, associate director, director of a health information management department, chief operating officer of the hospital, and chief executive officer of the hospital
B. Senior clerk, associate director, health information management supervisor, director of health information management department, chief operating officer of the hospital, and chief executive officer of the hospital
C. Health information management supervisor, coding specialist, associate director, chief operating officer of the hospital, chief executive officer of the hospital, and director of health information management department
D. Senior clerk, health information management supervisor, associate director, director of health information management department, chief operating officer of the hospital, chief executive officer of the hospital
Question 4 of 20
5.0 Points
All of the following are necessary to become a registered health information technician except:
A. working in a health information management department.
B. serving one term as a cancer registrar.
C. attending a two-year RHIT preparation course.
D. passing the national RHIT examination.
Question 5 of 20
5.0 Points
Based on training experience and responsibilities, which one of the following employees would be the best choice to be promoted to a case manager position in a large acute care hospital?
A. The Medical Records Technician I
B. The Medical Records Technician II
C. The Registered Health Information Administrator
D. The Registered Health Information Technician
Question 6 of 20
5.0 Points
John Paxton is an entry-level records clerk. He tells you he would like to advance to the level of coding specialist. Which of the following would be the best referral to assist him in meeting the necessary requirements for advancement?
A. A health records department at the closest local hospital
B. The American Health Information Management Association
C. The Medicare Financing Association
D. One of the physicians in your office
Question 7 of 20
5.0 Points
In order to be paid to type reports that physicians dictate, either in the hospital, medical office, or as a contract service, you would need to become a:
A. medical records technician II.
B. medical records technician I.
C. certified coder.
D. trained transcriptionist.
Question 8 of 20
5.0 Points
Which of the following is an example of a “third-party” regarding a recent surgical procedure?
A. Patient’s insurance company
B. Patient’s surgeon
C. Hospital where the patient had the surgery
D. Patient
Question 9 of 20
5.0 Points
If you need to learn about current standards for promoting the accuracy and quality of patient care documentation at your job, which organization are you most likely to contact?
A. Health Care Financing Administration (HCFA)
B. American Hospital Information Management Association (AHIMA)
C. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
D. American Association of Performance Improvement (AAPI)
Question 10 of 20
5.0 Points
You are the new medical information manager in the local hospital in a small town where it seems everyone knows everybody else. You are concerned about protecting patient confidentiality. As a manager, you should implement a policy that allows only:
A. hospital managers to enter the file area and/or pull records.
B. doctors, nurses, and medical records personnel to pull records.
C. hospital personnel to enter the file area and/ or pull records.
D. medical records personnel to enter the file area and/or pull records.
Question 11 of 20
5.0 Points
A medical records department would consider microfilming patient records or using an optical imaging system to:
A. protect the patient records from misuse.
B. cut the costs of the medical records department.
C. store old records and relieve space shortages.
D. provide easy and efficient access to new patient records.
Question 12 of 20
5.0 Points
One day at work a physician you know very well stops you in the hall and asks you to fax her some information from a patient’s record. Before complying with his request, the most important thing you need to do is:
A. find out if she is authorized to receive the information.
B. determine if you have her fax number.
C. determine if the information requested is available.
D. make a copy of the information so you can keep the original information with the record.
Question 13 of 20
5.0 Points
If you need to ensure that a physician’s diagnosis has been coded properly, which of the following would be your most reliable source?
A. The current director of the billing department
B. The Joint Commission on the Accreditation of Healthcare Organizations
C. The current edition of the International Classification of Diseases
D. The office manager at the Health Care Financing Administration
Question 14 of 20
5.0 Points
One purpose of abstracting is to:
A. maintain consistent organization from medical record to medical record.
B. obtain medical funding from state and/or federal government agencies.
C. ensure all chart documents are signed by the appropriate provider.
D. prepare the medical record for transcription.
Question 15 of 20
5.0 Points
Which of the following usually occurs first after a patient has been discharged from a health care facility?
A. Assistance with transcribing physician reports
B. Analysis of the medical record
C. Placement of the record in the physician incomplete area
D. Assembly of the medical record
Question 16 of 20
5.0 Points
Imagine that you are the manager of an outpatient private physician practice. Once you start working, you notice that medical records are disorganized, there is no consistency in the filing of documents from record to record, and when you need to find a particular document, you end up flipping through every page of the chart. To best solve this problem, you should:
A. implement a chart order list.
B. establish a physician incomplete area.
C. provide a final check area.
D. hire a transcriptionist.
Question 17 of 20
5.0 Points
The purpose of transcription is to:
A. turn the spoken word into a printed document.
B. interpret the physician’s handwriting for the coding specialist.
C. translate the medical record for a non-English-speaking patient.
D. turn the written word into a printed document.
Question 18 of 20
5.0 Points
A medical record should remain in the physician incomplete area:
A. 30 days, as mandated by the Joint Commission on the Accreditation of Healthcare Organizations.
B. 14 days, as recommended by the Joint Commission on the Accreditation of Healthcare Organizations.
C. until the physician has been notified of any deficiencies.
D. until all deficient items are completed.
Question 19 of 20
5.0 Points
The ______evaluates whether a patient’s hospital stay is appropriate and timely.
A. risk manager
B. case manager
C. patient’s physician
D. performance improvement team
Question 20 of 20
5.0 Points
If a patient has an allergic reaction to a medication while in the hospital, an incident report must be completed. As manager, you want to ensure that the incident report goes to:
A. case management.
B. performance improvement.
C. risk management.
D. the hospital’s Chief Operating Officer.