In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

Correct Answer: B 🗳️

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS would be

Correct Answer: B 🗳️

A good first step toward protecting the security of data contained in a health information computer system would be to

Correct Answer: B 🗳️

In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent?

Correct Answer: B 🗳️

A risk manager needs to locate a full report of a patients fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the

Correct Answer: C 🗳️

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

Correct Answer: D 🗳️

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

Correct Answer: B 🗳️

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

Correct Answer: A 🗳️

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.

Correct Answer: C 🗳️

As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility’s

Correct Answer: A 🗳️