11. Which of the following best describes the uses of ADT information? A. Direct incorporation into a medical report B. Reporting of admission, discharge, and transfer dates for a given patient C. Electronically recorded age, sex, and other information used to track patient demographics in an electronic medical record D. All of the above E. None of the above 12. Which of the following is NOT a limitation of healthcare-provider-driven electronic templated data entry systems? A. Different data input processes for different systems B. Immediate availability of finished report, with no waiting for someone else to complete a task C. Inflexibility of content creation constraining what can be recorded about the patient’s condition D. Extra time taken by healthcare provider to perform data entry that could be used to see more patients 13. Which of the following best describes a limitation of speech recognition for medical record creation? A. The best you will get is exactly what you said, not what you really meant to say. B. A highly skilled healthcare documentation specialist can serve as the safety net for dictators by reviewing a speech-recognized draft for potential errors. C. Some speech-recognized errors on draft reports are easy for the dictator to spot and correct immediately. D. Good dictation hygiene, including avoidance of background noise, side conversations, and cell phone static, will help dictating physicians produce a good speech recognition draft. 14. Which of the following describes a way that good healthcare documentation can improve the quality of care provided to patients? A. Standardize medical education B. Help manage and prevent communicable disease C. Assist in research to improve treatments D. All of the above E. None of the above 15 Which of the following correctly summarizes the initial process of creating a record for a new patient at a healthcare facility? A. Appointment with patient is made, permanent medical record number is retrieved or assigned, account number is assigned for that encounter, insurance information is obtained and entered. B. For each admission, a new chart is created, new medical record number given, release of information signed by patient. C. Special charts for each department, such as laboratory, radiology, and cardiology, are separately created with unique medical record numbers for each. D. Nurse sees patient on hospital bed and opens a new chart. 16. Which of the following inpatient health record documents is completed by the physician? A. Medication administration record B. Medication reconciliation sheet C. Admission order D. Graphs for recording vital signs and fluid intake and output 17. Which of the following questions about hospital inpatient records is the most correct? A. The Joint Commission requires surgeons to record a complete, detailed record of procedures by the time the patient is discharged. B. Discharge summaries must include final diagnoses, identify the details of patient care during the hospitalization, and describe the plan for care after discharge. C. Charges for services received by a patient are dictated by the physician and transcribed by the healthcare documentation specialist as part of the discharge summary. D. In a typical four-day hospital stay, fewer than 5 care providers interact with patients and document their care in the report. 18. Which of the following correctly describes responsibilities of the medical coder? A. Entering diagnosis and procedure coding such as those of ICD-9 and ICD-10 into the grouper program to create a DRG code B. Determining the level of insurance reimbursement the facility will receive by choosing the most complicated diagnosis for the patient C. Ensuring that A/R (accounts receivable) days are limited by quickly sending the patient’s bill for services rendered to the third-party payer D. Inputting CPT codes to ensure that the patient’s diagnosis is correctly reported to Medicare. 19. Which of the following was NOT an objective of HIPAA legislation when it was first enacted in 1996? A. Establish electronic health records as a national standard B. Allow people to maintain their health insurance coverage when they moved to a different employer C. Legally ensure security and confidentiality of patient health information D. Establish uniform standards for transmission of electronic data that included patient health information 20. Which of the following is NOT a right guaranteed to patients under HIPAA? A. Right to receive the correct medication B. Right to inspect and copy their protected health information C. Right to give consent before information is released to third parties, except as needed for treatment, payment, and healthcare operations D. Right to request amendment or correction to their medical information 21. Encryption is: A. A means of ensuring health record privacy, even if a laptop computer containing PHI is stolen from a provider’s car B. Required by the National Institute of Standards and Technology to b e 128-bit or 256-bit C. A technology that makes data unusable, unreadable, or undecipherable to people who are not authorized to use it D. All of these 22. Which of the following is the most CORRECT statement about healthcare privacy law? A. Because healthcare documentation specialists frequently work outside the healthcare facility, they rarely must be concerned about breach of personal health information. B. Covered entities perform all functions and activities of healthcare. C. Business associate (BA) agreements spell out obligations of both the covered entity and the BA to safeguard PHI. D. Business associates need only be concerned about creating and implementing policies and procedures that cover administrative safeguards. 23. An excellent method of ensuring confidentiality in transfer of patient information is to: A. Send a test fax to a new fax number prior to sending any PHI to ensure that the fax number is correct. B. Promptly dispose of PHI in properly marked recycling bins. C. Allow family members to use your transcription computer only to download material from approved sites.