SOLVED

11. You are interviewing for a healthcare documentation specialist position at a local hospital system. You have been told that the HIM director, with whom you will be meeting, appreciates applicants who understand the important functions of the HIM department. Given this situation, which of the following questions would be the most appropriate to ask this HIM director? A. “What is the per-line pay rate for the speech recognition editors in the department?” B. “What HIPAA-related policies and procedures apply to the transcription department?” C. “How frequently does your department change electronic medical record vendors?” D. “How much vacation time do healthcare documentation specialists receive?” 12. Which of the following is NOT a part of the typical HIM department’s mission and role? A. Abstraction and coding of all records, preparing them for billing B. Analyzing each record after discharge for consistency and completeness C. Helping the medical staff maintain efficient and complete record-keeping practices D. Making collections calls on past-due payments to the hospital 13.Which statement made by a healthcare documentation specialist shows knowledge of the components of the healthcare record? A. “Nursing personnel must dictate the patient’s history and physical exam within 24 hours of admission.” B. “Results of lab tests such as urinalyses and complete blood counts must be dictated by the radiologist within 4 hours.” C. “Physician orders are entered by the physician to indicate diagnostic tests, medications, and treatments for a patient during a hospitalization.” D. “Physical therapists must complete a consultation report when they are assigned to see a patient.” 14.Which of the following best describes the healthcare documentation specialist’s responsibility in demographic information capture? A. Edit HL7 codes to ensure that the right report uploads into the right patient record. B. Correct dates of dictation to make sure that records comply with The Joint Commission requirements to record and file patient records within 24 hours of admission. C. Ensure that the patient demographic information entered by the healthcare provider is correctly matched with the patient name and number dictated. D. Enter the HDS’s employee ID number into the dictation system to identify the person who edited the speech recognition draft. 15.Which of the following is NOT a type of health record entry made by nursing personnel? A. Medication administration record B. Patient care plan while admitted to the nursing floor C. Operating room record indicating names of participating personnel, status of sponge and needle counts, estimated blood loss, and fluid replacement.  D. Holter monitor study of findings and diagnoses 16. On your first day of work as a healthcare documentation specialist, the clinic you work for tells you to format Dr. Mayfield’s progress reports as SOAP notes. As a knowledgeable HDS, you recognize that this means: A. Dr. Mayfield is an infectious disease specialist, so universal precautions must be undertaken as you edit the speech recognition draft. B. You will organize Dr. Mayfield’s dictation in four paragraphs labeled Subjective, for history; objective, for physical exam findings; Assessment, for diagnosis; and Plan. C. The report will be organized in the following order: S for Summary of Findings, O for Obstetric for information relating to the patient’s status as a gravida and para, A for Admission Records regarding hospitalizations, and P for plan of treatment. D. Dr. Mayfield will be dictating a letter to the patient’s insurance company regarding its denial of her planned course of treatment. 17.As an experienced healthcare documentation specialist, you are asked to orient a student intern who is volunteering in your department. In explaining the operative report documentation process, you explain to the intern that A. Preoperative and postoperative diagnoses, title of operation, and names of surgeon and anesthesiologist are important parts of operative reports. B. Operative reports are transcribed as letters in full block format and are printed on letterhead paper. C. Any dictated references to drains, packs, and dressings can be omitted from the report because these portions are recorded by the operating room nursing staff. D. Sponge and needle counts are reported in the operative report as part of the patient billing process. 18.While you are editing a speech recognized draft H&P, you notice that the dictation is organized by body system and refers to subjective information, specifically the presence or absence of symptomatology in that body system. As an HDS, you are aware that this part of the report is called the: A. Physical Examination B. Past Medical History C. Family History D. Review of Systems 19.Your family members know that you work as a healthcare documentation specialist, and they rely upon you to explain some healthcare practices to them. One day your mother, whose doctor has ordered extensive blood testing for her, asks you to explain why she should have these expensive tests done when she feels fine. You tell her: A. Insurance will cover the costs. B. Lab tests are proven to be effective in screening for hidden disease conditions. C. She should be sure not to wear antiperspirant deodorant when she has blood drawn, because it can affect the test results. D. She should make sure she eats something before her blood is drawn so that she doesn’t faint. 20.Which of the following is NOT a reason that a physician would order a lab test? A. To diagnose disease in a patient who is acutely ill B. To see how much damage a disease has done to a patient’s body C. To reduce liability for billing fraud D. To monitor effectiveness of treatment protocols 21.While dictating a discharge summary, a surgical resident makes the statement, “H&H 14 over 42.” As a knowledgeable healthcare documentation specialist, you know that this should be transcribed as: A. Hemoglobin 14, hematocrit 42 B. H&H 14/42 C. Hematocrit 42, hemoglobin 14 D. Hct/Hgb 14/42 22. A physician dictates that a patient is taking Adderall XR 5 mg capsules that contain extended-release spheres. As a healthcare documentation specialist, you understand that this means this drug form is A. Covered with a special coating that causes the medication to dissolve in the small intestine, not the stomach. B. A patch that is applied to the chest and releases 5 mg of Adderall every 4 hours. C. A hard-shelled capsule holding a granular form of Adderall that is formulated to release in a continuous, sustained manner. D. Scored with a long indentation across its middle so that the pill can be broken in half to be administered in 2.5 mg doses. 23.You are working as a healthcare documentation specialist for a multispecialty physician practice. In a letter to the insurance company, a pediatrician specifies that a 3-year-old patient is to receive Dimetapp Syrup, not Dimetapp Elixir. As a healthcare documentation specialist, you know that this distinction is important because A. Elixirs are less effective than syrups in treatment of allergies B. Syrups are less expensive than elixirs. C. Syrups are sweeter and more palatable for children. D. Elixirs contain a drug dissolved in a solution of alcohol and water. 24.As a healthcare documentation specialist working as operations manager of the HDS department at a hospital system, you are attending a patient safety meeting at your organization. A nursing supervisor tells you that the HDS department can have little if any effect on patient medication safety because medications are given according to physician orders, not according to dictated and transcribed reports. You respond by saying that: A. Physician orders are always correctly entered, and there is no need to correlate them with previous records. B. Though physician orders should be used for medication administration, patient safety could be seriously compromised if a dosage of Levemir insulin were erroneously rendered by speech recognition as 800 units instead of 80. C. Nurses rarely make medication errors. D. She is correct in saying that the work of healthcare documentation specialists is unlikely to affect patient care. 25.Which dictated abbreviation, symbol, or dose designation forbidden by the Institute for Safe Medication Practices (ISMP) is shown as correctly transcribed? A. Dictated: Nexium 20 mg q.d. Transcribed: Nexium 20 mg daily. B. Dictated: Carafate oral suspension 1 g/10 cc. Transcribed: Carafate oral suspension 1 g per 10 cc. C. Dictated: Nasacort AQ nasal spray 55 micrograms. Transcribed: Nasacort AQ nasal spray 55 ug.