AHIMA Level 1 â Questions and Answers
Question 1: Patient data collecting criteria differ per health care facility. A data piece you expect to be gathered in the MDS but not in the UHDDS is ______________.
- procedures and dates
- personal identification
- principal diagnosis
- cognitive patterns (Correct answer)
Correct answer: cognitive patterns
The Minimum Data Set (MDS) is specifically designed for long-term care residents and includes detailed assessments of a patient's functional status, health problems, and cognitive patterns. In contrast, the Uniform Hospital Discharge Data Set (UHDDS), used for acute care, focuses on diagnoses, procedures, and patient demographics. Therefore, 'cognitive patterns' is a data piece expected in the MDS but not typically in the UHDDS.
Question 2: A good opening step toward maintaining the security of data included in a health information computer system would be ______________________.
- define security levels for various sorts of information based on their sensitivity. (Correct answer)
- offer online access to facility records.
- create a good tracking system.
- offer remote terminals for easier access to the records.
Correct answer: define security levels for various sorts of information based on their sensitivity.
A crucial initial step in maintaining the security of data in a health information computer system is to define security levels based on the sensitivity of various types of information. This allows for the implementation of appropriate access controls and safeguards tailored to the risk associated with different data, ensuring that highly sensitive information receives the strongest protection and preventing unauthorized access.
Question 3: What does the prefix "99" indicate in the tumor registry accession number "99-0001"?
- the year the case was put into the registry's database (Correct answer)
- the case's sequence number
- the tumor's stage according to the TNM staging method
- the total number of primary cancers recorded for that patient
Correct answer: the year the case was put into the registry's database
In tumor registry accession numbers, the initial digits typically indicate the year the case was entered into the registry's database. Therefore, in the accession number '99-0001', the prefix '99' signifies that the case was accessioned or added to the registry in the year 1999. The subsequent numbers usually represent the sequence of cases for that year.
Question 4: A risk manager must locate a complete record of a patient's fall from his bed, including witness statements and likely causes of the incident. She would probably discover this knowledge in the __________________.
- nursesâ notes
- incident report (Correct answer)
- doctorsâ progress notes
- integrated progress notes
Correct answer: incident report
An incident report is the primary document a risk manager would consult for a complete record of a patient's fall. These reports are specifically designed to detail adverse events, including witness statements, a description of the incident, and an analysis of likely causes. This comprehensive documentation is essential for risk management, investigation, and identifying preventative measures.
Question 5: Ambulatory care professionals are more likely than acute care providers to use the information available in the ______________________.
- discharge summary
- interdisciplinary patient care plan
- problem list (Correct answer)
- transfer record
Correct answer: problem list
Ambulatory care professionals, who manage ongoing outpatient visits, rely heavily on a problem list to track a patient's chronic and acute health issues over time. This list provides a concise, longitudinal summary of all active and inactive problems, facilitating continuity of care and informed decision-making across multiple encounters. Acute care, being more episodic, focuses more on the immediate admission and discharge diagnoses.
Question 6: The Joint Commission does not authorize automatic authentication of health record inputs. The fundamental argument against this approach is:
- electronic signatures are not accepted in all states
- it is too simple to delegate the usage of computer passwords
- tampering happens too often with this type of authentication
- evidence cannot be presented that the physician really reviewed and authorized each report (Correct answer)
Correct answer: evidence cannot be presented that the physician really reviewed and authorized each report
Automatic authentication of health record inputs is problematic because it removes the direct, explicit action of a physician reviewing and approving each entry. Without individual physician action for each input, it becomes difficult to legally and clinically prove that the physician genuinely reviewed and authorized the specific content. This lack of direct evidence undermines accountability and the integrity of the health record.
Question 7: As a new CTR, you want to identify all reportable cancer cases from the preceding year. A crucial resource will be the facility's _____________.
- physiciansâ index
- disease index (Correct answer)
- patient index
- number control index
Correct answer: disease index
A disease index is a crucial resource for a Certified Tumor Registrar (CTR) because it organizes patient records by diagnosis, including specific cancer codes. By consulting the disease index, the CTR can efficiently identify and track all patients who have been diagnosed and treated for reportable cancer cases within the facility during a given period. This ensures comprehensive case finding for cancer registries.
Question 8: A person stole and used another person's insurance information to get medical treatment. This action will be considered:
- Abuse
- Medical identity theft (Correct answer)
- Violation of bioethics
- Fraud and abuse
Correct answer: Medical identity theft
Medical identity theft occurs when an individual uses another person's personal identifying information, such as their insurance details, to obtain medical services or goods. In this scenario, stealing and using someone else's insurance information for treatment directly fits this definition. It is a specific form of identity theft focused on accessing healthcare benefits or services fraudulently.
Question 9: A clerical employee describes an event in which the clerk felt the first-line supervisor discriminated against her because of her gender. The greatest step for you to take now is to:
- tell the clerk to give objective proof of the discrimination.
- inquire with other clerical personnel whether they have had similar issues.
- thoroughly explore the situation and record your findings. (Correct answer)
- consult the first-line supervisor to discover what occurred.
Correct answer: thoroughly explore the situation and record your findings.
When an employee reports discrimination, the most appropriate initial step for a manager is to conduct a thorough and objective investigation. This involves gathering all relevant facts, interviewing involved parties, and meticulously documenting the findings. This comprehensive approach ensures fairness, helps determine the validity of the claim, and provides a basis for any necessary subsequent actions.
Question 10: Encoding software was deployed at your facility two years ago. The coders are well-trained in it and like utilizing it. It works great and just requires ICD code revisions once a year. In terms of the Information Systems Life Cycle stages, the coding system is probably in the ________________.
- operation and maintenance phase (Correct answer)
- design phase
- obsolescence or decline phase
- implementation phase
Correct answer: operation and maintenance phase
The Information Systems Life Cycle (ISLC) describes the stages of an information system. Since the encoding software has been deployed for two years, is well-liked, works effectively, and only requires annual updates, it is actively in use and being maintained. This indicates that the system is currently in the operation and maintenance phase, where it provides value and receives ongoing support.
Question 11: The file clerks at your department's main file area report that they were able to locate 400 of the 450 required records over the last month. The primary file contains a total of 4,500 entries. What is the area's accuracy rate?
- 8.90%
- 88.90% (Correct answer)
- 1.10%
- 10.00%
Correct answer: 88.90%
The accuracy rate is calculated by dividing the number of successfully located records by the total number of records required, then multiplying by 100 to get a percentage. In this case, 400 records were located out of 450 required. Therefore, (400 / 450) * 100% equals approximately 88.88%, which rounds to 88.90%.
AHIMA Level 1
Patient data collecting criteria differ per health care facility.
A data piece you expect to be gathered in the MDS but not in the UHDDS is ______________.