Question 1: You are completing a complete facility inventory of all currently in use forms in preparation for a HER. For bar coding and indexing into a document management system, each form needs a name. The nameless document in front of you describes tissue removed during surgery from a microscopic perspective. You are most likely to submit a document of the following type to this form:

• pathology report (Correct answer)
• operative report
• discharge summary
• recovery room record

Correct answer: pathology report

A pathology report is the official document generated by a pathologist after examining tissue or fluid samples (e.g., biopsies, surgical specimens) under a microscope. It details the microscopic findings, provides a diagnosis, and includes other relevant information about the tissue, precisely matching the description of a document describing tissue from a microscopic perspective.

Question 2: The standards for collecting patient data differ depending on the setting for healthcare. Among the data elements you could anticipate being gathered in the MDS but not in the UHDDS is

• principal diagnosis
• procedures and dates
• personal identification
• cognitive patterns (Correct answer)

Correct answer: cognitive patterns

The Minimum Data Set (MDS) is a standardized assessment tool used in long-term care settings, such as nursing homes, to comprehensively assess residents' health, functional status, and cognitive abilities. Cognitive patterns are a critical component of the MDS to evaluate a resident's mental status and guide care planning, whereas the UHDDS (Uniform Hospital Discharge Data Set) focuses on acute care inpatient data like diagnoses and procedures.

Question 3: Taking the following actions would be a good first step in ensuring the security of the data in a health information computer system:

• define levels of security for different types of information, depending on sensitivity (Correct answer)
• provide internet access to facility records
• establish a good record tracking system
• provide remote terminals for improved access to the record

Correct answer: define levels of security for different types of information, depending on sensitivity

A crucial first step in securing data is to classify information based on its sensitivity and criticality. Defining different levels of security for various types of information allows for the implementation of appropriate, tiered security controls, ensuring that highly sensitive data receives the strongest protections while less sensitive data has adequate, but not excessive, safeguards. This approach is both effective and efficient.

Question 4: What does the prefix "99" stand for in the number "99-0001" listed in a tumor registry accession register?

• the sequence number of the case
• the number of primary cancers reported for that patient
• the stage of the tumor based upon the TNM system of staging
• the year the case was entered into the database of the registry

In tumor registries, accession numbers are typically structured to include the year the case was first entered into the registry, followed by a sequential number for that year. Therefore, '99' in '99-0001' indicates that the case was accessioned in the year 1999. This system helps in organizing and tracking cases chronologically within the registry database.

Question 5: The full report of a patient's fall from his bed, including witness accounts and likely causes of the incident, must be located by a risk manager. She would probably discover this data in the

• incident report (Correct answer)
• doctors’ progress notes
• nurses’ notes
• integrated progress notes

Correct answer: incident report

An incident report is a formal document used in healthcare facilities to record details of an unexpected event, such as a patient fall, that could potentially lead to harm or liability. It typically includes witness accounts, contributing factors, and follow-up actions, making it the primary source for a risk manager investigating such an event.

Question 6: Who is responsible for creating and updating the data in a patient's progress note?

• Registration staff
• Provider (Correct answer)
• Health information management (HIM) professional
• Administrator

Correct answer: Provider

The provider (e.g., physician, nurse practitioner, physician assistant) is directly responsible for creating and updating a patient's progress notes. These notes document the patient's clinical course, treatment, and response to care, reflecting the provider's ongoing assessment and plans. They are a critical part of the legal health record and are generated by the clinicians directly involved in patient care.

Question 7: Acute care service providers are less likely than ambulatory care providers to depend on the documentation contained in the

• transfer record
• interdisciplinary patient care plan
• problem list (Correct answer)
• discharge summary

Correct answer: problem list

While problem lists are valuable in all settings, ambulatory care providers often rely heavily on a comprehensive and up-to-date problem list to manage chronic conditions and long-term patient health over multiple visits. In acute care, the focus is often on the immediate, presenting problem and stabilization, making the problem list less central to daily acute decision-making compared to the detailed, ongoing management in an outpatient setting.