A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is
now removed via a percutaneous nephrostomy tube. What is the root operation performed for
this procedure?
a. Destruction
b. Extirpation
c. Fragmentation
d. Release - ✔️✔️b. Extirpation
***Taking or cutting out solid matter from a body part
Which type of data consists of *factual details* a *aggregated or summarized* from a group of
health records that provides *no means to identify specific patients*?
a. Orginal
b. Source
c. Protected
d. Derived - ✔️✔️d. Derived
Which of the following data management domains would be responsible for establishing
standards for data retention and storage?
a. Data architecture management
b. Metadata management
c. Data life cycle management
d. Master data management - ✔️✔️c. Data life cycle management
When a healthcare entity destroys the health records after the acceptable retention period has
been met, a *certificate of destruction* is created. How long must the healthcare entity maintain
the the certificate of destruction?
a. Two years
b. Five years
c. Ten years
d. Permanently - ✔️✔️d. Permanently
Which of the following processes is an ancillary function of the health record?
a. Admitting and registration information
b. Billing and reimbursement
c. Patient assessment and care planning
d. Biomedical research - ✔️✔️d. Biomedical research
***Ancillary function- medical services or supplies that are not provided by acute care hospitals,
doctors, or healthcare professionals
What are LOINC codes used for?
a. Identifying test results
b. Reporting test results
c. Identifying tests unique to a specific company
d. Reporting a code for reimbursement - ✔️✔️a. Identifying test results
Logical Observation Identifiers, Names and Codes (LOINC) is a well-accepted set of
terminology standards that provide a standard set of universal names and codes for identifying
individual laboratory and clinical results.
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient
data collection is on:
b. Activities of daily living
c. Discharge diagnosis
d. Reason for encounter - ✔️✔️d. Reason for encounter
The inpatient data set that has been incorporated into federal law and is *required for Medicare
reporting* is the:
a. Ambulatory Care Data Set
b. Uniform Hospital Discharge Data Set
c. Minimum Data Set for Long-term Care
d. Health Plan Employer Data and Information Set - ✔️✔️b. Uniform Hospital Discharge Data Set
Unstructured data may be preferred over structured data because:
a. It does not require processing
b. It provides greater detail
c. Clinicians know how to enter it
d. It is more complete - ✔️✔️b. It provides greater detail
What document is a snapshot of a patient's status and includes everything from social issues to
disease processes as well as critical paths and clinical pathways that focus on a specific disease
process or pathway in a long-term care hospital (LTCH)?
a. Face sheet
b. Care plan
c. Diagnosis plan
d. Flow sheet - ✔️✔️b. Care plan
***Care plan is required for patients in a LTCH
Name of element, definition, application in which the data element is found, locator key,
ownership, entity relationships, date first entered system, date terminated from system, and
system of origin are all examples of:
b. Metadata
c. Data
d. Information fields - ✔️✔️b. Metadata
Data content standards are used to:
a. Share data in the same way the users interpret data
b. Share data in a unique way
c. Share data between disparate systems
d. Modify data - ✔️✔️a. Share data in the same way the users interpret data
A barrier to effective computer-assisted coding is the:
a. Resistance of physicians
b. Resistance of HIM professionals
c. Poor quality of documentation
d. Reduction of consistency without human coders - ✔️✔️c. Poor quality of documentation
Personal information about patients such as their names, ages, and addresses is considered what
type of information?
a. Clinical
b. Administrative
c. Operational
d. Accreditation - ✔️✔️b. Administrative
To ensure authentication of data entries, which type of signature is the most secure?
a. Digital
b. Electronic
c. Handwritten
d. Virtual - ✔️✔️a. Digital
Who is responsible for ensuring the quality of health record documentation?
4
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