Certified Coding Associate Exam Health Information Management 3

Question 1

Which of the following best defines a hybrid health record?

Accepted Answer

A record with a combination of paper and electronic components

Answer

A record that contains only electronic data

Answer

A record used only for outpatient visits

Answer

A record shared between two different facilities

Question 2

What is the purpose of an advance directive?

Accepted Answer

To document a patient's wishes regarding healthcare decisions if they become incapacitated

Answer

To authorize billing for future services

Answer

To assign a healthcare proxy without documentation

Answer

To schedule follow-up appointments after discharge

Question 3

The term 'concurrent review' in health information management refers to:

Accepted Answer

Review of records and care while the patient is still admitted

Answer

Review of records after a patient is discharged

Answer

Review of records by external auditors

Answer

Review of outpatient encounter documentation only

Question 4

Which of the following is the best example of secondary data in health information management?

Accepted Answer

Data in a disease registry compiled from multiple patient records

Answer

A physician's progress note in a patient's chart

Answer

An operative report for a specific surgical procedure

Answer

A patient's signed consent form

Question 5

What is the primary role of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule?

Accepted Answer

To establish national standards for the protection of individual health information

Answer

To mandate electronic health record adoption

Answer

To regulate hospital accreditation

Answer

To set Medicare physician payment rates

Question 6

Which document in the health record provides a physician's assessment of a patient's condition at the end of a hospitalization?

Accepted Answer

Discharge summary

Answer

Admission note

Answer

Consultation report

Answer

Nursing assessment