Medical Records Librarian Gr II in Health Services Answer

Question 1

The lymphatic system contains four organs :

A

Spleen, tonsils, bone marrow and thymus

B

Spleen, Peyer"s patches and tonsils

C

Spleen, tonsils, Peyer"s patches and thymus

D

Tonsils, Peyer"s patches, thymus and bone marrow

Question 2

Which coding and classification system is primarily used by dentists ?

A

CPT

B

ICD-10-PCS

C

CDT

D

ICD-10-CM

Question 3

The process of simply taping the small items to a larger sheet of paper (especially lab reports) and then filing that paper in the patient"s medical records is called

A

collating

B

conserving paper

C

unit filing

D

shingling

Question 4

Medical records of patients who are deceased or moved away, probably never to be seen again by the provider, are under what status ?

A

Closed

B

Inactive

C

Active

D

Charged out

Question 5

MAR refers to

A

Medical Allergies Required

B

Medication Administration Record

C

Medication and Allergies Record

D

Medical Alert Record

Question 6

Which of the following may be used in telemedicine ?

A

“Store and forward” technology

B

“Cut and paste” technology

C

“VHS” technology

D

“Tap and GoTM” technology

Question 7

Important uses of the medical record include all of the following Except :

A

means of communication

B

statistical data

C

payment data

D

information to pharmaceutical companies

Question 8

Documentation in a medical record that supports the skilled services that are medically reasonable and necessary are called

A

treatment plan

B

medical approval

C

medical necessity

D

admission necessity

Question 9

The standard of care in cases of medical negligence is measured against

A

The most recent medical research evidence available

B

What is expected of a reasonable doctor

C

What the majority of doctors would recommend

D

The standard of experts in the field

Question 10

Which term describes a best way to organize and chart patient progress ?

A

SOAP

B

POMR

C

MAR

D

PRN

Question 11

Which of the following standards are used to create standardized nomenclature within an electronic health record program ?

A

ICD-10 CM

B

NADA PC

C

CTNS HER

D

SNOMED CT

Question 12

If a patient is in the prone position, he is :

A

Lying flat on his back.

B

Lying flat on his stomach.

C

Sitting up straight.

D

Lying flat on his back with his feed elevated

Question 13

When you see the symbol # in front of a CPT code, what does it mean ?

A

That the code is listed out of numerical order.

B

That the code is listed in numerical order.

C

That the code used to be listed with a different number.

D

That the code description has changed.

Question 14

What is removed by a pneumonectomy ?

A

The pleural sac

B

A tumor of the inner ear

C

The lung

D

A cyst in the muscle of the foot

Question 15

The Hospital Management Committee is concerned about the growing number of history and physical examination reports that are not being completed in a timely manner. Which monitoring process will the Medical records department implement to correct this problem ?

A

Concurrent analysis

B

Discharge analysis

C

Discharge planning

D

Retrospective review

Question 16

In ICD _____ symbol is used in listing of inclusion and exclusion terms when the words that precede it are not complete terms for assignment to the rubric.

A

( ) Parenthesis

B

: Colon

C

[ ] Brackets

D

} Brace

Question 17

_____ is defined as the symptom of disease (such as rash or fever) which appear before and signal the onset of approaching more severe illness.

A

Prognosis

B

Relapse

C

Prodrome

D

Remission

Question 18

_____ is the defined as the number of hospital beds, exclusive of newborn bassinets, normally available for use by Inpatients.

A

Bed Turnover

B

Bed compliment

C

Bed occupancy

D

None of these

Question 19

What is one advanced method used to input data into an EMR ?

A

Typing with a keyboard

B

Use an iPod

C

Use of voice recognition system

D

Use of a transcriptionist

Question 20

Chiropractors are complementary and alternative healthcare professionals who focus on the diagnosing and treating of what body part ?

A

Respiratory system

B

Spine and musculoskeletal system

C

Cardiovascular system

D

Intestinal system

Question 21

What type of code is assigned when the provider documents reason for a patient seeking healthcare that is not an injury or disease ?

A

Z code

B

U code

C

V code

D

Y code

Question 22

The process of moving an active file to inactive status is called

A

collating

B

shingling

C

purging

D

sequestering

Question 23

Who ultimately decides whether a medical record can be released for insurance / reimbursement ?

A

Physician

B

Medical Records personnel

C

Third party payers

D

Patient

Question 24

Which of the following is NOT considered as part of the integumentary system ?

A

Skin

B

Hair

C

Exocrine glands

D

Teeth

Question 25

A condition occurring without a clearly identified cause is known as :

A

Idiopathic

B

Systemic

C

Progressive

D

Symptom

Question 26

Which of the following guards against duplication of patients records ?

A

In-patient index

B

Disease/operation index

C

Number index

D

Master patient index

Question 27

MRD files the records as follows :
13-40-05, 14-40-05, 14-41-05, 15-41-05 and 16-41-05.
Which system is being used ?

A

Terminal digit

B

Middle digit

C

Unit numbering

D

Serial numbering

Question 28

In which chapters of the ICD 10 could the following diagnostic statement have their codes ? They are : pulmonary tuberculosis, ebola virus and disease and malarial fever.

A

Certain infectious and parasitic disease and diseases of the digestive system.

B

Diseases of the respiratory system and certain infectious and parasitic diseases.

C

Diseases of the respiratory system and External Causes of Morbidity.

D

Diseases of the nervous system and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.

Question 29

Sequela describes a condition that is (a) :

A

Combination of two or more diseases

B

Late effect of a previous condition

C

Manifestation of an underlying etiology

D

Not represented in ICD-10

Question 30

What would be the best process to follow if Patient"s records and information in hospital information systems is discovered to have duplicated during the patient care or after the care of patient ?

A

Merging of Medical Records

B

Cancelling the duplicate Medical Records

C

Preserving both the Medical Records separately

D

Sequestering of Medical Records

Question 31

A method to quickly assess the health of newborn children immediately after birth is named after this physician

A

Babinski

B

Charcot

C

Apgar

D

Pick

Question 32

A patient who receives ambulatory care services in a hospital based clinic or department is statistically considered as a/an :

A

Outpatient

B

Inpatient

C

Emergency

D

Day Care

Question 33

As per the guidelines of ICD 10, when Acute and Chronic Conditions are noted :

A

Code only the Chronic Condition

B

Code both and sequence the Chronic Condition code first

C

Code both and sequence the acute (sub-acute) code first

D

Code only the Acute Condition

Question 34

How should an unanticipated death of a full-term infant be reported in a hospital mortality committee by the Medical Records Department ?

A

As a sentinel event

B

As a violation of a clinical practices guideline

C

As medical negligence

D

As a medical complication

Question 35

Which of the following Qualitative analysis method is done by medical records department after an Inpatient has been discharged ?

A

Concurrent Analysis

B

Quality Assurance

C

Retrospective Analysis

D

Peer Review Audits

Question 36

Why is an open-ended query preferred to a closed-ended query format by coding professionals ?

A

Allows physicians to communicate their medical expertise describing the diagnosis and treatment of the patient.

B

Open-ended options are required by the Insurance Companies.

C

Closed-ended options are not efficient to formulate in the varying EHR systems.

D

Either format is accepted in all situations.

Question 37

Which key clinical document is essential in outlining a patient"s course of treatment while submitting the claims for reimbursement ?

A

History and physical examination

B

Operative reports

C

Consultation reports

D

Discharge summary

Question 38

Protected health information may be disclosed to law enforcement officials :

A

Only with the patient"s written authorization.

B

With the patient"s verbal permission.

C

Only if the law enforcement official requests it in person.

D

Upon written request for essential government functions.

Question 39

________ is the use of medical information transmitted from one site to another via electronic communication to improve a patient"s health status.

A

Telemedicine

B

Diagnostic imaging

C

Mobile health units

D

Video conferencing

Question 40

A storage solution based on digital scanning technology in which Medical record documents are scanned to create digital images of the documents that can be stored electronically ?

A

Electronic Health Record (EHR)

B

Database Management Systems (DBMS)

C

Electronic Document Management System (EDMS)

D

Health Information Exchange (HIE)

Question 41

What is the proper way to destroy medical records ?

A

Incineration

B

Giving the record to the patient

C

Demagnetizing

D

Shredding

Question 42

Which medical record format is arranged in chronological order with documentation from various sources intermingled ?

A

Source oriented

B

Problem oriented

C

Integrated

D

None of these

Question 43

________ is a late entry added to a Medical record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record.

A

Addendum

B

Abstracting

C

Aggregate data

D

Amendment

Question 44

Which of the following activities is not a traditional medical records function ?

A

Forms control

B

Quantitative analysis

C

Retrospective Review

D

Data administration

Question 45

An incomplete record not finished or made complete within the time frame determined by the medical records department of the hospital is called

A

Deficiency slip

B

Delinquent record

C

Audit trail

D

Hybrid health record

Question 46

What would you term a situation in which a patient is issued a medical record number that has been previously issued to a different patient ?

A

Overlay

B

Overlap

C

Outguide

D

None of these

Question 47

Which of the following is considered as ‘impersonal" use of a medical record ?

A

Used for Insurance Claim processing

B

Used for treatment purpose

C

Submitting to court

D

Used for academic/research purpose

Question 48

Which of the following is “True” regarding “Copying and pasting notes from a patient"s previous visit into the current progress notes” ?

A

is not a recommended practice

B

is also known as Cloning

C

is a risk to Data integrity

D

All of these

Question 49

In which of these records you normally would not find physician documentation ?

A

Admission Record

B

Triage forms

C

Informed Consent

D

Drug Order forms

Question 50

The method by which records with medico-legal implications are secured in such a manner as to prevent loss and to ensure that no alteration after the fact can occur is called

A

Inactivation of medical records

B

Sequestering of medical records

C

Purging of Medical records

D

Weeding of Medical records

Question 51

________ is the process of withdrawing samples of fluid from a joint.

A

Arthrocentesis

B

Paracentesis

C

Thoracocentesis

D

Cannulation

Question 52

Find the correctly spelled word.

A

Acetiminophen

B

Acetaminophen

C

Acetaminophin

D

Acetamenophen

Question 53

Which form of medication administration involved a liquid or ointment that is rubbed into the skin ?

A

Rectal suppository

B

Topical application

C

Sublingual administration

D

Transdermal medication

Question 54

Which term describes the surgical incision of the eardrum to create an opening for the placement of tympanostomy tubes ?

A

Myringoplasty

B

Otoplasty

C

Myringotomy

D

Tympanoplasty

Question 55

The abbreviation ________ means left eye, especially used in lens prescriptions.

A

OD

B

AU

C

OS

D

OU

Question 56

Which term describes the surgical repair of the tube extending from the kidney to the bladder ?

A

Pyeloplasty

B

Urethroplasty

C

Meatoplasty

D

Ureteroplasty

Question 57

A medical condition that coexists with the primary cause of hospitalization and affects the patients treatment and length of stay is known as

A

complication

B

differential diagnosis

C

prognosis

D

comorbidity

Question 58

A legal term referring to a patient"s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed

A

Informed consent

B

General consent

C

Implied consent

D

None of these

Question 59

What is the most common type of tracking system used to track paper-based medical records ?

A

Master patient index

B

Registers

C

Outguide

D

Number Index

Question 60

The process of assuring that all records of discharged patients have been received by the Medical records department for processing is called :

A

record retention

B

record reconciliation

C

file maintenance

D

downtime management

Question 61

Process that determines which individuals or groups should be granted permission to make entry in medical records, what portions of the medical record should be made available and what right should be granted related to his or her job requirements, is referred to as

A

Release of Information

B

Review of system

C

Access control

D

Information Governance

Question 62

In a paper-based system, individual Medical records are organized in a pre-established order. This is called

A

Analysis

B

Assembly

C

Numbering

D

Serial-unit filing

Question 63

Right of individuals to control access to their personal health information is

A

privacy

B

confidentiality

C

security

D

None of these

Question 64

Final event in the causal sequence that occurred closest to the time of death. Filled in as top line diagnosis on Medical Certification for Cause of Death form. It is

A

Underlying Cause of Death

B

Pronouncement of Death

C

Immediate Cause of Death

D

Manner of Death

Question 65

According to rules and guidelines for mortality & morbidity coding; If there is no reported sequence terminating in the condition first entered on the certificate, select this first-mentioned condition. State the selection rule for selection of the underlying cause of death for mortality tabulation.

A

Rule 1

B

Rule 2

C

Rule A

D

Rule D

Question 66

The certifier"s report in Medical Certificate of cause of death is stated as below :
Cause of death

Part I	(a)	Cerebral haemorrhage	1 Month	I61.9
	(b)	Nepharitis	6 Month	N05.9
	(c)	Cirrhosis of liver	2 Years	K74.6
Part II	Large bowel obstuction

Which is the underlying cause of Death ?

A

Nephritis

B

Cerebral haemorrhage

C

Cirrhosis of liver

D

Large bowel obstruction

Question 67

A surgical patient develops a wound infection during hospitalization. How is this type of infection classified ?

A

Primary

B

Secondary

C

Superimposed

D

Nosocomial

Question 68

Which of the following is not a benefit of EMR ?

A

Little or no training necessary

B

Enhanced access to clinical information

C

Improved patient safety

D

Decreased medical errors

Question 69

Which of the following terms refers to the ability to breathe comfortably only when in an upright position ?

A

Dyspnea

B

Apnea

C

Hypercapnia

D

Orthopnea

Question 70

Which of the following is the master gland of the endocrine system ?

A

Pancreas

B

Pineal

C

Pituitary

D

Thyroid

Question 71

Blood flows from the right ventricle of the heart into which of the following structures ?

A

Inferior vena cava

B

Left ventricle

C

Pulmonary arteries

D

Pulmonary veins

Question 72

The anatomic location of the spinal canal is

A

Caudal

B

Dorsal

C

Frontal

D

Transverse

Question 73

The term, “iatrogenic” refers to :

A

Occurring during patient"s hospitalization

B

Occurring because of the patient"s medical treatment

C

Present on admission

D

Contagious

Question 74

Which rate is based on the presence of a pre-existing condition at the time of admission ?

A

Comorbidity rate

B

Nosocomial infection rate

C

Admission rate

D

Complication rate

Question 75

Medico legal autopsy required the permission of

A

Magistrate

B

Relatives

C

Police

D

Medical Superintendent

Question 76

Information required for an informed consent generally does not include :

A

diagnosis (and/or any other possible diagnosis).

B

alternative options for treatment.

C

significant risks and benefits of a recommended treatment plan.

D

anticipated charges for treatment.

Question 77

The year in which Supreme Court of India legalized passive euthanasia is

A

9th March, 2015

B

8th April, 2018

C

9th March, 2018

D

8th April, 2015

Question 78

Before release of patients medical records the following conditions must be met, except :

A

Request must be in writing.

B

Patient permission must be sought.

C

There must be reason for the request.

D

Duration of use of the records must be stated.

Question 79

The disadvantage of chronological documentation is

A

subjective data may be missing.

B

objective data may be missing.

C

vital signs are not done.

D

medical problems may go undiscovered.

Question 80

Who can make a correction in the medical record ?

A

The Physician

B

Anybody from the medical office

C

The author of the incorrect information

D

Head of the Department

Question 81

Which of the following is the medical term for hair loss ?

A

Folliculitis

B

Eczema

C

Pediculosis

D

Alopecia

Question 82

Which of the following allows gas exchange in the lungs ?

A

Alveoli

B

Bronchioles

C

Capillaries

D

Pleurae

Question 83

Calcium, potassium and sodium are classified as which of the following ?

A

Androgens

B

Catecholamines

C

Electrolytes

D

Estrogens

Question 84

Diagnosis coding under ICD 10-CM uses how many digits ?

A

4-8

B

3-6

C

2-6

D

3-7

Question 85

The abbreviation “PRN” means :

A

as required

B

immediately

C

three times a day

D

four times a day

Question 86

This lab test measures the level of oxygen and carbon dioxide in the blood to determine how well your lungs are working ?

A

HDL

B

ABG

C

Hgb

D

BUN

Question 87

Which of the following represents the most common cancer staging system used to indicate the tumor size and whether it has spread to lymph nodes or other sites in the body ?

A

FIGO staging

B

TNM staging

C

Gleason Score

D

Dukes Classification

Question 88

What does the medical abbreviation “a.c.” mean ?

A

After Completion

B

Before Meals

C

After Meals

D

Before Bed

Question 89

Which is not a best practice for the document imaging process ?

A

Duplicate documents received for scanning should not be rescanned.

B

Placing patient"s medical record number on each page of the document prior to scanning.

C

Use of highlighters is recommended to enhance and portion of the document that is difficult to read.

D

Production and quality should be measured

Question 90

In which type of record format would SOAP notes most likely be found ?

A

MAR

B

Integrated

C

Source Oriented

D

POMR

Question 91

Which of the following procedures would be the best process to follow when a charting error has been discovered in the EMR ?

A

Make the correction as an addendum.

B

Make a backdated note

C

All incorrect information must be deleted from the record when discovered.

D

None of these

Question 92

In cases where patient care is questioned, the patient medical record will provide legal protection to which of the following parties ?

A

Organizations

B

Patients

C

Physicians

D

All of the above

Question 93

A document keyed by a medical transcriptionist is introduced into a patient"s clinical record. Which of the following statements regarding this information is correct ?

A

The user will see a “modified” notation associated with the notes

B

Only the medical transcriptionist should apply the signature to their transcribed entry.

C

Make the note as an addendum.

D

The practitioner who dictated the information must authenticate the transcribed entry.

Question 94

A patient statement “feels queasy, especially when standing up quickly.” This is an example of which SOAP format component ?

A

S

B

O

C

A

D

P

Question 95

The disease or condition that was present on admission, was the principal reason for admission and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care is known as

A

Prognosis

B

Principle diagnosis

C

Chief Complaint

D

Complication

Question 96

The process that provides a means of addressing requests for additional information from physicians as part of the coding and reimbursement process is called

A

Quantitative Analysis

B

Physician query process

C

Delinquency

D

Ongoing record review process

Question 97

________ is a procedure used by Joint Commission surveyors in the accreditation process for assessment of operational systems and processes in relation to the actual experiences of selected patients who are currently under the organization"s care. This allows the surveyor to identify performance issues.

A

Tracer Methodology

B

Structured Interview

C

Unstructured Interview

D

Unannounced Survey

Question 98

An unexpected occurrence involving death or serious physical or psychological injury or risk thereof in a hospital setting is called

A

unusual event

B

sentinel event

C

unexpected event

D

serious event

Question 99

Inappropriate timing of dose, transcription errors, missed doses and extra doses are all examples of this type of medication error

A

pharmacy

B

discharge

C

prescribing

D

administration

Question 100

Which of the following is an accessory organ of the gastrointestinal system that is responsible for secreting insulin ?

A

Gallbladder

B

Liver

C

Pancreas

D

Spleen

002/2021 - Medical Records Librarian Gr II in Health Services