RHIA D1: Questions Flashcards
The HIM manager tasked the coding manager to development a dashboard that shows the discharges pending final billing so that she can plan for staffing. Because this data changes throughout the day, what analysis technique is needed?
a. Predictive modelling
b. Indirect standardization
c. Real-time analytics
d. Data mining
A physician on your staff asked you to help her collect information about the effects of smoking during pregnancy on the birth weight of babies. You were asked to collect the following information: whether or not the mothers smoke during pregnancy; birth weight of the babies; Apgar scores at one minute; and Apgar scores at five minutes. The scales of these variables would be:
a. Nominal, ordinal, interval, ratio
b. Nominal, ratio, ordinal, ordinal
c. Ordinal, nominal, ratio, interval
d. Ratio, ordinal, interval, nominal
The following descriptors about the data element DISCHARGE_DATE are included in a data dictionary: definition: date patient was discharged from the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if:
a. The template was defined
b. The data type was numeric
c. The field was not required
d. The field length was longer
The HIM director at Community Hospital has noticed that history and physicals and operative reports are not being transcribed and returned by the transcription service within the negotiated timeframes. What should be her primary concern related to this issue?
a. That the transcription service company will overcharge the hospital for reports that are delayed
b. That physicians will stop dictating reports and just include comments in the progress notes
c. That the Joint Commission will find that history and physicals are not being uploaded to the EHR system within the required 24-hour timeframe
d. That information is not being made available in the patient portal within the required timeframe
Which statistics should a health data analyst recommend to a manager who would like to measure the relationship between length of stay and time to code a health record?
a. Slope of the linear regression time
b. T-test
c. Correlation
d. Intercept of the linear regression line
Danny, an HIM analyst for Memorial Hospital, is conducting a qualitative analysis of a discharged patient’s chart. His goal in this process is:
a. Determining if the documentation includes all requirements set by CMS, the state, and accrediting bodies
b. Identifying whether all lab orders have corresponding lab reports in the chart
c. Verifying that health professionals are providing appropriate care
d. Ensuring the hospital bill is correct
Gladys was admitted to Sunshine Nursing Facility for rehabilitation following her hip fracture. Upon admission, the nursing staff assessed Gladys in multiple areas, some of which are cognitive loss, mood, vision function, pain, and the medications she is taking. This information will be recorded in her health record for the:
a. Minimum data set to plan her care
b. Pay-for-performance initiatives to manage payment
c. Requirements of the CDC
d. Identification of patients for NPSGs
In order to set the budget for next year, the hospital administrator tasked a business analyst with determining the average charges and average length of stay for Medicaid patients. The business analyst uses hospital claims data for this analysis and provides the results to the administrator. What type of data are the claims data in this case?
a. Clinical data
b. Statistical data
c. Secondary data
d. Primary data
The Western Hospital Corporation’s HIM director wants to compare the time that each of the hospitals in the corporation are spending on chart analysis and determine how they are performing against the best practice standard. The HIM director generated the following data for comparison. What is this comparison process called?
Western Hospital Corporation
HIM Corporate Dashboard
April, 20xx
Analysis Days
Delinquency Rate
IP
SDS
ED
Community Region Facilities
Hospital A
- 0
- 0
- 0
5%
Hospital B
- 0
- 0
- 0
0%
Hospital C
- 0
- 0
- 0
8%
Urban Region Facilities
Hospital D
- 0
- 0
- 0
12%
Hospital E
- 0
- 0
- 0
23%
Hospital F
3.0
- 0
- 0
8%
Corporate Average
2.33
- 00
- 33
9%
Best Practice Standard
2.0
2.0
1.0
<15%
a. Process comparison
b. Outcome comparison
c. Comparing
d. Benchmarking
At Memorial Hospital, HIM professionals are located in the nursing stations, where they are responsible for all aspects of health record processing. While the patient is in the facility, the HIM professional does a daily concurrent review of the record. How does this assist the organization?
a. By helping to remind providers to complete documentation requirements and sign orders, which is easier to do while the patient is still at the facility
b. By indicating to physicians what documentation must be completed once the patient goes home
c. By giving the billing department a list of all the charges to date for the patient
d. By allowing the documentation to be uploaded to the patient portal for the patient to use after discharge
A staff member is assigned to sit in the waiting room of the physician’s office to collect data on patient waiting times. The staff member records the time at which the patient comes in the door and when the patient is called to the examining room. This is an example of what type of data collection?
a. Direct observation
b. Interview
c. Survey
d. Work imaging
Lisa, an HIM analyst for Healthwise Hospital, is conducting a quantitative analysis of a discharged patient’s chart. Her goal in this process is:
a. To ensure that the record is legible
b. To identify deficiencies in the chart early so they can be corrected
c. To verify that health professionals are providing appropriate care
d. To ensure that the hospital bill is correct
Which of the following is not associated with a typical data dictionary?
a. Table names
b. An entity-relationship diagram
c. A description of each attribute
d. Whether the attribute is required
David was admitted to the hospital following an automobile accident in which he suffered a fractured femur. Two days after surgery to repair the fracture, he developed pneumonia and was transferred to the ICU. Because the pneumonia was not present at the time of admission to the hospital, it is considered a:
a. Healthcare-associated infection
b. Hospital sickness
c. Community-acquired infection
d. Community sickness
What type of report would give administrators structured information in a variety of graphs to better plan facility operations?
a. Enterprise master patient index
b. Integrated delivery system
c. Registration—admissions, discharge, transfer system
d. Executive information system dashboard
Which of the following would not be an appropriate duty for an HIM professional?
a. Documenting additions or deletions in a patient’s record
b. Monitoring documentation guidelines as set forth in legislation or regulatory standards
c. Training care providers in documentation techniques
d. Auditing patient records to determine the quality of the documentation
When an entity relational diagram is implemented as a relational database, an entity will become a(n):
a. Query
b. Form
c. Object
d. Table
A health data analyst has been asked to compile a report on the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?
a. Physician progress notes and medication record
b. Nursing and physician progress notes
c. Medication administration record and clinical laboratory reports
d. Physician orders and clinical laboratory reports
City Hospital’s revenue cycle management team has established the following benchmarks: (1) The value of discharged, not final billed (DNFB) cases should not exceed two days of average daily revenue; and (2) accounts receivable days are not to exceed 60 days. The net average daily revenue is $1,000,000. What do the following data indicate about how City Hospital is meeting its benchmarks?
a. DNFB cases met the benchmark 100 percent of the time.
b. DNFB cases met the benchmark 75 percent of the time.
c. DNFB cases met the benchmark 50 percent of the time.
d. DNFB cases met the benchmark 25 percent of the time.
An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis?
a. The average wait time is shorter on weekends.
b. The average wait time is longer on weekends.
c. The average wait time is different on weekends and weekdays.
d. The average wait time is the same on weekends and weekdays.
The data that describe other data in order to facilitate data quality are found in the:
a. Data definition language
b. Data dictionary
c. Data standards
d. Data definition
Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient’s EHR. These different information systems that feed information into the EHR are known as:
a. Interoperability
b. Source systems
c. Continuity of care records
d. Clinical decision support systems
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
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the:
a. Reason for admission
b. Activities of daily living
c. Discharge diagnosis
d. Reason for encounter
The inpatient data set incorporated into federal law and 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
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
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
Which of the following personnel should be authorized, per hospital policy, to take a physician’s verbal order for the administration of medication?
a. Unit secretary working on the unit where the patient is located
b. Nurse working on the unit where the patient is located
c. Health information director
d. Admissions registrars
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:
a. Auto-authentication fields
b. Metadata
c. Data
d. Information fields
. Which statement is true about the following figure?
a. There is no correlation between the variables.
b. There is a negative relationship between the variables.
c. There is a weak negative correlation between the variables.
d. There is a positive relationship between the variables.
Which of the following represents dataflow for a hospital inpatient admission?
a. Registration > diagnostic and procedure codes assigned > services performed > charges recorded
b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned
c. Services performed > charges recorded > registration > diagnostic and procedure codes assigned
d. Diagnostic and procedure codes assigned > registration > services performed > charges recorded
Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals?
a. Ensuring the record is legible
b. Identifying deficiencies early so they can be corrected
c. Verifying that health professionals are providing appropriate care
d. Checking to ensure bills are correct
To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following?
a. Core measure
b. Resident Assessment Instrument
c. Precertification
d. Record of transfer
Data content standards are used to:
a. Share data in the same way the users interpret data
b. Share data is a unique way
c. Share data between disparate systems
d. Modify data
How do healthcare providers use the administrative data they collect?
a. For regulatory, operational, and financial purposes
b. For statistical data purposes
c. For electronic health record tracking purposes
d. For continuity of patient care purposes
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
To ensure authentication of data entries, which type of signature is the most secure?
a. Digital
b. Electronic
c. Handwritten
d. Virtual
Mrs. Bolton is an angry patient who resents her physician “bossing her around.” She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton’s behavior in the patient health record is:
a. Mean
b. Noncompliant and hostile toward staff
c. Belligerent and out of line
d. A pain in the neck
Who is responsible for ensuring the quality of health record documentation?
a. Board of directors
b. Administrator
c. Provider
d. Health information management professional
Which of the following is an example of a 1:1 relationship?
a. Patients to hospital admissions
b. Patients to consulting physicians
c. Patients to clinics
d. Patients to hospital beds
According to the UHDDS definition, ethnicity should be recorded on a patient record as:
a. Race of mother
b. Race of father
c. Hispanic, non-Hispanic
d. Free-text descriptor as reported by patient
Which of the following is a component of the resident assessment instrument?
a. The resident’s health record
b. A standard Minimum Data Set (MDS)
c. Preadmission Screening Assessment
d. Annual Resident Review
The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following?
a. Authorship
b. Validation
c. Integrity
d. Identification
Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay?
a. Uniform Hospital Discharge Data Set
b. Data Elements for Emergency Department Systems
c. Uniform Ambulatory Care Data Set
d. Essential Medical Data Set
Identify the level in the data model that describes how the data is stored within the database:
a. Conceptual data model
b. Physical data model
c. Logical data model
d. Data manipulation language
The purpose of the data dictionary is to ________ definitions and ensure consistency of use.
a. Identify
b. Standardize
c. Create
d. Organize
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS
It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records.
a. Training sessions
b. Policies and procedures
c. Verbally communicated instructions
d. A supervisory committee
A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of?
a. Data collection
b. Edit check
c. Data reliability
d. Hot spot
An alteration of the health information by modification, correction, addition, or deletion is known as a(n):
a. Change
b. Amendment
c. Copy and paste
d. Deletion
A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a:
a. Spreadsheet
b. Database
c. File
d. Data table
The process of providing proof of the authorship of health record documentation is called:
a. Identification
b. Standardization of data capture
c. Standardization of abbreviations
d. Authentication
Which of the following plans address how information can be documented in the health record during down time or a catastrophic event?
a. Disaster
b. E-discovery response
c. Business continuity
d. Emergency documentation
The distribution in this curve is:
a. Normal
b. Bimodal
c. Skewed left
d. Skewed right
What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or is otherwise dying and unable to speak for themselves?
a. Durable power of attorney
b. Living consent form
c. Informed consent
d. Advance directive
Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called:
a. Default records
b. Delinquent records
c. Loose records
d. Suspended records
A patient born with a neural tube defect would be included in which type of registry?
a. Birth defects
b. Cancer
c. Diabetes
d. Trauma
Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of:
a. Patient identification and demographic accuracy
b. Authorship integrity
c. Documentation integrity
d. Auditing integrity
Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called:
a. Electronic medical records
b. Electronic health records
c. Hybrid health records
d. Computerized health records
Which of the following terms is used for the process of scanning past health records into the information system so there is an existing database of patient information, making the information system valuable to the user from the first day of implementation?
a. CPOE
b. OCR
c. Backscanning
d. Barcoding
A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n):
a. Diabetes registry
b. Cancer registry
c. Immunization registry
d. Trauma registry
The statement “All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88” represents a possible case definition for what type of registry?
a. Birth defect registry
b. Cancer registry
c. Diabetes registry
d. Trauma registry
A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables?
a. One-to-one
b. One-to-many
c. Many-to-many
d. One-to-two
Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered:
a. Secondary data source
b. Aggregate data source
c. Primary data source
d. Reliable data source
The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity’s mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called:
a. Information asset management
b. Information management
c. Information governance
d. Enterprise information management
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use?
a. UHDDS
b. UACDS
c. MDS
d. ORYX
Ensuring that only the most recent report is available for viewing is known as:
a. Documentation integrity
b. Authorship
c. Validation
d. Version control
In long-term care, the resident’s comprehensive assessment is based on data collected in the:
a. UHDDS
b. OASIS
c. MDS
d. HEDIS
Which of the following are considered dimensions of data quality?
a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency
b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency
c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency
d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency
What is a primary purpose for documenting and maintaining health records?
a. Effective communication among caregivers for continuity of care
b. Substantiate claims for reimbursement
c. Provide evidence for malpractice lawsuits
d. Contribute to medical science
A method that has been developed for presenting a variety of data on a single display in an easy-to-read format is called a:
a. Graph
b. Dashboard
c. Table
d. Data visualization
The practices or methods that defend against charges questioning the integrity of the data and documents are called:
a. Authentication
b. Security
c. Accuracy
d. Nonrepudiation
Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons?
a. Physician
b. Master patient
c. Procedure
d. Disease and operation
Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?
a. Case definition
b. Case finding
c. Follow-up
d. Reporting
The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure.
a. Object-oriented database
b. Relational database
c. Access database
d. Structured database
A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n):
a. Accreditation manual
b. Core content
c. Continuity of care record
d. Data dictionary
Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to:
a. Have the administrator of the hospital complete them
b. Have the charge nurse on the respective nursing units complete them
c. Ask the chief of staff to complete them
d. File the incomplete records with a notation about the physician’s death
The first deliverable from a legal health record (LHR) definition project is a:
a. List of LHR stakeholders
b. Document matrix of LHR components
c. Letter of support from management
d. Master source system matrix
When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n):
a. Secondary data source
b. Reliable data source
c. Primary data source
d. Unreliable data source
The name of the government agency that has led the development of basic data sets for health records and computer databases is:
a. The Centers for Medicare and Medicaid Services
b. The National Committee on Vital and Health Statistics
c. The American National Standards Institute
d. The National Institute of Health
What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met?
a. Qualitative analysis
b. Legal record review
c. Utilization analysis
d. Ongoing record review
Which of the following is a concept designed to help standardize clinical content for sharing between providers?
a. Continuity of care record
b. Interoperability
c. Personal health record
d. SNOMED
A regular review of legal health record policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called a legal health record:
a. Maintenance plan
b. Management plan
c. Attribute plan
d. Strategic plan
Reviewing a health record for authentication and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing
Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record?
a. Document name, media type, source system, electronic storage start date, stop printing start date
b. Document name, media type
c. Document name, medical record number, source system
d. Document name, source system
This functionality can result in confusion from incessant repetition of irrelevant clinical data.
a. Change
b. Amendment
c. Copy and paste
d. Deletion
