RHIA Domain 1 Practice Questions Flashcards
Learn Domain 1 Data and Information Governance
As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the
Postpartum record
labor & delivery record
discharge summary
prenatal record
prenatal record
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the
Office for Civil Rights
FBI
Office of Inspector General
Dept. of Recovery Audit Coordinators
Department of Recovery Audit Coordinators (RAC)
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
Transfer record
Problem list
Discharge summary
Interdisciplinary patient care plan
Problem List
In creating a new form or computer view, the designer should be most driven by
- needs of the user
- medical staff bylaws
- flow of the data on the page or screen (wrong)
- QIO standards
needs of the user
In determining your acute care facility’s degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the
- hospital bylaws
- Joint Commission accreditation manual
- Federal Register
- CARF manual
Federal Register
The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient’s record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing
a. clinical pertinence review
b. point-of-care documentation
c. quantitative record review
d. concurrent record analysis
point-of-care documentation
The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate
- quality of care through the use of preestablished criteria
- the overall quality of documentation in the record
- potentially compensable events
- adverse effects and contraindications of drugs utilized during hospitalization
the overall quality of documentation in the record
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
- risk manager
- chief of staff
- attending physician
- HIM director
attending physician
You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that by 2015, sanctions for noncompliance began to appear in the form of
- monetary fines up to $100,000
- a mandatory action plan for implementing a meaningful use EHR
- the withdrawal of permission to treat Medicare and Medicaid patients
- downward adjustments to Medicare reimbursement
downward adjustments to Medicare reimbursement
Sally is the HIM director at Memorial Hospital and has been asked to compose a record retention policy for the hospital. What should be her first consideration in determining how long paper and electronic records must be retained?
a. The amount of space allocated for record filing and server set up
b. The number of paper records currently filed and the number of electronic files added on a daily basis
c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
d. The cost of filing space and equipment
c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain.
The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
a. Abdominal pain
b. Cholelithiasis
c. Exploratory laparoscopy
d. Ruptured appendix
a. Abdominal pain
Mrs. Smith’s admitting data indicates that her birth date is March 21, 1948. On the discharge
summary, Mrs. Smith’s birth date is recorded as July 21, 1948. Which data quality element is
missing from Mrs. Smith’s health record?
a. Data accuracy
b. Data consistency
c. Data accessibility
d. Data comprehensiveness
b. Data consistency
The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours.
a. 30 days, 48 hours, 24 hours
b. 14 days, 24 hours, 48 hours
c. 14 days, 48 hours, 24 hours
d. 30 days, 24 hours, 48 hours
d. 30 days, 24 hours, 48 hours
A method of documenting nurses’ progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:
a. Problem-oriented progress notes
b. Charting by exception
c. Consultative notations
d. Open charting
b. Charting by exception
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):
a. Resident Assessment Protocols (RAPs)
b. Resident Assessment Instrument (RAI)
c. Utilization Guidelines (UG)
d. Minimum Data Sets (MDS)
a. Resident Assessment Protocols (RAPs)
Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:
a. Closed review
b. Qualitative review
c. Concurrent review
d. Delinquent review
c. Concurrent review
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
a. Administrative information
b. Demographic information
c. Progress notes
d. Uniform data sets
d. Uniform data sets
Which of the following materials are required elements in an emergency care record?
a. Patient’s instructions at discharge and a complete medical history
b. Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
c. Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
d. Treatment rendered, instructions at discharge, and the patient’s complete medical history
b. Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n):
a. Indicator
b. Measurement
c. Assessment
d. Outcome
a. Indicator
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?
a. Master data
b. Metadata
c. Structured data
d. Unstructured data
b. Metadata
Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident’s care?
a. Case management
b. Minimum Data Set
c. Outcomes and assessment information set
d. Core measure abstracting
b. Minimum Data Set
Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value
report she received during her last physical exam. Dr. Ward responded to Jane’s email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled?
a. Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient’s medical record.
b. Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
c. Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.
d. Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.
b. Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?
a. Integrated
b. Practice-oriented
c. Chronological
d. Source-oriented
d. Source-oriented
A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility’s internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area?
a. Comparative performance data
b. Internal infection reporting
c. Master patient index
d. Provider performance data
a. Comparative performance data
According to Joint Commission Accreditation Standards, which document must be placed in the patient’s record before a surgical procedure may be performed?
a. Admission record
b. Physician’s order
c. Report of history and physical examination
d. Discharge summary
c. Report of history and physical examination
The following data have been collected by the hospital quality committee. What conclusions can be made from the data on the hospital’s quality of care between the first and second quarters?
**Measure 1st Qtr, 2nd Qtr **
Medication errors 3.20%, 10.40%
Patient falls 4.20%, 8.60%
HAC infections 1.80%, 4.90%
Transfusion reactions 1.40%, 2.50%
a. Quality of care improved between the first and second quarters.
b. Quality of care is about the same between the first and second quarters.
c. Quality of care declined between the first and second quarters.
d. Quality of care should not be judged by these types of measures.
c. Quality of care declined between the first and second quarters.
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and
correcting the duplicates in the patient information system, the MPI manager needs to notify
which department to correct the source system data?
a. Laboratory
b. Radiology
c. Quality management
d. Registration
a. Laboratory
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:
a. Case-mix index
b. Master patient index
c. Health record matrix
d. Retention schedule
c. Health record matrix
Documentation including the date of action, method of action, description of the disposed
record series of numbers or items, service dates, a statement that the records were eliminated in
the normal course of business, and the signatures of the individuals supervising and witnessing
the process must be included in this:
a. Authorization
b. Certificate of destruction
c. Informed consent
d. Continuity of care record
b. Certificate of destruction
Decision-making and authority over data-related matters is known as:
a. Data management
b. Data administration
c. Data governance
d. Data modeling
c. Data governance
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates
a. compliance with Joint Commission standards
b. compliance with Joint Commission standards for nonsurgical patients
c. noncompliance with Joint Commission standards
d. compliance with Medicare regulations
c. noncompliance with Joint Commission standards
As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?
a. ORYX
b. DEEDS
c. UHDDS
d. MDS
b. DEEDS
Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and:
a. AMA
b. OIG
c. CMS
d. WHO
c. CMS
Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to
a. decrease medication errors through CPOE systems
b. increase patient engagement through patient portals
c. report sentinel events to the Joint Commission
d. reduce clinical denials for medical necessity
d. reduce clinical denials for medical necessity
In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission’s national patient safety goals, the focus has shifted to the
a. use of prohibited or “dangerous” abbreviations
b. use of abbreviations in the final diagnosis
c. prohibited use of any abbreviations
d. flagrant use of specialty-specific abbreviations
a. use of prohibited or “dangerous” abbreviations
The first patient with cancer seen in your facility on January 1, 2017, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is
a. 17-0001/01
b. 17-0000/01
c. 17-0000/00
d. 17-0001/00
d. 17-0001/00
The patient has a biopsy of the colon followed by a hemicolectomy. In the ICD-10-PCS coding system, which procedure(s) are coded?
a. the hemicolectomy only
b. the biopsy only
c. both the biopsy and the hemicolectomy
d. it depends on the results of the biopsy
c. both the biopsy and the hemicolectomy
What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options?
a. core measures
b. enhanced discharge planning
c. data mining
d. clinical practice guidelines
d. clinical practice guidelines
What is the first step a healthcare entity should take when developing a data dictionary?
a. develop an approvals process
b. integrate common data elements
c. design a plan
d. ensure consistency
d. ensure consistency
When a healthcare entity destroys health records after the acceptable retention period has been met, a certificate of destruction is created. How long must the healthcare entity maintain the certificate of destruction?
a. two years
b. five years
c. ten years
d. permanently
d. permanently
Which health record format is arranged in chronological order with documentation from various sources intermingled?
a. electronic
b. source-oriented
c. problem-oriented
d. integrated
d. integrated
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS
C. ERD An entity relationship diagram (ERD) is used to describe how the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool
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
d. patients to hospital beds
You recommend that the staff at your home health agency routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every
a. week
b. 90 days
c. month
d. 60 days
d. 60 days
