RHIA Domain 1 Practice Questions

Question 1

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

Answer 1

prenatal record

Question 2

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

Answer 2

Department of Recovery Audit Coordinators (RAC)

Question 3

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

Answer 3

Problem List

Question 4

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

Answer 4

needs of the user

Question 5

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

Answer 5

Federal Register

Question 6

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

Answer 6

point-of-care documentation

Question 7

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

Answer 7

the overall quality of documentation in the record

Question 8

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

Answer 8

attending physician

Question 9

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

Answer 9

downward adjustments to Medicare reimbursement

Question 10

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

Answer 10

c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards

Question 11

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

Answer 11

a. Abdominal pain

Question 12

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

Answer 12

b. Data consistency

Question 13

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

Answer 13

d. 30 days, 24 hours, 48 hours

Question 14

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

Answer 14

b. Charting by exception

Question 15

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)

Answer 15

a. Resident Assessment Protocols (RAPs)

Question 16

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

Answer 16

c. Concurrent review

Question 17

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

Answer 17

d. Uniform data sets

Question 18

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

Answer 18

b. Time and means of the patient’s arrival, treatment rendered, and instructions at discharge

Question 19

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

Answer 19

a. Indicator

Question 20

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

Answer 20

b. Metadata

Question 21

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

Answer 21

b. Minimum Data Set

Question 22

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.

Answer 22

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.

Question 23

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

Answer 23

d. Source-oriented

Question 24

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

Answer 24

a. Comparative performance data

Question 25

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

Answer 25

c. Report of history and physical examination

Question 26

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.

Answer 26

c. Quality of care declined between the first and second quarters.

Question 27

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

Answer 27

a. Laboratory

Question 28

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

Answer 28

c. Health record matrix

Question 29

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

Answer 29

b. Certificate of destruction

Question 30

Decision-making and authority over data-related matters is known as:

a. Data management

b. Data administration

c. Data governance

d. Data modeling

Answer 30

c. Data governance

Question 31

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

Answer 31

c. noncompliance with Joint Commission standards

Question 32

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

Answer 32

b. DEEDS

Question 33

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

Answer 33

c. CMS

Question 34

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

Answer 34

d. reduce clinical denials for medical necessity

Question 35

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

Answer 35

a. use of prohibited or “dangerous” abbreviations

Question 36

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

Answer 36

d. 17-0001/00

Question 37

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

Answer 37

c. both the biopsy and the hemicolectomy

Question 38

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

Answer 38

d. clinical practice guidelines

Question 39

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

Answer 39

d. ensure consistency

Question 40

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

Answer 40

d. permanently

Question 41

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

Answer 41

d. integrated

Question 42

Which of the following is a graphical display of the relationships between tables in a database?

a. RDMS
b. SQL
c. ERD
d. SAS

Answer 42

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

Question 43

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

Answer 43

d. patients to hospital beds

Question 44

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

Answer 44

d. 60 days