RHIA Practice Exam Deck Flashcards
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?
The amount of space allocated for record filing and server set up
The number of paper records currently filed and the number of electronic files added on a daily basis
The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
The cost of filing space and equipment
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:
Abdominal pain
Cholelithiasis
Exploratory laparoscopy
Ruptured appendix
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?
Data accuracy
Data consistency
Data accessibility
Data comprehensiveness
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.
30 days, 48 hours, 24 hours
14 days, 24 hours, 48 hours
14 days, 48 hours, 24 hours
30 days, 24 hours, 48 hours
30 days, 24 hours, 48 hours
Which of the following is an acceptable means of authenticating a record entry?
The physician’s assistant electronically signs for the physician.
The HIM clerk electronically signs using the physician’s login.
The charge nurse electronically signs for the physician.
The physician personally signs the entry electronically.
The physician personally signs the entry electronically.
A method of documenting nurses’ progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:
Problem-oriented progress notes
Charting by exception
Consultative notations
Open charting
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):
Resident Assessment Protocols (RAPs)
Resident Assessment Instrument (RAI)
Utilization Guidelines (UG)
Minimum Data Sets (MDS)
Resident Assessment Protocols (RAPs)
HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) ten that information is not shared with other departments within the healthcare entity. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Administration
Registration or patient access
Risk management
Radiology and laboratory
Registration or patient access
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:
Closed review
Qualitative review
Concurrent review
Delinquent review
Concurrent review
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
Administrative information
Demographic information
Progress notes
Uniform data sets
Uniform data sets
The data elements in a patient’s automated laboratory result are examples of:
Unstructured data
Free-text data
Financial data
Structured data
Structured data
Which of the following materials are required elements in an emergency care record?
Patient’s instructions at discharge and a complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
Treatment rendered, instructions at discharge, and the patient’s complete medical history
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):
Indicator
Measurement
Assessment
Outcome
Indicator
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?
Master data
Metadata
Structured data
Unstructured data
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?
Case management
Minimum Data Set
Outcomes and assessment information set
Core measure abstracting
Minimum Data Set
Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John’s hospital bill. Upon discharge from the hospital, who owns John’s health record?
John
Blue Cross
University Hospital
Dr. Collins
University Hospital
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?
Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient’s medical record.
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.
Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.
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.
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?
Integrated
Practice-oriented
Chronological
Source-oriented
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?
Comparative performance data
Internal infection reporting
Master patient index
Provider performance data
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?
Admission record
Physician’s order
Report of history and physical examination
Discharge summary
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 Quarter
2nd Quarter
Medication errors
3.2%
10.4%
Patient falls
4.2%
8.6%
Hospital-acquired infections
1.8%
4.9%
Transfusion reactions
1.4%
2.5%
Quality of care improved between the first and second quarters.
Quality of care is about the same between the first and second quarters.
Quality of care declined between the first and second quarters.
Quality of care should not be judged by these types of measures.
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?
Laboratory
Radiology
Quality management
Registration
Laboratory
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:
Identification and demographic integrity
Authorship integrity
Statistical integrity
Auditing integrity
Authorship integrity
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:
Case-mix index
Master patient index
Health record matrix
Retention schedule
Health record matrix
Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:
Standardized data
Codified data
Aggregate data
Unstructured clinical information
Unstructured clinical information
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:
Authorization
Certificate of destruction
Informed consent
Continuity of care record
Certificate of destruction
Decision-making and authority over data-related matters is known as:
Data management
Data administration
Data governance
Data modeling
Data governance
A professional basketball player from the local team was admitted to your facility for a procedure. During this patient’s hospital stay, access logs may need to be checked daily in order to determine:
Whether access by employees is appropriate
If the patient is satisfied with their stay
If it is necessary to order prescriptions for the patient
Whether the care to the patient meets quality standards
Whether access by employees is appropriate
A patient has the right to request a(n) ________, which describes where the covered entity has disclosed patient information for the past six years outside of treatment, payment, and healthcare operations.
Disclosure list
Designated record set
Amendment of medical record
Accounting of disclosures
Accounting of disclosures
Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information?
It can exist in separate and multiple paper-based or electronic systems.
The record is incomplete.
Numerous physicians have not given consent to release the record.
Risk management will not allow the legal health record to be released.
It can exist in separate and multiple paper-based or electronic systems.
Dr. Hansen saw a patient with measles in his office. He directed his office staff to call the local department of health to report this case of measles. The office manager called right away and completed the report as instructed. Which of the following provides the correct analysis of the actions taken by Dr. Hansen’s office?
Dr. Hansen’s office followed protocol and reported this case of measles correctly.
Dr. Hansen’s office did not need to report this case to the local health department.
Dr. Hansen’s office should have mailed a letter to the local health department to report this case.
Dr. Hansen’s office should have reported the case to the local hospital and not to the health department.
Dr. Hansen’s office followed protocol and reported this case of measles correctly.
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?
There is no impact.
The person making the entry in the health record may not be called as a witness in trial.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The incident report cannot be discovered even though it is mentioned in a discoverable document.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient’s records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?
Yes, HIPAA only requires that current records be produced for the patient.
Yes, this is hospital policy over which HIPAA has no control.
No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
No, the records from the previous hospital are not included in the designated record set but should be released anyway.
No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
John is the privacy officer at General Hospital and conducts audit log checks as part of his job duties. What does an audit log check for?
Loss of data
Presence of a virus
Successful completion of a backup
Unauthorized access to a system
Unauthorized access to a system
An outpatient laboratory routinely mails the results of health screening exams to its patients. The lab has received numerous complaints from patients who have received another patient’s health information. Even though multiple complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. How should the Privacy Officer for this healthcare entity respond to this situation?
Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule
Fire the responsible employees
Do nothing, as these types of errors occur in every healthcare entity
Retrain the entire hospital entity because these types of errors could result in a huge fine from the Office of Inspector General
Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule
Anywhere Hospital’s coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA Security Rule. What type of network uses a private tunnel through the Internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely?
Intranet
Local area network
Virtual private network
Wide area network
Virtual private network
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
Context-based
Role-based
Situation-based
User-based
Role-based
The Security Rule leaves the methods for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be:
Its own characteristics and environment
The potential threats and vulnerabilities
The level of risk
An assessment of current security measures
Its own characteristics and environment
Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room.
Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule.
Sally owns the information in her record, so she must be granted her request.
Sally’s request does not have to be granted because the hospital is responsible for the integrity of the medical record.
Patients should never be given access to their actual medical records.
Sally’s request does not have to be granted because the hospital is responsible for the integrity of the medical record.
Who has the legal right to refuse treatment?
1.
Juanita who is 98 years old and of sound mind.
2.
Christopher who is 10 years old and of sound mind.
3.
Jane who is 35, incompetent, and did not express her treatment wishes prior to becoming incompetent.
4.
Linda who is 35, incompetent, and created a living will prior to becoming incompetent stating that she did not wish to be kept alive by artificial means.
5.
William who is a 35-year-old born with an intellectual disability and has the mental capacity of a 12-year-old.
1 and 2
1 and 3
1 and 4
4 and 5
1 and 4
Linda Wallace is being admitted to the hospital. She is presented with a Notice of Privacy Practices. In the Notice, it is explained that her PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes. Of the options listed here, what is the best course of action?
The hospital must honor her wishes and not use her PHI for TPO.
The hospital may decline to treat Linda because of her refusal.
The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only.
The hospital is not required to honor her wishes for treatment purposes but must honor them for payment and operations purposes.
The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only.
Jack Mitchell, a patient in Ross Hospital, is being treated for heart failure. He has not opted out of the facility directory. Callers who request information about him may be given:
No information due to the highly sensitive nature of his illness
Admission date and location in the facility
General condition and acknowledgment of admission
Location in the facility and diagnosis
General condition and acknowledgment of admission
A data breach occurred in your organization, and after the investigation it was determined that a total of 785 individuals were impacted by the data breach. What must be completed within 60 days of learning about the data breach?
Update the notice of privacy practices and send to all patients
Report the incident to the individuals impacted, local media, and the Department of Health and Human Services
Conduct privacy training for members of the organization
Document a note mentioning the data breach in each of the patients’ charts and tell the local media
Report the incident to the individuals impacted, local media, and the Department of Health and Human Services
The “custodian of health records” refers to the individual within a healthcare entity who is responsible for which of the following actions?
Determining alternative treatment for the patient
Preparing physicians to testify
Testifying to the authenticity of records
Testifying regarding the care of the patient
Testifying to the authenticity of records
Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient’s physician. Of the options listed here, what is the best course of action?
Allow Dr. Smith to see the records because he was the daughter’s guardian at the time of the tonsillectomy.
Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff.
Inform Dr. Smith that he cannot access his daughter’s health record without her signed authorization allowing him access to the record.
Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.
Inform Dr. Smith that he cannot access his daughter’s health record without her signed authorization allowing him access to the record.
St. Joseph’s Hospital has a psychiatric service on the sixth floor. A 31-year-old male came to the HIM department and requested to see a copy of his health record. He told the clerk he was a patient of Dr. Schmidt, a psychiatrist, and had been on the sixth floor of St. Joseph’s for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is:
Prohibit the patient from accessing his record as it contains psychiatric diagnoses that may greatly upset him.
Allow the patient to access his record.
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.
Deny access because HIPAA prevents patients from reviewing their psychiatric records.
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.
You are a member of the hospital’s Health Information Management Committee. The committee has created a HIPAA-compliant authorization form. Which of the following items does the Privacy Rule require for the form?
Signature of the patient’s attending physician
Identification of the patient’s next of kin
Identification of the person or entity authorized to receive PHI
Patient’s insurance information
Identification of the person or entity authorized to receive PHI
Protected health information that is maintained in a designated record set can be accessed by the patient or other authorized party upon request. Covered entities must respond to requests within what timeframe after receipt of the request?
15 days
30 days
60 days
90 days
30 days
A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient’s medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?
Inform defense and plaintiff lawyers that the records no longer exist
Submit a certification of destruction in response to the subpoena
Refuse the subpoena since no records exist
Contact the clerk of the court and explain the situation
Submit a certification of destruction in response to the subpoena
An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s).
A list of newborns to the local newspaper for publication in the birth announcements section
Data about cancer patients to the state health department cancer surveillance program
Birth information to the country registrar
Information about patients with sexually transmitted infections to the county health department
A list of newborns to the local newspaper for publication in the birth announcements section
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?
There is no impact.
The person making the entry in the health record may not be called as a witness in trial.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The incident report cannot be discovered even though it is mentioned in a discoverable document.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration is called:
Secure messaging
Consumer informatics
Personalized medicine
Telehealth
Telehealth
In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n):
Primary key interface (PKI)
Application programming interface (API)
Continuity of care record (CCR)
Record locator service (RLS)
Record locator service (RLS)
Which of the following is the unique identifier in the relational database patient table?
Patient Table
Patient #
Patient Last Name
Patient First Name
Date of Birth
021234
Smith
Donna
03/21/1944
022366
Jones
Donna
04/09/1960
034457
Smith
Mary
08/21/1977
Patient last name
Patient last and first name
Patient date of birth
Patient number
Patient number
In a relational database, which of the following is an example of a many-to-many relationship?
Patients to hospital admissions
Patients to consulting physicians
Patients to hospital health records
Primary care physician to patients
Patients to consulting physicians
A possible justification for building an information system in-house rather than purchasing one from a vendor is that:
It is cheaper to buy than to build
The facility has development teams they do not want to give up
Integration of systems will be easier
Vendor products are not comprehensive enough
The facility has development teams they do not want to give up
What is the formatting problem in the following table?
Medical Center Hospital Admission Types
Elective
2,843
62.4
Emergency admission
942
37.6
Total
3,785
100.0
The variable names are missing
The title of the table is missing
The column headings are missing
The column totals are inaccurate
The column headings are missing
Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital’s gross death rate for the month of June was:
0.05%
2%
5%
20%
5%
In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed?
Initial study
Design
Testing
Operation
Testing
In the data warehouse, the patient’s last name and first name are entered into separate fields. This is an example of what?
Query
Normalization
Key field
Slicing and dicing
Normalization
