RHIT review Flashcards
quiz
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Care plan
Which of the following has been responsible for accrediting healthcare orgs since the mid-1950’s and determining whether the org is continually monitoring and improving the quality of care provided?
The joint commission
Which of the following is an example of clinical data?
Admitting diagnosis
What type of health records may contain family and caregiver input?
Behavioral health records
A transition technology used by many hospitals to increase access to health record content is:
Electronic document management system
Which of the following should be taken into consideration when designing a health record form?
Including original and revised dates
The primary purpose of a data set in healthcare is to:
Recommend common data elements to be collected in health records
Dr Jones entered a progress note in a pt’s health record 24hrs after he visited the pt. Which quality element is missing from the progress note?
Data currency
Identify where the following info would be found in the acute care reocord: Following induction of an adequate general anesthesia and with the pt supine on the padded table, the Left upper extremity was prepped and draped in the standard fashion.
Operative report
When all required data elements are included in the health record, the quality characteristic for data _____ is met.
Comprehensiveness
Which if the following contains the physicians findings based on an exam of the pt
Physical exam
AHIMA has created 8 principles to help orgs create ______within their organizations
Information governance
Critique the following statement: When writing a query for clinical documentation ?’s the physician should be told specifically what needs to be written
This is false, as queries should not lead physician
This data set was developed by the National Committee for Quality Assurance to aid consumers with health related issues with information to compare performance of clinical measures for health plans:
HEDIS
Healthcare effectiveness data and information set
2 HIM professionals are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking?
Reliability
A physicain is reviewing lab results on a pt in his office. The EHR screen displays one set of results in red with a flashing asterisk & also shows that this results is 3 times higher than expected value. This is an example of a ______
Alert
Which of the following is a primary purpose of the health record?
Document patient care delivery
Why should the copy and paste function not be used in the electronic health record?
The content may contain outdated info
Ensuring data are not altered during transmission across a network or during Storage is called?
Integrity
Which of the following materials is not documented in an emergency care record?
Patient complete medical history
The following descriptors about the data element PATIENT_Last_Name are including in a data dictionary: definiton:legal surname of the patient : field type:numeric field length: 50 req fields: Yes: default value
The field type should be changed to alphanumeric
A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort?
This an example of reverse mapping
What is the primary benefit of point of care charting?
Ensures that appropriate data are collected timely
The home health prospective payment system uses the ___ data set for pt assessments.
OASIS-C
