RHIT review

Question 1

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

Answer 1

Care plan

Question 2

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?

Answer 2

The joint commission

Question 3

Which of the following is an example of clinical data?

Answer 3

Admitting diagnosis

Question 4

What type of health records may contain family and caregiver input?

Answer 4

Behavioral health records

Question 5

A transition technology used by many hospitals to increase access to health record content is:

Answer 5

Electronic document management system

Question 6

Which of the following should be taken into consideration when designing a health record form?

Answer 6

Including original and revised dates

Question 7

The primary purpose of a data set in healthcare is to:

Answer 7

Recommend common data elements to be collected in health records

Question 8

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?

Answer 8

Data currency

Question 9

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.

Answer 9

Operative report

Question 10

When all required data elements are included in the health record, the quality characteristic for data _____ is met.

Answer 10

Comprehensiveness

Question 11

Which if the following contains the physicians findings based on an exam of the pt

Answer 11

Physical exam

Question 12

AHIMA has created 8 principles to help orgs create ______within their organizations

Answer 12

Information governance

Question 13

Critique the following statement: When writing a query for clinical documentation ?’s the physician should be told specifically what needs to be written

Answer 13

This is false, as queries should not lead physician

Question 14

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:

Answer 14

HEDIS

Question 15

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?

Answer 15

Reliability

Question 16

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 ______

Answer 16

Alert

Question 17

Which of the following is a primary purpose of the health record?

Answer 17

Document patient care delivery

Question 18

Why should the copy and paste function not be used in the electronic health record?

Answer 18

The content may contain outdated info

Question 19

Ensuring data are not altered during transmission across a network or during Storage is called?

Answer 19

Integrity

Question 20

Which of the following materials is not documented in an emergency care record?

Answer 20

Patient complete medical history

Question 21

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

Answer 21

The field type should be changed to alphanumeric

Question 22

A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort?

Answer 22

This an example of reverse mapping

Question 23

What is the primary benefit of point of care charting?

Answer 23

Ensures that appropriate data are collected timely

Question 24

The home health prospective payment system uses the ___ data set for pt assessments.

Answer 24

OASIS-C

Question 25

Electronic systems used by nurses and drs to document assessments and findings are called:

Answer 25

Electronic point of care charting

Question 26

At the time a hospital implemented an electronic health record, the health Record Comittee determined that all records of pts who have not been treated at the facility in the past 2 yrs would be moved to an inactive file area. These pts records are considered _____from the active filing area

Answer 26

Purged

Question 27

How long should the MPI be retained?

Answer 27

Permanently

Question 28

The following is documented in an acute care record: “Spoke to the attending re: my assessment. Provided adoption & counseling info. Spoke to CPS re: referral. Case manager to meet with pt and family. Where does this appear?

Answer 28

Social service note

Question 29

Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an orgs data assets?

Answer 29

Data governance

Question 30

Which one of the following indexes contains a list maintained in procedure code # order for the pts who are discharged from a facility during a particular time period?

Answer 30

Operation

Question 31

Which of the following is not true of good electronic forms design?

Answer 31

Uses radio buttons to select multiple items from a set of options

Question 32

Which type of health record contains info about the means by which the pt arrived at the healthcare setting & documentation of care provided to stabilize the pt?

Answer 32

Emergency care

Question 33

A healthcare provider org, when defining its legal health record must:

Answer 33

Assess the legal environment system limitations and standards of care

Question 34

Which of the following systems is the key to identifying a pts multiple hospitalizations?

Answer 34

MPI

Question 35

When creating requirements for the hospital bylaws, which of the following should be evaluated?

Answer 35

The documentation needs based on accrediting bodies

Question 36

What is the primary purposes of structured data entry?

Answer 36

reduce documentation variability

Question 37

The term used to describe controlling info is ____

Answer 37

Information governance

Question 38

HIM depts maybe the hub of identifying, mitigating and correcting MPI errors but that info often is not shared with other depts inthe healthcare org. After identifying procedural problems with admitting pts that contribute to the creation of the MPI errors which dept should the MPI manager work with to correct these procedural problems?

Answer 38

Registration

Question 39

An RAI/MDS and care plan are found in records of pts in what settings?

Answer 39

Long term care

Question 40

Which of the following is not a characteristic of the common healthcare data sets as UHDDS and UACDS?

Answer 40

They provided a complete and exhaustive list of data elements that must be collected

Question 41

Identify where the following info would be found in acute care record: 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?

Answer 41

Operative report

Question 42

A healthcare provider org, when defining its legal health record must:

Answer 42

Assess the legal environment system limitations and standards of care

Question 43

In coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution

Answer 43

Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines