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
Electronic systems used by nurses and drs to document assessments and findings are called:
Electronic point of care charting
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
Purged
How long should the MPI be retained?
Permanently
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?
Social service note
Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an orgs data assets?
Data governance
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?
Operation
Which of the following is not true of good electronic forms design?
Uses radio buttons to select multiple items from a set of options
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?
Emergency care
A healthcare provider org, when defining its legal health record must:
Assess the legal environment system limitations and standards of care
Which of the following systems is the key to identifying a pts multiple hospitalizations?
MPI
When creating requirements for the hospital bylaws, which of the following should be evaluated?
The documentation needs based on accrediting bodies
What is the primary purposes of structured data entry?
reduce documentation variability
The term used to describe controlling info is ____
Information governance
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?
Registration
An RAI/MDS and care plan are found in records of pts in what settings?
Long term care
Which of the following is not a characteristic of the common healthcare data sets as UHDDS and UACDS?
They provided a complete and exhaustive list of data elements that must be collected
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?
Operative report
A healthcare provider org, when defining its legal health record must:
Assess the legal environment system limitations and standards of care
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
Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines
A registered health information technician (RHIT) can earn continuing education units by _________
Taking a college course
Creating a chart to show trends in the number of inpatient hospitalizations in an example of _________
Data use
Which of the following persons were intended to be supported by Medicaid in public law 89-97 of 1965?
Single parent families
Identify the HIM task that is eliminated by the electronic health record system?
Assembly
How many linear filing inches can a shelving unit hold based on the following data? Shelving unit shelf width = 36 inches number of shelves per unit = 9 shelves Average record thickness = 1/2 inch
324
36*9=324
To be recognized as a profession, which of the following does HIM required?
Preliminary training
The office of the National coordinator for health information technology was created as part of which act?
American recovery and reinvestment act
Which of the following is a way that patient care managers and support staff use the data documented in the health record?
Evaluate the performance of employees
The use of the health record by a clinician to facilitate quality patient care is considered a ________
A primary purpose of the health record
Dr Smith dictated his report and then immediately edited it. Identify the type of speech recognition used.
Front-end
Identify the screen design concept that assists with data validation
Checking to ensure that the data is in an appropriate range
Determine the number of shelving units required to shelve 2,000 pt health records if the avg health record is 0.75 inches. The shelving unit is 36 inches wide and has 8 shelves.
6
Shelves will hold 36 * 8 = 288 inches
Linear filing inches needed: 2000*0.75=1,500
Shelving units needed: 1,500/288=5.2 units =6 units. Round up to the next full unit
Identify the documentation that records the attending physician’s of the patients current health status.
Physical examination
