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HITT 1301 > RHIT review > Flashcards

RHIT review Flashcards

quiz

1
Q

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

A

Care plan

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2
Q

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?

A

The joint commission

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3
Q

Which of the following is an example of clinical data?

A

Admitting diagnosis

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4
Q

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

A

Behavioral health records

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5
Q

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

A

Electronic document management system

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6
Q

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

A

Including original and revised dates

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7
Q

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

A

Recommend common data elements to be collected in health records

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8
Q

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?

A

Data currency

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9
Q

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.

A

Operative report

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10
Q

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

A

Comprehensiveness

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11
Q

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

A

Physical exam

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12
Q

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

A

Information governance

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13
Q

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

A

This is false, as queries should not lead physician

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14
Q

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:

A

HEDIS
Healthcare effectiveness data and information set

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15
Q

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?

A

Reliability

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16
Q

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 ______

A

Alert

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17
Q

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

A

Document patient care delivery

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18
Q

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

A

The content may contain outdated info

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19
Q

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

A

Integrity

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20
Q

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

A

Patient complete medical history

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21
Q

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

A

The field type should be changed to alphanumeric

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22
Q

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

A

This an example of reverse mapping

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23
Q

What is the primary benefit of point of care charting?

A

Ensures that appropriate data are collected timely

24
Q

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

A

OASIS-C

25
Q

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

A

Electronic point of care charting

26
Q

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

A

Purged

27
Q

How long should the MPI be retained?

A

Permanently

28
Q

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?

A

Social service note

29
Q

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

A

Data governance

30
Q

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?

A

Operation

31
Q

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

A

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

32
Q

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?

A

Emergency care

33
Q

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

A

Assess the legal environment system limitations and standards of care

34
Q

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

A

MPI

35
Q

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

A

The documentation needs based on accrediting bodies

36
Q

What is the primary purposes of structured data entry?

A

reduce documentation variability

37
Q

The term used to describe controlling info is ____

A

Information governance

38
Q

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?

A

Registration

39
Q

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

A

Long term care

40
Q

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

A

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

41
Q

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?

A

Operative report

42
Q

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

A

Assess the legal environment system limitations and standards of care

43
Q

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

A

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

44
Q

A registered health information technician (RHIT) can earn continuing education units by _________

A

Taking a college course

45
Q

Creating a chart to show trends in the number of inpatient hospitalizations in an example of _________

A

Data use

46
Q

Which of the following persons were intended to be supported by Medicaid in public law 89-97 of 1965?

A

Single parent families

47
Q

Identify the HIM task that is eliminated by the electronic health record system?

A

Assembly

48
Q

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

A

324
36*9=324

49
Q

To be recognized as a profession, which of the following does HIM required?

A

Preliminary training

50
Q

The office of the National coordinator for health information technology was created as part of which act?

A

American recovery and reinvestment act

51
Q

Which of the following is a way that patient care managers and support staff use the data documented in the health record?

A

Evaluate the performance of employees

52
Q

The use of the health record by a clinician to facilitate quality patient care is considered a ________

A

A primary purpose of the health record

53
Q

Dr Smith dictated his report and then immediately edited it. Identify the type of speech recognition used.

A

Front-end

54
Q

Identify the screen design concept that assists with data validation

A

Checking to ensure that the data is in an appropriate range

55
Q

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.

A

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

56
Q

Identify the documentation that records the attending physician’s of the patients current health status.

A

Physical examination

HITT 1301 (10 decks)

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