RHIT Mock Exam Cards
Community Hospital is planning implementation of various elements of EHR in the next six months. Physicians have requested the ability to access the HER from their offices and from home. What advice should the HIM director provide? a. HIPAA regulation do not allow this type of access b. This access would be covered un the release of PHI for treatment purposes and poses no security or confidentiality threats. c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. d. Access can be permitted because the physicians are on the medical staff of the hospital and are covered by HIPAA employees.
. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security.
88. A patient is admitted to the hospital with shortness of breath & congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation w/ ventilator management. Which of the following would be the correct sequencing & coding of this case?
. Congestive heart failure, respiratory failure, ventilator management, intubation CHF is a principal diagnosis and must be sequenced first
94. This individual assists in educating medical staff members on documentation need for acurate coding. a. Physician champion b. Compliance officer c. Chargemaster coordinator d. Data monitor
. Physician champion Physician champions assit in educating medical staff members on documentation needed for accurate billing & Medical staff is more likely to listen to a peer than a facility employee like the health information manager who must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and rreimbursement.
3. Community Hospital's HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timeliness rate. Thirteen discharged were determined to be out of compliance with completion standards. Which of the following percentages represents the timeliness rate for discharge summaries at Community Hospital? a. 8.7% b. 9.5% c. 41.5% d, 91.3%
137 / 150 x 100 = 91.3% A discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of patient discharge from the hospital. Accreditation requirements state that the record needs to be complete within 30 days of discharge. Hospitals set completion standards based on this requirement. Record completion would include the discharge summary.
104. Given the information here, which of the following MS- DRGs would have the highest payment? a. 191 b. 192 c. 193 d. 194
193 MS-DRG 193 has the highest weight and therefore would have had the highest payment
96. City's Hospital's Revenue Cycle Management team has established the following benchmarks: (1) The value of discharged not final billed cases should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. The net average daily revenue is $1,000,000. The following data indicate that City Hospital's DNFB cases net it's benchmarks:
50 percent of the time In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 % of the time
30. Which of the following is an institutional user of the health record? a. A third-party payer b. Patient c. Physician d. Employer
A third-party payer
33. A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data
Administrative data
36. Which of the following is not a recommended guideline for maintaining integrity in the health record? a. Specifying consequences for the falsification of information b. Requiring periodic training covering the falsification of information and information security c. Assuring documentation that is being changed is permanently deleted from the record d. Prohibiting the entry of false information into any of the organization's records
Assuring documentation that is being changed is permanently deleted from the record
40. A coding compliance manager is reviewing a tool that identifies when a user logs in and out, what he or she does, and more. What is the manager reviewing? a. Audit trail b. facility access control c. Forensics d. Security management plan
Audit trail
A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended? a. Username and password b. Automatic session termination c. Cable locks d. Encryption
Automatic session termination In the HIPAA Security Rule, one of the technical safeguard standards is access control. This includes automatic log-off, which ensures processes that terminate an electronic session after a predetermined time of inactivity
48. A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at trial d. Bring records to a legal proceeding
Bring records to a legal proceeding A subpoena duces tecum instructs the recipient to bring documents and other records with himself or herself to a deposition or to court
The hospital currently has a hybrid health record. Nurses & clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes & orders, are paper based & stored in a paper health record, making retrieval of the complete record after discharge difficult & risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problem & preserve the efficiencies of an electronic record?
C. Digitally scan all paper records post-discharge, and integrate and index these into the existing electronic document management system
86. Which of the following is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis
Comorbidity A comorbidity is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay
Managing an organization's data and those who enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following?
Data Dictionary Data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology
In a database the LAST_NAME column in a table would be considered a: a. Data element b. Record c. Primary key d. Row
Data element A data element is an individual fact or measurement that is the smallest unique subset of a database
20. What is the information identifying the patient (such as name, health record number, address, and telephone number) called? a. Accession data d. Indicator data c. Reference data d. Demographic data
Demographic data
A dietary department donated its old microcomputer to a school. Some old patient data were still on the computer. What controls would have minimized this security breach? a. Access controls b. Device and media controls c. Facility access controls d. Workstation controls
Device and media controls
89. A newborn is treated for pulmonary valve stenosis, with stretching of the valve opening accomplished via a percutaneous balloon pulmonary valvuloplasty. In ICD-10- PCS, what root operation would be coded for this procedure? a. Alteration b. Dilation c. Repair d. Restriction
Dilation Though the term valvuloplasty in the index leads to Repair, Replacement, or Supplement, this procedure was performed as percutaneous Dilation. The root operation Dilation is expanding an orifice or the lumen of a tubular body part
23. A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error? a. Access Controls b. Audit Trail C. Edit Checks d. Password Control
Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer
In this experimental study, blood pressure is taken before and after an experimental medication is used as the intervention in a sample of participants that wee previously unable to control their blood pressure with other medications. In this example, the independent variable is the and the dependent variable is the .
Experimental medication; blood pressure The independent variable in this example is the intervention used (medication) and the dependent variable is the disease that is being assessed (blood pressure)
87. Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Health information management b. Patient access c. Patient accounts d. Utilization management
Health information management Resolving failed edits is one of the many duties of the Health Information Management (HIM) department. Various hospital departments depends on the coding expertise of the HIM professionals to avoid incorrect coding and potential compliance issues
25. Which of the following is the goal of the qualitative analysis performed by HIM professionals? a. Ensuring that the health record is legible b. Verifying that health professionals are providing appropriate car c. Identifying deficiencies early so they can be corrected d. Ensuring bills are correct
Identifying deficiencies early so they can be corrected Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record
29. Which of the following is an argument against the use of copy and paste function in the EHR? a. Inability to identify the author b. Inability to print the data out c. The time it takes to copy and paste the documentation d. The users will not know how to perform the copy and paste function
Inability to identify the author
35. Information assets are: a. Information considered to add value to an organization b. data entered into a patient's health record by a provider c. Clearly defined elements required to be documented in the health record d. A list of all data elements added within a record
Information considered to add value to an organization
54. Which of the following refers to guarding against improper information modification or destruction? a. Confidentiality b. Integrity c. Privacy d. Security
Integrity Data integrity means that data should be complete, accurate, consistent, and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules
The three elements of a security program are ensuring data availability, protection, and: a. Suitability b. Integrity c. Flexibility d. Robustness
Integrity Data security embodies three basic concepts: Protecting privacy of data Ensuring integrity of data Ensuring availability of data
Spoliation can be defined as which of the following? a. it is required after a legal hold is imposed b. It is the negligent destruction or changing of information c. It is destroying, changing, or hiding evidence intentionally d. It can only be performed on records that are involved in a court proceeding
It is destroying, changing, or hiding evidence intentionally
26. The credentialing process of independent practitioners within a healthcare organization must be defined in: a. Hospital policies and procedures b. Medical staff bylaws c. Accreditation regulations d. Hospital licensure rules
Medical staff bylaws The credentialing and privileging process for the initial appointment and reappointment of independent practitioners should be defined in the healthcare organization's medical staff bylaws and should be uniformly applied
28. Physician orders for DNR and DNI should be consistent with: a. Patient's advance directive b. Patient's bill of rights c. Notice of privacy practices d. Authorization for release of information
Patient's advance directive
7. AHIMA's retention standards recommend that the master patient index be maintained: a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently
Permanently Record retention should only be done in accordance with federal and state law and written retention and destruction policies of the organization. AHIMA's recommended retention standards for the master patient index (MPI) is permanent retention
47. A home health agency plans to implement a computer system whereby its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect laptop and network data from a virus introduced from an external device? a. Biometrics b. Encryption c. Personal firewall software d. Session terminations
Personal firewall software
32. Version control of documents in the EHR requires: a. the deletion of old versions and the retention of the most recent b. Policies and procedures to control which version(s) is displayed c. Signed and unsigned documents not to be considered two versions d. Previous versions to be accessible to administration only
Policies and procedures to control which version(s) is displayed
49. Which of the following is a core ethical obligation of health information professional? a. Coding diseases and operations b. Protecting patients' privacy and confidential communications c. Transcribing health reports d. Performing quantitative analysis on record content
Protecting patients' privacy and confidential communications The HIM professional's core ethical obligations are to protect patient privacy and confidential information and communication and to assure security of that information
37. A hospital HIM dept. wants to move five years of health records to a remote storage location. The records will be stored in boxes and will be filed on open shelves at the remote location. Which of the following should be done so that record location can be easily identified in the remote storage area? a. Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier b. Prepare a sequential list of all records sent to remote storage c. Provide a unique box identifier and list the records by health record number on the outside of each box d. File the records in terminal digit order in each box
Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier
6. Which of the following should be avoided when designing forms for an electronic document management systems (EDMS)?
Shading of bars or lines that contain text The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images
41. Which of the following should be considered first when establishing health record retention policies? a. State retention requirements b. Accreditation standards c. AHIMA's retention guidelines d. Federal requirements
State retention requirements
46. A hospital HIM dept. receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's health 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? a. Inform defense and plaintiff lawyers that the records no longer exist b. Submit a certification of destruction in response to the subpoena c. Refuse the subpoena since no records exist d. Contact the clerk of the court and explain the situation
Submit a certification of destruction in response to the subpoena
27. The legal health record: a. Is inadmissible into evidence b. May not be hybrid c. Must consist in part on paper d. Will be disclosed upon request
Will be disclosed upon request One of the major purposes of a health record is to serve as the legal business record of an organization and as evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request
If an employee produces 2,080 hours of work in the course of one year, how many employees will be required for the coding are if the coding time on average for one record is 30 minutes and there are 12,500 records that must be coded each year? a. 3 b. 6 c. 36 d. 69
a. 3 The number of records per FTE is 2 (number of records per hour) x 2,080 = 4,160. Therefore, three employees per year are required: 12,500 / 4,160 = 3.0
i. Dr. .Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list1 a. A disease index b. A master patient index c. An operative index d. A physician index
a. A disease index a listing in diagnosis code number order patients discharged from the facility during a particular time period
75. What number is assigned to a case when it is first entered in a cancer registry? a. Accession number b. patient number c. health record number d. Medical record number
a. Accession number Accession number is a number assigned to each case as it is entered in a cancer registry
74. Secondary data is used for multiple reasons including: a. Assisting researchers in determining effectiveness of treatments b. Assisting physicians and other healthcare providers in providing patient care c. Billing for services provided to the patient d. Coding diagnoses and procedures treated
a. Assisting researchers in determining effectiveness of treatments Secondary data is used in research. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternate treatment methods
1. Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS
a. DEEDS - Data Elements for Emergency Department Systems. The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.
8. A Hospital's HER defines the expected values of the gender data elements as female, male, and unknown. This type of specificity is known as: a. Data precision b. Data consistency c. Data granularity d. Data comprehensiveness
a. Data Precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For Example, a precise data definition related to gender would include 3 values: male, female, and unknown
17. Patient name, Zip code, and health record number are typical: a. Data elements b. Data sources c. Aggregate data d. Data monitors
a. Data elements
84. The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors is called: a. Data mining b. Data warehouse c. Data searching d. Big data
a. Data mining Data mining is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors
52. Community Hospital wants to provide transcription svcs for office notes of the privacy patients of physicians who all have medical staff privileges at the hospital. This provides an essential svc to the physicians and provides additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital's HIM director advise in order to comply w/ HIPAA regulations?
a. Each physician practice should obtain a business associate agreement with the hospital
. With regard to training in PHI policies and procedures: a. Every member of the covered entity's workforce must be trained b. Only individuals employed by the covered entity must be trained c. Training only needs to occur when there are material changes to the policies and procedures d. Documentation of training is not required
a. Every member of the covered entity's workforce must be trained
57. When an individual request a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may: a. Impose a reasonable cost-based fee b. Not charge the induvial c. Impose any fee authorized by state statute d. Charge only for the cost of the paper on which the information is printed
a. Impose a reasonable cost-based fee
92. Assign codes for the following scenario: A 35- year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed. K21.9 Esophagitis, Unspecified K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis
a. K21.9, ODB58ZX Patient has esophageal reflux with no esophagitis mentioned. K21.9. Procedure code, closed biopsy of the esophagus was performed via esophagoscopy 0DB58ZX - Medical & Surgical 0, Body system - gastrointestinal D, root operation Excision - B, Body Part - esophagus - 5, Approach - endoscopic natural opening - 8, no device - Z, biopsy - X
102. A patient has liver metastasis due to adenocarcinoma of the rectum, which was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is: a. Liver metastasis b. Adenocarcinoma of the rectum c. Anemia d. Admission for radiotherapy
a. Liver metastasis Admission or encounter for management of anemia associated with the malignancy, and the treatment is only for anemia - code malignancy as principal then anemia (Guideline I.C.2.c.1)
18. The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: a. Master patient index (MPI) b. Audit trail c. Case-mix management d. Electronic document management system (EMDS)
a. Master patient index (MPI)
4. Activities of daily living (ADL) are components of: a. OASIS-C b. UHDDS c. UACDS d. ORYX and RAPs
a. OASIS-C Outcomes and Assessment Information Set A standardized data set of more than 30 data elements designed to gather data about Medicare beneficiaries who are receiving services from a home health agency
68. A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst include in the database? a. Patient date of birth b. Name of attending physician c. patient room number d. Admitting diagnosis
a. Patient date of birth
53. Removing health records of patients who have not been treated at the facility for a specific period of time from the storage area is called: a. Purging records b. Assembling records c. Logging records d. Cycling records
a. Purging records
In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case?
a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results This is an example of a circumstance in which the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS, and whether the COPD does is not clear
82. Which of the following is not a component of the data analytics process? a. Software testing b. Dissemination c. Data extraction d. Data preparation
a. Software testing The components of data analytics are: data extraction data preparation descriptive statistics statistical analyses dissemination
80. Which events must occur in order to maintain patient identity data integrity? a. The data must be accurately queried b. The data must be accurately analyzed c. the data must be accurately normalized d. The data must be accurately coded
a. The data must be accurately queried
71. The hospital-acquired infection rate for our is 0.2%, whereas the rate at a similar hospital across town is 0.3%. This is an example of a: a. benchmark b. Check sheet c. data abstract d. Run chart
a. benchmark Benchmark is a systematic comparison of one organization's measurement characteristics to those of another similar organization. When an organization compares its current performance to its own internal historical data, or uses data from similar external organizations, it helps establish an organizations benchmark
67. In May, 270 women were admitted to the obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculation the C-section rate? a. 33 b. 263 c. 270 d. 296
b. 263 The denominator (number of times an event could have occurred) in this case would be 263 as 263 women delivered
63. Community Hospital discharged 9 patients on April 1. The length of stay for each of the patients was as follows: for patient A, 1 day; for patient B, 5 days; for patient C, 3 days; for patient D, 3 days; for patient E, 8 days; for patient F, 8 days; for patient G, 8 days; for patient H, 9 days; for patient I, 9 days. What was the average length of stay for these nine patients? a. 5 days b. 6 days c. 8 days d. 9 days
b. 6 days ALOS - Average length of stay is the mean length of stay of hospital inpatients discharged during a given period of time. Add total days for each patient (total of 54 days) and divide by 9 patients = 6 days
15. You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide the physician with? a. Patient-Specific Data b. Aggregated Data c. Operation room data d. Nothing - you can't obtain this data after the fact
b. Aggregate data
50. Which of the following ethical principles is being followed when a health information management professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence
b. Beneficence Beneficence would require the HIM professional to ensure that the information is released only to individuals who need it to do something that will benefit the patient. Example: insurance company for payment of a claim
o. Which of the following documentation must be included in a patient's health record prior lo performing a surgical procedure? a. Consent for operative procedure, anesthesia report, surgical report b. Consent for open live procedure, history, physical examination c. History, physical examination, anesthesia report d. Problem list, history, physical examination
b. Consent for operative procedure, history, physical examination Documentation of health history, consents, and the physical examination must be available in the patient's record before any surgical procedures may be performed
. What is the term used often to describe the individual within an organization who is responsible for protection health information in conjunction with the court system? a. Administrator of records b. Custodian of records c. Director of records d. Supervisor of records
b. Custodian of records
76. Why is the MEDPAR file limited in terms of being used for research purposes? a. It only provides demographic data about patients b. It only contains Medicare patients c. It uses ICD-10-CM diagnoses and procedure codes d. It breaks charges down by specific type of service
b. It only contains Medicare patients The MEDPAR file is frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients
. Which of the following would be part of the release of information system? a. Letter asking for additional information on a patient previously treated at the hospital b. Letter notifying the individual that the authorization was invalid c. Letter notifying the physician that he has delinquent health records d. Letter asking the physician to clarify primary diagnosis
b. Letter notifying the individual that the authorization was invalid
101. Placenta previa with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergency C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be: a. Third-degree perineal laceration b. Placenta previa c. Twin gestation d. vaginal hemorrhage
b. Placenta Previa Placenta previa is the reason for the C-section and therefore is the principle diagnosis
19. Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an EHR?
b. Provide a template for entering data in the field
73. Health departments use the health record to monitor outbreaks of diseases. In this situation what type of use of the health record does this represent? a. Educational b. Public health and research c. Medical review organization d. Patient care
b. Public health and research Public health and research uses data in the health record for many reasons including monitoring disease outbreaks
Which of the following can be used to develop a focused inpatient coding review? a. Controversial issues identified in CPT Assistant b. Recent data quality issues identified by external review agencies c. Analysis of HCPCS comparative data d. Top 25 APC groups by volume and charges
b. Recent data quality issues identified by external review agencies The HIM department can plan focused review based on specific problem areas after the initial baseline review has been completed
9. Cancer registries are maintained by hospitals: a. By federal law or state law b. Voluntarily or by state law c. Voluntarily or by federal law d. By mandate from the American College of Surgeon
b. Voluntarily or by state law
81. The facility privacy officer receives a phone call from a patient who is concerned that her former sister-in-law who is a hospital employee has accessed her health record. The privacy officer requests an audit log of activity within the patient's health record. What part of the audit log must be analyzed to determine if this complaint has merit? a. The patient demographic information b. Which employees viewed, created, updated, or deleted information c. The ownership of the record d. Whether the patient had requested to be omitted from the facility patient directory
b. Which employees viewed, created, updated, or deleted information
62. The HIM department recently performed an audit of health records. The audit showed that for the 10,000 records filed there was a 7 % error rate. Given that the national average labor cost of each misfile is $200, what is the labor cost for the department for handling these misfiled records? a. $1,400 b. $14,000 c. $140,000 d. $285,714
c. $140,000 10,000 x 0.07= 700 x $200= $140,000
95. According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy
c. Colonoscopy Colonoscopy includes examining the transverse colon. Proctosigmoidoscopy examines the rectum & sigmoid colon. Sigmoidoscopy examines the rectum, sigmoid colon, and may include portions of descending colon
70. Data found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. This data collection is called: a. Patient-specific b. Aggregated c. Comparative d. Detailed
c. Comparative Comparative data collection uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care. Hospital Compare is located on the CMS website and provides aggregate data of hospitals across the country
72. Community Hospital has been collecting quarterly data on the average monthly health record delinquency rate for the hospital. This graph depicts the trend in the delinquency rate. The hospital has established a 35% benchmark. Given this data, what should the hospital's performance Improvement Council recommend? a. Continue tracking the delinquency rate to see if the last two quarters trends continues b. Establish a higher benchmark to accommodate an increase in delinquent records c. Further analyze the data to determine why the benchmark is not being met. d. Take an average of all the data points to arrive at a new benchmark
c. Further analyze the data to determine why the benchmark is not being met
13. The hospital is revising its policy on health record documentation. Currently, all entries in the health record must legible, complete, dated, and signed. The committee chairperson wants to add that all entries must have the time noted. However, another clinician suggests that adding the time of notation difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Give this discussion, which of the following might the HIM director suggest?
c. Inform the committee that according to the Conditions of Participation, all documentation must include date and time
59. Which of the following is a characteristic of breach notification? a. it is only required when 500 or more individuals are affected b. It applies to both secured and unsecured PHI c. It applies when one person's PHI is breached d. Is only applied when 20 or more individuals are affected
c. It applies when one person's PHI is breached
56. Which of the following would be considered a security vulnerability? a. Lack of laptop encryption b. Workforce employees c. Tornado d. Electrical outage
c. Lack of laptop encryption A security threat is anything that can exploit a security vulnerability. Vulnerability is a weakness or gap in security protection. In this situation, the lack of encryption for the laptop would be considered a security vulnerability as the contents could be more easily accessed
64. Suppose that you want to display the number of deaths due to breast cancer for the years 2005 through 2015. What is the best graphic technique to use? a. Table b. Histogram c. Line graph d. Bar chart
c. Line graph Line graph may be used to display time trends. A line graph is especially useful for plotting a large number of observations. It also allows several sets of data to be presented on one graph
16. Which of the following would be the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in an EHR? a. Add validation edits on all essential fields b. Provide an input mask for essential data fields c. Make all essential data fields required d. Provide sufficient space for all essential fields
c. Make all essential data fields required
69. The following data fields a database table: patient last name, first name, street address, city, state, zip code, date of birth. Given this information, which of the following is a true statement about maintaining the data integrity of the database table? a. Patient last name should be used as the primary key for the table. b. patient date of birth should be used as the primary key for the table. c. None of the data fields are adequate to use as a primary key for the table. d. Patient last and first name should be used as the primary key for the table.
c. None of the data fields are adequate to use as a primary key for the table A primary key must uniquely identify a record. None of the options provided will uniquely identify a record. Multiple individuals may have the same name and birth dates
10. Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report
c. Operative report
51. An individual's right to control access to his or her personal information is known as: a. Security b. Confidentiality c. Privacy d. Access control
c. Privacy
103. Which of the following is on the list of the hospital- acquired conditions provision of the inpatient prospective payment system? a. Congestive heart failure b. Acute myocardial infarction c. Stage III or IV pressure ulcers d. Diabetic retinopathy
c. Stage III or IV pressure ulcers Stage III or IV pressure ulcer not present on admission or identified with the POA indicator on claim would not be paid for as a CC or MCC because it is considered an HAC Hospital acquired condition.
58. Release of birth and death information to public health authorities: a. Is prohibited without patient consent b. is prohibited without patient authorization c. is a public interest and benefit disclosure that does not require patient authorization d. Requires both patient consent and authorization
c. is a public interest and benefit disclosure that does not require patient authorization
98. The sum of a hospital;s relative DRG weights for a year was 15,192, and the hospital had 10,471 discharges for the year. Given this information, what would the hospital's case- mix for that year? a. 0.689 b. 0.689 x 100 c. 1.45 x 100 d. 1.45
d. 1.45 The weight of each DRG - Diagnosis-related group X number of discharges = total weight for each DRG (15,192) Total weights / number of total discharges = case-mix index 15,195 / 10,471 = 1.45
65. Community Hospital had a total of 3,000 inpatient service days for the month of September. What was the average daily census for the hospital during September? a. 10 patients b. 96.77 patients c. 97 patients d. 100 patients
d. 100 patients The average daily census is the average number of inpatients treated during a given period of time. There are 30 days in September, so 3,000 / 30 = 100
34. Which of the following are components of AHIMA's principles of information governance? a. Accountability and accessibility b. Integrity and safeguards c. Safeguards and accessibility d. Accountability and integrity
d. Accountability and integrity
85. A hospital can monitor its performance under the MS-DRG system by monitoring its: a. Accounts receivable b. Operating costs c. RBRVS payments d. Case-mix index
d. Case-mix index
. Two coders have found the same abbreviation on two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye". The other abbreviation on another patient's record was used to mean "overdose" on an abuse record. What data quality component is lacking here? a. Timeliness b. Completeness c. Security d. Consistency
d. Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Abbreviations are extremely easy to use; however, data must have definitions and be uniform to prevent information inconsistencies
83. This type of chart plots all data points as a cell for two given variables of interest and, depending on frequency of observations in each, provides color to visualize high or low frequency. a. Barplot b. Scatter plot c. Boxplot d. Heatmap
d. Heatmap A heat map plots all data points as a cell for two given variables or interest, and depending on frequency of observations in each cell, provides color to visualize high or low frequency
99. A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin
d. Hematuria; adverse reaction to Coumadin Hematuria is an adverse effect as opposed to a poisoning because it was correctly prescribed and correctly taken
77. In which type of distribution are the mean, median, and mode equal? a. Bimodal distribution b. Simple distribution c. Non-normal distribution d. Normal distribution
d. Normal distribution Normal distribution is where data follows a symmetrical curve. He normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. In a normal distribution, the mean, median, and mode are equal
14. Identify the report where the following information would be found: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." a. Discharge Summary b. Health History C. Medical laboratory Report d. Physical Examination
d. Physical examination
31. How are amendments handled in the HER? a. Amendments are automatically appended to the original note. No additional signature is required. b. Amendments must be entered by the same person as the original note. c. Amendments cannot be entered after 24 hours of the event. d. The amendment must have a separate signature, date, and time
d. The amendment must have a separate signature, date, and time
61. A consumer nonprofit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. An HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. Which of the following would not be a quality consideration in using billing data? a. Accuracy of the data b. Consistency of the data c. Appropriateness of the data elements d. cost to process the data
d. cost to process the data Several factors must be addressed when assessing data quality. These include: data accuracy, consistency, completeness, and timeliness. Cost to process the data does not influence the quality
12. In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. Because of unexpected complications, however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case?
request that the physician dictate an addendum to the discharge summary
