RHIT Study Guide Exam

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate A. the overall quality of documentation in the record. B. potentially compensable events. C. adverse effects and contraindications of drugs utilized during hospitalization. D. quality of care through the use of preestablished criteria.

CORRECT A "Adverse effects and contraindications of drugs utilized during hospitalization" and "quality of care through the use of preestablished criteria" deals with issues directly linked to quality of care reviews. Potentially compensable events deals with risk management. Only "the overall quality of documentation in the record" points to a review aimed at evaluating the quality of documentation in the health record

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates A. Noncompliance with Joint Commission standards. B. Compliance with Medicare regulations. C. Compliance with Joint Commission standards. D. Compliance with Joint Commission standards for nonsurgical patients.

CORRECT A Joint Commission specifies that H&Ps must be completed within 24 hours or prior to surgery.

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for A. marking the surgical site. B. including the surgeon in the preanesthesia assessment. C. including the primary caregiver in surgery consults. D. apprising the patient of all complications that might occur.

CORRECT A The Joint Commission requires hospitals to mark the correct surgical site and to involve the patient in the marking process to help eliminate wrong site surgeries.

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the A. MDS. B. OASIS. C. UHDDS. C. DEEDS.

CORRECT A The Minimum Data Set (MDS) is a basic component of the long-term care RAI. UHDDS is used primarily in acute care. OASIS is used in home health, and DEEDS is used in emergency departments

The minimum length of time for retaining original medical records is primarily governed by A. state law. B. Joint Commission. C. medical staff. D. readmission rates.

CORRECT A The statute of limitations for each state is information that is crucial in determining record retention schedules.

Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that A. Evidence cannot be provided that the physician actually reviewed and approved each report. B. Electronic signatures are not acceptable in every state. C. It is too easy to delegate use of computer passwords. D. tampering too often occurs with this method of authentication.

CORRECT A Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.

The purpose of the NCCI medically unlikely edits is A. To prevent inaccurate payments when services are reported with incorrect units of service. B. Designed to link reimbursement to quality care. C. To identify services that should not be performed on the same patient on the same day of service. D. To examine standard medical and surgical practices.

CORRECT A The purpose of the NCCI medically unlikely edits is to prevent inaccurate payments when services are reported with incorrect units of service.

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the A. risk manager. B. attending physician. C. HIM director. D. chief of staff.

CORRECT B Although the nursing staff, hospital administration, and the health information management director play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the A. transfer record. B. problem list. C. discharge summary. D. interdisciplinary patient care plan.

CORRECT B Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients

Discharge summary documentation must include A. note from social services or discharge planning. B. significant findings during hospitalization. C. correct codes for significant procedures. D. A detailed history of the patient.

CORRECT B Some reference to the patient's history may be found in the discharge summary but not a detailed history. The attending physician rather than a social worker records the discharge summary. Procedure codes are usually recorded on a different form in the record.

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? A. disease index B. operation index C. physician index D. master patient index

CORRECT B The master patient index—the disease index is a listing in diagnostic code number order. Physician index—The physician index is a listing of cases in order by physician name or number. Disease index—The MPI cross-references the patient name and medical record number. Therefore, operation index is the correct choice.

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is A. operative report. B. pathology report. C. discharge summary. D. recovery room record.

CORRECT B Although a gross description of tissue removed may be mentioned on the operative report or discharge summary, only the pathology report will contain a microscopic description.

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the A. Use of abbreviations in the final diagnosis. B. Use of prohibited or "dangerous" abbreviations. C. Flagrant use of specialty-specific abbreviations. D. Prohibited use of any abbreviations.

CORRECT B As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be A. Principal diagnosis. B. Procedures and dates. C. Cognitive patterns. D. Personal identification.

CORRECT C Principal diagnosis, procedures and dates, and personal identification represent items collected on Medicare inpatients according to UHDDS requirements. Only cognitive patterns represent a data item collected more typically in long-term care settings and required in the Minimum Data Set for Long Term Care

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency. A. CMS B. CDC C. ONC D. OSHA

CORRECT C The Office of the National Coordinator (ONC) for Health Information Technology is the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A. Integrated progress notes. B. Doctors' progress notes. C. Incident report. D. Nurses' notes.

CORRECT C Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record.

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that A. a new H&P is required for every inpatient admission. B. you apologize for not noticing the H&P she provided. C. Joint Commission standards do not allow copies of any kind in the original record. D. the H&P copy is acceptable as long as she documents any interval changes.

CORRECT D Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the original H&P is readily available.

The best example of point-of-care service and documentation is A. using occurrence screens to identify adverse events. B. doctors using voice recognition systems to dictate radiology reports. C. using an automated tracking system to locate a record. D. nurses using bedside terminals to record vital signs.

CORRECT D Of the processes listed, only "nurses using bedside terminals to record vital signs" pertains to the clinical application of data entry into the patient's record at the time and location of service.

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to disclose proof of immunization to a school without A. documentation of any kind. B. any communication with the parent. C. written authorization by the child. D. written authorization of the parent.

CORRECT D The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.

The Quality Payment Program was implemented as part of ________. A. APMs B. HIPAA 5010 regulations. C. UCR D. MACRA

CORRECT D The Quality Payment Program was implemented as part of Medicare Access and Chip Reauthorization Act (MACRA). APMs are Advanced Alternative Payment Models. UCR stands for usual, customary and reasonable. HIPAA 5010 regulations govern the electronic transmission of health information between health care entities.

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the A. Labor and delivery record. B. Discharge summary. C. Postpartum record. D. Prenatal record. .

CORRECT D The antepartum or prenatal record should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history

Joint Commission requires the attending physician to countersign health record documentation that is entered by A. physician partners. B. business associates. C. consulting physicians. D. interns or medical students.

CORRECT D Those who make entries in the medical record are given that privilege by the medical staff. Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.

The foundation for communicating all patient care goals in long-term care settings is the A. Cognitive assessment. B. legal assessment. C. Uniform Hospital Discharge Data Set. D. interdisciplinary plan of care.

CORRECT D Unlike the acute care hospital, where most health care practitioners document separately, the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved.

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process? A. Mark the surgical site. B. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. C. Review the medical records and/or imaging studies. D. Confirm the patient's true identity.

CORRECT D Confirm the patient's true identity, mark the surgical site, and review the medical records and/or imaging studies—these are usually in the protocol to prevent wrong site, wrong patient, or wrong surgery. The correct answer is following the daily surgical patient listing—that choice would NOT be an appropriate step in making sure you have the correct identity of the patient, the correct site, or the correct surgery

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's A. patient index. B. physicians' index. C. number control index. D. disease index.

CORRECT D The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. The number index identifies new health record numbers and the patients to whom they were assigned. The physicians' index identifies all patients treated by each doctor. The patient index links each patient treated in a facility with the health number under which the clinical information can be located.