RHIT & RHIA Exam Mod 1
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? [Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient.] a. discharge summary b. physical exam c. admission note d. clinical laboratory report
A
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? [The patient is alert and in no acute distress. Initial vital signs: T 98, P 102 and regular, R 20 and BP 120/69...] a. physical exam b. chief complaint c. social history d. past medical history
A
Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical quality indicator for patients with pneumonia might be a. blood culture before first antibiotic received. b. early administration of aspirin. c. beta blocker at discharge. d. discharged on antithrombotic.
A
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the a. MDS. b. Uniform Clinical Data Set. c. Uniform Ambulatory Core Data. d. UHDDS.
A
In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from a. the R-ADT system. b. the indicator monitoring program. c. the disease index. d. generic screens used by record abstractors.
A
Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to a. bar code placement. b. signature line for authentication. c. use of box design. d. placement of hospital logo.
A
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. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. b. Review the medical records and/or imaging studies. c. Mark the surgical site. d. Confirm the patient's true identity.
A
One record documentation requirement shared by both acute care and emergency departments is a. patient's condition on discharge. b. time and means of arrival. c. advance directive. d. problem list.
A
The Quality Payment Program includes a. Advanced Alternative Payment Models and Merit-Based Incentive Payment System b. Advanced Alternative Payment Models c. Merit-Based Incentive Payment System d. Diagnosis-related groups
A
The minimum length of time for retaining original medical records is primarily governed by a. state law. b. medical staff. c. Joint Commission. d. readmission rates.
A
The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the a. Conditions of Participation for Rehabilitation Facilities. b. CARF manual. c. Medical Staff Bylaws, Rules, and Regulations. d. Joint Commission manual.
B
The foundation for communicating all patient care goals in long-term care settings is the a. legal assessment. b. interdisciplinary plan of care. c. cognitive assessment. d. Uniform Hospital Discharge Data Set.
B
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. discharge summary. b. problem list. c. interdisciplinary patient care plan. d. transfer record.
B
A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the medical staff as well as to administration the powerful impact that precise documentation has on the internal and external data reporting. In this role, he/she is acting as a(n) a. reviewer. b. educator. c. ambassador. d. manager.
B
A primary focus of screen format design in a health record computer application should be to ensure that a. paper forms are easily converted to computer forms. b. the user is capturing essential data elements. c. programmers develop standard screen formats for all hospitals. d. data fields can be randomly accessed.
B
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. compliance with Joint Commission standards for nonsurgical patients. b. noncompliance with Joint Commission standards. c. compliance with Joint Commission standards. d. compliance with Medicare regulations.
B
As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use a. patient abstracts. b. accession register. c. patient index. d. follow-up files.
B
As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the a. glossary of health care terms. b. facility's data dictionary. c. MDS. d. UHDDS.
B
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the a. Department of Recovery Audit Coordinators. b. Office for Civil Rights. c. FBI. d. Office of Inspector General.
B
The best example of point-of-care service and documentation is a. doctors using voice recognition systems to dictate radiology reports. b. nurses using bedside terminals to record vital signs. c. using an automated tracking system to locate a record. d. using occurrence screens to identify adverse events.
B
In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show a. missing discharge summaries. b. missing operative reports. c. absence of SOAP format in progress notes. d. missing signatures on progress notes.
B
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of a. peer review. b. qualitative review. c. quantitative review. d. legal analysis.
B
Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. a. Patient admitted with COPD 1/4/2020 and discharged 1/7/2020. b. Baby Boy Hiltz, born 1/5/2020, maintained normal status, discharged 1/7/2020. c. Baby Boy Doe admitted 1/3/2020, died 1/4/2020. d. Baby Boy Hiltz's mother admitted 1/5/2020, C-section delivery, and discharged 1/7/2020.
B
Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? a. physical exam b. pharmacy consultation c. medical consultation d. emergency record
B
Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? a. pediatric census sheet b. disease index c. patient register d. procedure index
B
Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? a. database b. problem list c. initial plan d. progress notes
B
You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at: a. 12 hours after admission or prior to surgery. b. 24 hours after admission or prior to surgery. c. 24 hours after admission. d. 12 hours after admission.
B
You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's a. physicians' index. b. disease index. c. number control index. d. patient index.
B
In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain a. stop orders. b. standing orders. c. discharge order. d. telephone orders.
C
An example of a primary data source for health care statistics is the a. accession register. b. disease index. c. health record. d. MPI.
C
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the a. consolidated manual for hospitals. b. policy and procedure manual. c. hospital bylaws, rules, and regulations. d. Federal Register.
C
As the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with a. MEDPAR representatives. b. the OIG. c. recovery audit contractors. d. QIO physicians.
C
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing? a. quantitative analysis b. legal review c. qualitative analysis d. utilization review
C
For inpatients, the first data item collected of a clinical nature is usually a. principal diagnosis. b. expected payer. c. admitting diagnosis. d. review of systems.
C
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. flagrant use of specialty-specific abbreviations. c. use of prohibited or "dangerous" abbreviations. d. prohibited use of any abbreviations.
C
Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that a. it is too easy to delegate use of computer passwords. b. tampering too often occurs with this method of authentication. c. evidence cannot be provided that the physician actually reviewed and approved each report. d. electronic signatures are not acceptable in every state.
C
Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data a. validity. b. reliability. c. precision. d. timeliness.
C
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. written authorization by the child. b. any communication with the parent. c. written authorization of the parent. d. documentation of any kind.
C
The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding a. whether the severity of illness and/or intensity of service warranted acute level care. b. whether a postoperative infection occurred and how it was treated. c. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. d. the quality of follow-up care.
C
Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data a. timeliness. b. security. c. comprehensiveness. d. accuracy.
C
While data governance focuses primarily on managing data as it is being created within a healthcare system, information governance focuses instead on managing a. the granularity of health care systems. b. data currency. c. the output of those systems. d. data accuracy.
C
A data item to include on a qualitative review checklist of newborn inpatient health records that need NOT be included on adult records would be a. chief complaint. b. time and means of arrival. c. condition on discharge. d. APGAR score.
D
A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the a. instructions for follow-up care. b. physical findings. c. lab and diagnostic test results. d. time and means of arrival.
D
An effective information governance system should include all of the following principles except one: a. the principle of disposition b. the principle of availability c. the principle of retention d. the principle of interoperability
D
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. apprising the patient of all complications that might occur. b. including the surgeon in the preanesthesia assessment. c. including the primary caregiver in surgery consults. d. marking the surgical site.
D
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's a. expert system. b. CPOE. c. EDMS system. d. RHIO.
D
In creating a new form or computer view, the designer should be most driven by a. flow of data on the page or screen. b. QIO standards. c. medical staff bylaws. d. needs of the users.
D
In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the a. subjective review of systems. b. chief complaint. c. family history as related by the patient. d. general appearance as assessed by the physician.
D
Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a a. data warehouse. b. continuum of care. c. data retrieval portal group. d. regional health information organization.
D
Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? a. X-ray report charted on the wrong record b. need for physician authentication of two verbal orders c. missing discharge summary d. discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist
D