RHIT EXAM PREP
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?
91.3%
Dr. Jones comes into the HIM department and requests that the HIM director provides 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 list?
A disease index
Which of the following is an institutional user of the health record?
A third-party payer
Which of the following are components of AHIMA's principles of information governance?
Accountability and integrity
Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:
By the hospital
Which of the following documentation must be included in a patient's health record prior to performing a surgical procedure?
Consent for operative procedure, history, physical examination
Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
Data currency. Data currency and data timeliness mean that healthcare data should be up-to-date and recorded at or near the time of the event or observation. Because care and treatment rely on accurate and current data, an essential characteristic of data quality is the timeliness of the documentation or data entry
A critical early step in designing an EHR is to develop a(n) ________ in which the characteristics of each data element are defined.
Data dictionary
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
In a database the LAST_NAME column in a table would be considered a:
Data element
Patient name, zip code, and health record number are typical:
Data elements
Which of the following best describes data comprehensiveness?
Data include all required elements.
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a:
Data map
99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: problem focused history and examination, straightforward medical decision.
Date of service: 1/3/2017. Last date of treatment: 2/12/2016. The patient is seen in the physician's office for a cough and sore throat. The physician performs a problem-focused history, expanded problem-focused examination, and medical decision making is straightforward. What is the correct E/M code for this service?
A health record with deficiencies that is not completed within the time-frame specified in the medical staff rules and regulations is called a(n):
Delinquent record
What are the patient data such as name, age, and address called?
Demographic data
What is the information identifying the patient (such as name, health record number, address, and telephone number) called?
Demographic data
The attending physician is responsible for which of the following types of acute-care documentation?
Discharge summary
On the problem list in a problem-oriented health record, problems are organized:
In numeric order. The problem-oriented health record is better suited to serve the patient and the end user of the patient information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. Each problem is indexed with a unique number
Which of the following is an argument against the use of the copy and paste function in the EHR?
Inability to identify the author
Which of the following are data that have been filtered and put into context?
Information
The credentialing process of independent practitioners within a healthcare organization must be defined in:
Medical staff bylaws
The home health prospective payment system uses the ________ data set for patient assessments.
OASIS-C
How long should the MPI be retained?
Permanently
Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:
Vocabulary standards
State retention requirements. Health record retention policies depend on a number of factors. They must comply with state and federal statutes and regulations. Retention regulations vary by state and possibly by organization type. Health records should be retained for at least the period specified by the state's statute of limitations for malpractice, and other claims must be taken into consideration when determining the length of time to retain records as evidence
Which of the following should be considered first when establishing health record retention policies?
Identifying the performance measures Most quality improvement methodologies recognize that the organization must identify and continuously monitor the important organizational and patient-focused functions that they perform. The first step in this process is to identify performance measures
Which of the following should be the first step in any quality improvement process?
An authorization must be obtained for uses and disclosures for treatment, payment, and operations. Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personal identifiable information for treatment, payment, and healthcare operations
Which of the following statements is false with regard to the HIPAA Privacy Rule?
The legal health record:
Will be disclosed upon request
Which of the following represents an example of data granularity?
A numerical measurement carried out to the appropriate decimal place. Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. For example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results—or in the collection of demographic data, data elements should be defined appropriately to determine the differences in outcomes of care among various populations
A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?
Administrative data
Which of the following is an example of clinical data?
Admitting diagnosis
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?
Aggregate data
General documentation guidelines apply to:
All categories of health records
A healthcare provider organization, when defining its legal health record must:
Assess the legal environment, system limitations, and HIE agreements
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written?
Assessment
The patient registration department assists the HIM department in what way?
Assigning the health record number
Which of the following is not a recommended guideline for maintaining integrity in the health record?
Assuring documentation that is being changed is permanently deleted from the record
Which of the following is considered a secondary data source?
Cancer registry
Procedure A procedure is a document that describes the steps involved in performing a specific function that define the processes by which the policies are put into action
Community Hospital recently implemented a fully integrated electronic health record (EHR) system. The process for record analysis will be significantly different with this new system. The process is changing from the hybrid to a fully electronic analysis process. Which of the following should the HIM manager modify to reflect this process change?
The HIM department is planning to scan paper-based components of the medical record such as consent forms and lab orders from physician offices. Which of the following methods would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
Concurrent scanning
Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?
Conditions of Participation
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?
Consistency
The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation?
Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report?
Consultation
A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is:
Continuity of care record
Which of the following is a risk of copy and pasting?
Copying the note in the wrong patient's record
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
DEEDS
Which of the following is not a characteristic of high-quality healthcare data?
Data accountability
Which of the following best describes data accessibility?
Data are easy to obtain.
At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:
Data consistency
Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
Data consistency
A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as:
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 three values: male, female, and unknown
A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?
Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records
The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?
Digitally scan all paper records post-discharge, and integrate and index these into the existing electronic document management system
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
Document name, media type, source system, electronic storage start date, stop printing start date
Which of the following is a primary purpose of the health record?
Document patient care delivery
What is the function of a consultation report?
Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
In designing an input screen for an EHR, which of the following would be best to capture structured data?
Drop-down menus
The advent of the EHR has increased the amount of documentation largely due to:
Ease of entry
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?
Edit checks
A transition technology used by many hospitals to increase access to health record content is:
Electronic document management system, When electronic document management systems (EDMSs) are well indexed, certain content within the documents can be uniquely retrieved making EDMS a good transition for the healthcare organization on their way to a fully interactive EHR
A patient's birth date and gender documented in the health record are examples of a data
Element
Why does an ideal EHR system require point-of-care charting?
Ensures that appropriate data are collected timely
Authentication of a record refers to:
Establishment of its baseline trustworthiness
Patient care managers use the data documented in the health record to:
Evaluate patterns and trends of patient care
How do patient care managers use the data documented in the health record?
Evaluate the performance of employees
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data:
Granularity
The data set designed to organize data for public release about the outcomes of care is:
HEDIS. The Healthcare Effectiveness Data and Information Set (HEDIS) is sponsored by the National Committee for Quality Assurance (NCQA). HEDIS is a set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of managed healthcare plans
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?
Identify data content requirements for all areas of the organization
Which of the following is the goal of the quantitative analysis performed by HIM professionals?
Identifying deficiencies early so they can be corrected
In which of the following examples does the gender of the patient constitute information rather than a data element?
In a study comparing the incidence of myocardial infarctions in black males as compared to white females
Normal distribution The normal distribution is where data follows a symmetrical curve. The 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
In which type of distribution are the mean, median, and mode equal?
an individual user
Individual users are those who depend on the health record in order to complete their job. Documentation in the health record is the basis for reimbursement or payment for the care provided. Patient care providers and the coding and billing staff use patient specific information in their day-to-day work. An insurance company would be considered an institutional user of the health record and only needs access to process the claim
The hospital is revising its policy on health record documentation. Currently, all entries in the health record must be 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 is 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. Given this discussion, which of the following might the HIM director suggest?
Inform the committee that according to the Conditions of Participation, all documentation must include date and time
Information assets are:
Information considered to add value to an organization
Which of the following is not an individual user of the health record?
Insurance companies that cover healthcare expenses
What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?
Integrity
Which of the following elements is not a component of most patient health records?
Invoice for services
Which of the following is characteristic of the legal health record?
It is the record disclosed upon request
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data?
Laboratory
Identify where the following documentation would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."
Laboratory report
Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state or county in which they are located.
Licensure. Compliance with state licensing laws is required in order for healthcare organizations to begin or remain in operation within their states. To continue licensure, organizations must demonstrate their knowledge of, and compliance with, documentation regulations
Which of the following is the best definition of a forward map in data mapping?
Linking an older version of a code set to a newer version
An RAI/MDS and care plan are found in records of patients in what setting?
Long-term care. The long-term care health record contains the patient's registration forms, personal property list, RAI/MDS, care plan and discharge or transfer information
In long-term care, the resident's care plan is based on data collected in the:
MDS. The data collected by the Minimum Data Set (MDS) are used to develop care plans for residents and to document placement at the appropriate level of care. The MDS provides a structured way to organize resident information and develop a resident care plan
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?
Make all essential data fields required
Which of the following is considered the authoritative key in locating a health record?
Master patient index
The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as:
Master patient index (MPI)
Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family history?
Medical history
Which of the following represents documentation of the patient's current and past health status?
Medical history
A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?
Medication administration record and clinical laboratory reports
Dr. Hall is an orthopedic surgeon performing a knee replacement on Mary. Mary was seen in Dr. Hall's office 2 months before the surgery and Dr. Hall documented her history and physical (H&P) at that point. Does this H&P meet documentation requirements for the surgery?
No, the H&P must be documented within 30 days before admission with an update within 24 hours after admission
Activities of daily living (ADL) are components of:
OASIS-C. Outcomes and Assessment Information Set (OASIS-C) is 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
Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching?
Obliterating or deleting errors
Identify where the following information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."
Operative report
Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?
Operative report
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
Outcomes and Assessment Information Set
Two patients' records were filed together by mistake. This is an example of:
Overlay
In which department or unit is the health record number typically assigned?
Patient registration
Physician orders for DNR and DNI should be consistent with:
Patient's advance directive
AHIMA's retention standards recommend that the master patient index be maintained:
Permanently
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."
Physical examination
The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear?
Physical examination
Version control of documents in the EHR requires:
Policies and procedures to control which version(s) is displayed
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?
Provide a template for entering data in the field
In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to:
Provide uniform data definitions
The forms design committee:
Provides oversight for the development, review, and control of forms and computer screens
At the time a hospital implemented an electronic health record, the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two years would be moved to an inactive file area. These patient records are considered ________ from the active filing area.
Purged
The primary purpose of a minimum data set in healthcare is to:
Recommend common data elements to be collected in health records
HIM departments may be the hub of identifying, mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Registration
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
Which of the following is considered a clinical documentation best practice?
Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, rules, and regulations
To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?
Review each patient's health record concurrently to make sure that history and physicals are present
Which of the following should be avoided when designing forms for an electronic document management system (EDMS)?
Shading of bars or lines that contain text
The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear?
Social service note
Which of the terms below represents fixed rules that must be followed?
Standard
What type of standards provide clear descriptors of data elements to be included in computer-based patient record systems?
Structure and content
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record progress note would this be written?
Subjective
Which of the following is a secondary purpose of the health record?
Support for research
Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?
Systematized Nomenclature of Medicine Clinical Terminology
Request a new data chart be presented that accurately reflects the trend of infection rate Both x and y axes are in unequal measures, so data are not accurately represented. Line graphs are used to display time trends as opposed to a histogram or bar chart
The HIM data analytics professional is reviewing a chart (shown here) on nosocomial infections presented by the hospital's infection control committee. The committee is reporting that the decrease in infection rate has accelerated during the past 10 years. What comments should the data analytics professional make?
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
The Joint Commission
Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided?
The Joint Commission
How are amendments handled in the EHR?
The amendment must have a separate signature, date, and time.
Which of the following is true regarding the reporting of communicable diseases?
The diseases to be reported are established by state law.
When creating requirements of documentation for the hospital bylaws, which of the following should be evaluated?
The documentation needs based on accrediting bodies
Performance measurement in healthcare provides an indication of an organization's performance in relation to a specified process or outcome. Healthcare performance improvement philosophies most often focus on measuring performance in the areas of systems, processes, and outcomes. Outcomes should be scrutinized whether they are positive and appropriate or negative and diminishing
The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance?
Which of the following is a true statement about the content of the legal health record?
The legal health record may contain metadata
Master patient index (MPI) The MPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility
The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as:
Recommend common data elements to be collected in health records In 1969, a conference on hospital discharge abstract systems was sponsored jointly by NCHS, the National Center for Health Services Research and Development, and Johns Hopkins University. Conference participants recommended that all short-term general hospitals in the United States collect a minimum set of patient-specific data elements. They also recommended that these data elements be included in all databases compiled from hospital discharge abstract systems
The primary purpose of a minimum data set in healthcare is to:
The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if:
The template was defined
Which of the following is not a characteristic of the common healthcare data sets such as UHDDS and UACDS?
They provide a complete and exhaustive list of data elements that must be collected.
A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort?
This is an example of reverse mapping
How do accreditation organizations such as the Joint Commission use the health record?
To determine whether standards of care are being met
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?
Tracer methodology The Joint Commission uses tracer methodology for on-site surveys. The tracer methodology incorporates the use of the priority focus process (PFP) review, follows the experience of care through the organization's entire healthcare process, and allows the surveyor to identify performance issues
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?
UACDS
A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?
UHDDS
A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:
UHDDS. The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases
Which of the following is a key characteristic of the problem-oriented health record?
Uses an itemized list of the patient's past and present health problems
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 of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?
Validity
Which of the following is not a true statement about a hybrid health record system?
Version control is easy to implement.
Policies and procedures to control which version(s) is displayed The health record may have multiple versions of the same document; for example, a signed and an unsigned copy of a document. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed
Version control of documents in the EHR requires:
A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information?
Vital signs record
Cancer registries are maintained by hospitals:
Voluntarily or by state law
D23.11
When coding a hydrocystoma of the right eyelid, which of the following codes should be used?
Behavior One way hiring managers can improve effectiveness of job interviews includes using job-related situational or behavioral questions based on job description. An example of a behavioral question would be to ask a candidate to relate behavior from the past to a job situation (for example, describe a situation where you had to deal with a subordinate's chronic tardiness, and explain how you handled it)
When interviewing candidates for a job, Angela likes to get a feel for how their experiences will shape their future actions. She likes to ask the question, "Tell me about a time when you had to prioritize three or four courses of action, what they were, and how you decided to prioritize each one. Did you choose correctly? How did it work out?" This is what type of interview question?
Cause and effect diagram A cause and effect diagram is an investigational technique that facilitates the identification of the various factors that contribute to a problem
Which of the following is an investigational technique that facilitates the identification of the various factors that contribute to a problem?
Compliance Compliance is the process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies. In other words, compliance actively prevents fraud and abuse
Which of the following is the process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies?
The diseases to be reported are established by state law. All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department
Which of the following is true regarding the reporting of communicable diseases?
