RHIA Practice Exam Deck Flashcards
(151 cards)
Sally is the HIM director at Memorial Hospital and has been asked to compose a record retention policy for the hospital. What should be her first consideration in determining how long paper and electronic records must be retained?
The amount of space allocated for record filing and server set up
The number of paper records currently filed and the number of electronic files added on a daily basis
The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
The cost of filing space and equipment
The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
Abdominal pain
Cholelithiasis
Exploratory laparoscopy
Ruptured appendix
Abdominal pain
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 data quality element is missing from Mrs. Smith’s health record?
Data accuracy
Data consistency
Data accessibility
Data comprehensiveness
Data consistency
The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours.
30 days, 48 hours, 24 hours
14 days, 24 hours, 48 hours
14 days, 48 hours, 24 hours
30 days, 24 hours, 48 hours
30 days, 24 hours, 48 hours
Which of the following is an acceptable means of authenticating a record entry?
The physician’s assistant electronically signs for the physician.
The HIM clerk electronically signs using the physician’s login.
The charge nurse electronically signs for the physician.
The physician personally signs the entry electronically.
The physician personally signs the entry electronically.
A method of documenting nurses’ progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:
Problem-oriented progress notes
Charting by exception
Consultative notations
Open charting
Charting by exception
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):
Resident Assessment Protocols (RAPs)
Resident Assessment Instrument (RAI)
Utilization Guidelines (UG)
Minimum Data Sets (MDS)
Resident Assessment Protocols (RAPs)
HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) ten that information is not shared with other departments within the healthcare entity. 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?
Administration
Registration or patient access
Risk management
Radiology and laboratory
Registration or patient access
Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:
Closed review
Qualitative review
Concurrent review
Delinquent review
Concurrent review
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
Administrative information
Demographic information
Progress notes
Uniform data sets
Uniform data sets
The data elements in a patient’s automated laboratory result are examples of:
Unstructured data
Free-text data
Financial data
Structured data
Structured data
Which of the following materials are required elements in an emergency care record?
Patient’s instructions at discharge and a complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
Treatment rendered, instructions at discharge, and the patient’s complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n):
Indicator
Measurement
Assessment
Outcome
Indicator
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?
Master data
Metadata
Structured data
Unstructured data
Metadata
Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident’s care?
Case management
Minimum Data Set
Outcomes and assessment information set
Core measure abstracting
Minimum Data Set
Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John’s hospital bill. Upon discharge from the hospital, who owns John’s health record?
John
Blue Cross
University Hospital
Dr. Collins
University Hospital
Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value report she received during her last physical exam. Dr. Ward responded to Jane’s email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled?
Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient’s medical record.
Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.
Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.
Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?
Integrated
Practice-oriented
Chronological
Source-oriented
Source-oriented
A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility’s internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area?
Comparative performance data
Internal infection reporting
Master patient index
Provider performance data
Comparative performance data
According to Joint Commission Accreditation Standards, which document must be placed in the patient’s record before a surgical procedure may be performed?
Admission record
Physician’s order
Report of history and physical examination
Discharge summary
Report of history and physical examination
The following data have been collected by the hospital quality committee. What conclusions can be made from the data on the hospital’s quality of care between the first and second quarters?
Measure
1st Quarter
2nd Quarter
Medication errors
3.2%
10.4%
Patient falls
4.2%
8.6%
Hospital-acquired infections
1.8%
4.9%
Transfusion reactions
1.4%
2.5%
Quality of care improved between the first and second quarters.
Quality of care is about the same between the first and second quarters.
Quality of care declined between the first and second quarters.
Quality of care should not be judged by these types of measures.
Quality of care declined between the first and second quarters.
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
Radiology
Quality management
Registration
Laboratory
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:
Identification and demographic integrity
Authorship integrity
Statistical integrity
Auditing integrity
Authorship integrity
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:
Case-mix index
Master patient index
Health record matrix
Retention schedule
Health record matrix