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RHIA Exam - Health Data Content & Standards
(Chapter 3)
In preparation for an EHR, you are conducting a total facility inventory of inventory of all forms currently used. You must name each 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. recovery room record B. pathology report C. operative report D. discharge summary 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. personal identification. B. cognitive patterns. C. procedures and dates. D. principal diagnosis. 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. prohibited use of any abbreviations. B. flagrant use of specialty-specific abbreviations. C. use of prohibited or "dangerous" abbreviations. D. use of abbreviations used in the final diagnosis. In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent? A. The number of primary cancers reported for that patient B. The year the case was entered into the database of the registry C. The sequence number of the case D. The stage of the tumor based upon the TNM system of staging
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. doctors' progress notes. B. integrated progress notes. C. incident report.
governed by: state law. The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of: electronic signatures
Discharge summary documentation must include: A. a detailed history of the patient. B. a note from social services or discharge planning. C. significant findings during hospitalization. D. correct codes for significant procedures. The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate: A. quality of care through the use of pre-established criteria. B. adverse effects and contraindications of drugs utilized during hospitalization. C. potentially compensable events. D. completeness, adequacy, and quality of documentation. Ultimate responsibility for the quality and completion of entries in patient health records belongs to the: attending physician. lthough the nursing staff, hospital administration, and the health information management professional play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatric facility are generally in the form of: A. retrospective deficiency analysis. B. special study audits. C. concurrent chart review. D. occurrence screening. The foundation for communicating all patient care goals in long-term care settings is the: A. legal assessment. B. medical history. C. individualized patient care plan. D. Uniform Hospital Discharge Data Set Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages? A. Health Record Committee B. Utilization Review
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. including the primary caregiver in surgery consults. B. including the surgeon in the preanesthesia assessment. C. marking the surgical site. D. apprising the patient of all complications that might occur. In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended change is to:have more frequent committee meetings. B. have the committee report to the Executive Committee. C. have a physician perform all the reviews. D. provide for record reviews to be performed by an interdisciplinary team of care providers According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited? A. 0.4 mg Lasix. B. 4 mg Lasix. C. 40 mg Lasix. D. .4 mg Lasix. 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 Joint Commission standards. C. compliance with Medicare regulations. D. compliance with Joint Commission standards for nonsurgical patients. A different diagnosis may be recorded for which of the following progress note elements of a problem-oriented medical record? A. Assessment B. Plan
C. Subjective D. Objective 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?
colon cancer, with no known history of previous malignancies. The accession number assigned to this patient is : A. 10-0000/00. B. 10-0000/01. C. 10-0001/00. D. 10-0001/01.
Setting up an edit that checks to see that all patients with the diagnosis of ectopic pregnancy are listed as females in the database is one method of ensuring data: A. reliability. B. timeliness. C. precision. D. validity. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the: A. CARF manual. B. hospital bylaws. C. Joint Commission accreditation manual. D. Federal Register. In an acute care hospital, a complete history and physical may not be dictated for a new admission when: A. the patient is readmitted for a similar problem within 1 year. B. the patient's stay is less than 24 hours. C. the patient has an uneventful course in the hospital. D. a legible copy of a recent H&P performed in the attending physician's office is available. You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? A. Minimum Data Set B. Uniform Hospital Discharge Data Set C. Conditions of Participation D. Federal Register Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should : A. complete a new cancer abstract. B. assign a new accession number. C. update the follow-up file.
C. hardware requirements. D. facility preference. 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. physical findings. B. lab and diagnostic test results. C. time and means of arrival. D. instructions for follow-up care. A data item to include on a qualitative review checklist of infant and children inpatient health records which need not be included on adult records would be: A. chief complaint. B. condition on discharge. C. time and means of arrival. D. growth and development record For each report of care rendered to a patient, the health record entry should include the date plus the provider's name and: A. department. B. discipline
. C. initials. D. supervising physician In creating a new form or computer view, the designer should be most driven by: A. QIO standards. B. medical staff bylaws. C. needs of the users. D. flow of data on the page or screen Under which of the following conditions can an original patient health record be physically removed from the hospital? A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital B. when the director of health records is acting in response to a subpoena duces
tecum and takes the health record to court C. when the patient is discharged by the physician and at the time of discharge is transported to a long-term care facility with his health record D. when the record is taken to a physician's private office for a follow-up patient visit post discharge
B. consultation report C. advance directive D. interdisciplinary care plan An example of objective entry in the health record supplied by a health care practitioner is the:
A. past medical history. B. physical assessment. C. chief complaint. D. review of systems. 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 be should be set at: A. 12 hours after admission. B. 24 hours after admission. C. 12 hours after admission or prior to surgery. D. 24 hours after admission or prior to surgery. Based upon the following documentation in an acute care record, where would you expect this excerpt to appear? "With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation.": A. Physician progress notes B. Operative record C. Nursing progress notes D. Physical examination A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery; he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should: A. provide the dictated tape to his staff. B. request a "stat" report. C. write a detailed operative note in the record. D. request that administration hire more transcriptionists.
C. Yes, prior to surgery D. Yes, within 24 hours postsurgery The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing: A. quantitative record review. B. clinical pertinence review. C. concurrent record analysis. D. point-of-care documentation. An example of a primary data source for health care statistics other than the patient health record is the: A. disease index. B. accession register. C. MPI. D. hospital census. 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. objective survey of body systems. B. chief complaint. C. family history. D. subjective review of systems. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? A. Utilization review B. Quantitative review C. Legal review D. Qualitative review Which of the following is least likely to be identified by a deficiency analysis
technician? A. Missing discharge summary B. Need for physician authentication of two verbal orders C. Discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist D. X-ray report charted on the wrong record
