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ALL RHIA Exam(28 sets) Questions with Verified Answers,100% CORRECT
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RHIA MOCK EXAM 391 Questions with Verified Answers,100% CORRECT
RHIA MOCK EXAM 391 Questions with Verified Answers Each month the staff of the clinic with the lowest overall waiting time is awarded a free dessert in ... [Show More] the Gulfside healthcare center cafeteria. take a look at the information listed above. the winner will be selected based on a. demonstrative clinical data b. comparative aggregate data c. objective individual data d. duplicate thematic dataCORRECT ANSWER b. comparative aggregate data a union campaign is being conducted at your facility. as a department manager, it is appropriate for you to tell employees that a. a strike is inevitable if the union wins b. wages will increase if the union is defeated c. you need the names of those involved in union activities d. you are opposed to the unionCORRECT ANSWER d. you are opposed to the union as the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. you will need to develop a professional relationship with a. the OIG b. MEDPAR representatives c. QIO physicians d. recovery audit contractorsCORRECT ANSWER d. recovery audit contractors employing the SOAP style of progress notes, choose the "assessment" statement from the following a. patient states low back pain with sciatica is as severe as it was on admission b. patient moving about very cautiously appears to be in pain c. adjust pain medication; begin physical therapy tomorrow. d. sciatica unimproved with hot pack therapyCORRECT ANSWER d. sciatica unimproved with hot pack therapy in preparation for an EHR, you are conducting a total facility inventory of all forms currently used. you must name each for for bar coding and indexing. the unnamed document in front of you includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. the document type you give to this form is. a. prenatal record b. labor record c. delivery room record d. postpartum recordCORRECT ANSWER d. postpartum record. based on the MS-DRG report above, what is the case-mix index for this facility? a. 0.204193 b. 2.965807 c. 11.639 d. 57CORRECT ANSWER b. 2.965807 the special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the a. interdisciplinary patient care plan b. medical history and review of systems c. interval summary d. problem listCORRECT ANSWER a. interdisciplinary patient care plan Four patients were discharged from crestview hospital yesterday. a final progress note is an appropriate discharge summary for a. howard, who died within 24 hours after his admission for a second heart attack in 2 weeks. b. jackson, who had no comorbidities or complications during this admission for replacement of a pacemaker battery c. fieldstone, who was admitted just 15 days following a heart attack for the acute onset of chest pain. d. babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission.CORRECT ANSWER d. babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below. MMBC receives the best reimbursement for well child visits from a. lifecare b. getwell c. surehealth d. behealthyCORRECT ANSWER b. getwell Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below. Most of the children who are seen at MMBC will have a well child visit and two immunizations. If you add the reimbursement for two immunizations to the reimbursement for each well child visit, which insurance company benefits MMBC most? a. lifecare b. getwell c. surehealth d. behealthyCORRECT ANSWER b. getwell You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. you already have the relative value unit figure. the only other information you need is a. the facility's case-mix index b. a national conversion factor c. the facility's base rate d. ms-drg relative weightsCORRECT ANSWER b. a national conversion factor Key west hospital collected the data displaye above concerning its four highest volume MS-DRGs. which MS-DRG generated the most revenue for the hospital? a. MS-DRG A b. MS-DRG B c. MS-DRG C d. MS-DRG DCORRECT ANSWER c. MS-DRG C In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post-surgery. there is no mention of a postoperative complication in the attending physician's discharge summary. before querying the doctor, the coder will seek to confirm the infection by reviewing the a. lab report b. nurses' notes c. operative report d. pathology reportCORRECT ANSWER a. lab report stan works in an acute care general hospital, fran works for a skilled nursing facility, ann is employed at an assisted living facility, and dan works for a home care provider. which people are employed in facilities that may seek Joint commission accreditation? a. only stan and fran b. only stan and dan c. only fran and dan d. dan, stan, and franCORRECT ANSWER d. dan, stan, and fran sunset beach clinic allows patients to communicate by e-mail to ask questions regarding their treatment and request appointment changes. e-mails and text messages are a. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. b. considered proof of patient contact and should be summarized in a progress note in the patient record c. generally maintained in a facility's electronic mail system until the next face-to-face patient encounter d. not typically maintained or documented as patient encounters.CORRECT ANSWER a. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters the proposed national healthcare information network (NHIN) dimensions are graphically depicted in the diagram above. roman numeral are added to allow for the identification of specific areas. where would information concerning a patient's health insurance be located on this chart? a. I b. II c. III d. VCORRECT ANSWER b. II The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. the first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. for this information you will consult the a. policy and procedure manual b. hospital's quality management plan. c. data dictionary d. hospital bylaws, rules, and regulationsCORRECT ANSWER d. hospital bylaws, rule, and regulations. Parker has type 1 diabetes with hypertension taht is currently controlled with medication. parker was admitted through the ED for an emergency appendectomy. following surgery, the patient developed an infection at the wound site that was treated with antibiotics. when making decision about sequencing the codes for this case, the coder should rely on definitions found in the a. UHDDS b. coding clinic c. CMS coding guidelines d. federal registerCORRECT ANSWER a. UHDDS Parker has type 1 diabetes with hypertension taht is currently controlled with medication. parker was admitted through the ED for an emergency appendectomy. following surgery, the patient developed an infection at the wound site that was treated with antibiotics. Parker's principal diagnosis is the a. complications of hypertension b. comorbidity of the wound infection c. comorbidity of type 1 diabets d. acute appendicitisCORRECT ANSWER d. acute appendicitis Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Bake (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions a. in the discharge summary b. on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record. c. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record. d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record.CORRECT ANSWER d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record The physician has documented the final diagnoses as acute myocardial infaraction, COPD, CHF, hypertension, atrial fibrillation, and status-post cholecystectomy. The following conditions should be reported: I10 Essential Hypertension, benign I10 Essential Hypertension, unspecified I11 Hypertension, heart disease, unspecified as to malignant or benign, with heart failure I21.3 Acute Myocardial infarction, unspecified site, initial episode of care I48.91 Atrial Fibrilation I50.9 Congestive Heart Failure, unspecified J44.9 Chronic Obstructive Pulmonary Disease Z90.89 Acquire absence of gallbladder a. I21.3, J44.9, I21.3, I48.91, Z90.89 b. I11, J44.9, I50.9, I10, I48.91 c. I11, J44.9, I50.9, I10, I48.91, Z90.89 d. I11, J44.9, I50.9, I10, I48.91CORRECT ANSWER B. I11, J44.9, I50.9, I10, I48.91 Mary is 6 weeks postmastectomy for carcinoma of the breast. she is admitted for chemotherapy. What is the correct sequencing of the codes C50.911 Malignant Neoplasm of the Breast Z85.3 Personal History of malignant neople of breast Z51.11 Encounter for antineoplastic chemotherapy Z08 Follow-up exam after surgery a. Z51.11, C50.911 b. Z51.11, Z85.3 c. Z08, Z51.11 d. Z85.3CORRECT ANSWER A. Z51.11, C50.911 Which of the following is coded as an adverse effect in ICD-9-CM? a. tinnitus due to allergic reaction after administration of ear drops b. mental retardation due to intracranial abscess c. rejection of transplanted kidney d. nonfunctioning pacemaker due to defective solderingCORRECT ANSWER a. tinnitus due to allergice reaction after administration of ear drops which of the following scenarios identifies a pathologic fracture? a. greenstick fracture secondary to fall from bed b. compression fracture of the skull after being hit with a baseball bat c. vertebral fracture with cord compression following a car accident d. compression fracture of the vertebrae as a result of bone metastasis.CORRECT ANSWER d. compression fracture of the vertebrae as a result of bone metastasis. If the same condition is described as both acute and chronic and separate sub entries exist in the ICD-10-CM alphabetic index at the same indentation level a. they should both be coded, acute sequence first. b. they should both be coded, chronic sequence first c. only the acute condition should be coded. d. only the chronic condition should be codedCORRECT ANSWER a. they should both be coded, acute sequence first. which of the following statements is true a. a surgical procedure may include one or more surgical operation b. the terms surgical operation and surgical procedure are synonymous c. a surgical operation may include one or more surgical procedures d. the term surgical procedure is an incorrect term and should not be used.CORRECT ANSWER c. a surgical operation may include one or more surgical procedures which of the following would be coded as a poisoning a. coumadin intoxication due to a cumulative effect b. idisoyncratic reaction to artane c. interaction between aldomet and a vasodilating agent d. reaction between coumadin and an over-the-counter medicationCORRECT ANSWER d. reaction between coumadin and an over-the-counter medication which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned? a. occiput presentation b. single liveborn c. episiotomy d. low forcepsCORRECT ANSWER d. low forceps which of the following are considered a (late effect) sequela regardless of time? a. congenital defect b. nonunion c. nonhealing fracture d. poisoningCORRECT ANSWER b. nonunion four people were seen in your emergency department yesterday. which one will be coded as a poisoning? - josh was diagnosed with digitalis intoxication -ben had an allergic reaction to a dye adminstered for a pyelogram - bryan developed syncope after taking Contac pills with a double scotch -matthew had an idiosyncratic reaction between two properly administered prescription drugs a. josh b. ben c. bryan d. matthewCORRECT ANSWER c. bryan Patient is admitted for elective cholecystectomy for treatment of chronic cholecystititis with cholelithiasis. prior to administration of general anesthesia, patient suffers cerebral thrombosis. surgery is subsequently canceled. code and sequence the coding from the following codes. I66.9 cerebral thrombosis without cerebral infarction K80.10 chronic cholecystitis with cholelithiasis Z53.09 Iatrogenic cerebrovascular infarction or hemorrhage OFT40ZZ Cholecystectomy, total a. I97.821, K80.10, OFT4OZZ b. K80.10, I66.9, Z53.09 C. I97.821, I66.9, Z53.09 d. I66.9, Z53.09CORRECT ANSWER b. K80.10, I66.9, Z53.09 The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. the coder would assign. a. a code for myocardial infarction b. a code for the patient's symptoms c. a code for an impending myocardial infarction d. no code for this conditionCORRECT ANSWER a. a code for myocardial infarction. staging a. refers to the monitoring of incidence and trends associated with a disease b. is continued medical surveillance of a case c. is a system for documenting the extent or spread of cancer d. designated the degree of differentiation of cellsCORRECT ANSWER c. is a system for documenting the extent or spread of cancer which of these conditions are always considered "present on admission" (POA)? a. congenital conditions b. E codes c. acute conditions d. possible, probable, or suspected conditionsCORRECT ANSWER a. congenital conditions in your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. when this occurs, who would be expected to authorize the release of the medical information documented in this episode of care to the patient's insurers? a. the patient b. a court-appointed guardian on behalf of the patient c. the custodial parent of the patient d. the patient's doctor on behalf of the patientCORRECT ANSWER a. the patient a patient is admitted through the emergency department. three days after admission, the physician documents uncontrolled diabetes mellitus. what is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? a. "Y" b. "U" c. "W" d. "N"CORRECT ANSWER D. "N" The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. 34203 embolectomy or thrombectomy, with or without catheter; popliteal-tibioperoneal 35226 repair blood vessel, direct; lower extremity 35302 thromboendarterectomy, including patch graft if performed; superficial femoral artery 37799 unlisted procedure, vascular surgery a. 34203 b. 37799 c. 35302 d. 35226CORRECT ANSWER a. 34203 Patient was seen for excision of two interdigital neuromas from the left foot 28080 excision, interdigital(morton) neuroma, single, each 64774 excision of neuroma; cutaneous nerve, surgically identifiable 64776 excision of neuroma; digital nerve, one or both, same digit a. 64774 b. 64776 c. 28080 d. 28080, 28080CORRECT ANSWER d. 28080, 28080 Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures 12002 simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities(including hands and feet); 2.6-7.5cm 12004 simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6-12.5 cm 12035 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet) 12.6-20.0cm 12045 Layer closure of wounds of neck, hands, feet and/or external genitalia; 12-6-20.0 cm a. 12045 b. 12035 c. 12002, 12004 d. 12004CORRECT ANSWER b. 12035 Office visit for 43-year old male, new patient, with no complications. patient is applying for life insurance and requests a physical examination. a detailed health and family history was obtained and a basic physical was done. physician completed life insurance physical form at patient's request. blood and urine were collected 99381- initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, new patient; infant (age under 1 year) 99386-initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, new patient; 40-64 years 99396- periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures, established patient; 40-64 years 99450- basic life and/or disability examination that includes completion of a medical history following a life insurance pro forms a. 99450 b. 99386 c. 99396 d. 99381CORRECT ANSWER a. 99450 Patient was seen today for regular hemodialysis. no problems reported, tolerated procedure well. 90935- hemodialysis procedure with single physician evaluation 90937- hemodialysis procedure required repeated evalution with or without substantial revision of dialysis prescription 90945- dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacemtn therapies), with single physician evaluation 99354 prolonged physican service in the office or other outpatient setting requiring direct (face-to-face) contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service) a. 90937 b. 99354 c. 90945 d. 90935CORRECT ANSWER d. 90935 an established patient was seen by the physician in the office for DTaP vaccine and Hib 90471- immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90700-diptheria, tetanus toxoids, and acellular pertussis vaccine DTaP, when admistered to indivduals younger than 7 years, for intramuscular use 90720-diptheria, tetanus toxoids, and whole cell pertussis vaccine and hemophilus influenza B vaccine (DTP-Hib), for intramuscular use. 90721- diptheria, tetanus toxoids, and acellular pertussis vaccine and hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use 90748- Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use 99211- office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. usually, the presenting problems are minimal. typically 5 minutes are spent performing or supervising procedure a. 90721 b. 90720, 90471 c. 90700, 90748, 99211 d. 90471, 90721CORRECT ANSWER d. 90471, 90721 a patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist 77236- therapeutic radiology treatment planning; complex 77290- therapeutic radiology simulation-aided field setting; complex 77315- teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77334- treatment devices, design and construction; complex(irregular blocks, special shields, compensators, wedges, molds or casts) a. 77315 b. 77263 c. 77290 d. 7734CORRECT ANSWER b. 77263 a 4-year-old had a repair of an incarcerated inguinal hernia. this is the first time this child had been treated for this condition 49496- repair initial inguinal hernia full-term infant, under age 6 months, or preterm infant over 50 weeks' post 49501- repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or strangulated 49521- repair recurrent inguinal hernia, any age; incarcerated or strangulated 49553- repair initial femoral hernia, any age; incarcerated or strangulated a. 49553 b. 49496 c. 49521 d. 49501CORRECT ANSWER d. 49501 a quantitative drug assay was performed for a patient to determine digoxin level 80050- general health panel 80101- drug screen, qualtitative; single drug class method (e.g. immunoassay, enzyme assay), each drug class 80162- digoxin (therapeutic drug assay, quantitative examination) 80166- doxepin (therapeutic drug assay, quantitative examination) a. 80101 b. 80050 c. 80166 d. 80162CORRECT ANSWER d. 80162 provide the CPT code for anesthesia servcies for the transvenous insertion of a pacemaker 00530- anesthesia for permanent transvenous pacemaker insertion 00560- anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 33202- insertion of epicardial electrodes; open incision 33206- insertion or replacement of permanent pacemaker with transvenous electrodes; atrial a. 00560 b. 33202, 00530 c. 00530 d. 33206, 00560CORRECT ANSWER c. 00530 the transiptionists have collected data on the number and types of problems with the dictation equipment. the best tool to display the data they collected is a a. flowchart b. pareto chart c. gantt chart d. pert chartCORRECT ANSWER b. pareto chart based on the information below, what was the net death rate at Seaside Hospital in January? Admission- 280 discharged to home-212 discharge transfers-28 death less than 48 hours- 8 death greater than 48 hours- 6 a. 2.4% b. 2.8% c. 3.8% d.5.8%CORRECT ANSWER a. 2.4% the formula used to calculate the percentage of ambulatory care visits made with same day appointments is a. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen with addvance appointments for the same period b. number of patients seen with advance appointments for a period x 100 divided by the number of patients seen with the same day appointments for the same period c. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen in the same period d. number of patients seen with advance apointments for a period x 100 divided by the number of patients seen in the same periodCORRECT ANSWER d. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen in the same period an HIM department budget report for may shows a payroll budget of $25,000 and an actual payroll exepnse of $22, 345. the percentage of budget variance for the month is a. $2,655 b. 11% c. $265 d. 0.9%CORRECT ANSWER b. 11% diverticulitis large bowel with abscess; right hemicolectomy with colostomy performed K57.90 Diverticulosis of colon (without mention of hemorrhage) K57.92 Diverticulitis of colon (without mention of hemorrhage) K63.0 Abscess of intestine ODTK0ZZ Open and other right hemicolectomy OKTL0ZZ Open and other resection of transverse colon OD1K0Z4 Exteriorization of large intestine (loop colostomy) a. K57.90, ODTL0ZZ, OD1K0Z4 b. K57.92, ODTK0ZZ, OD1K0Z3 c. K57.92, K63.0, ODTK0ZZ d. K57.92, K63.0, ODTL0ZZCORRECT ANSWER c. K57.92, K63.0, ODTK0ZZ Your facility is engaged in a research project concerning patients newly diagnosed with type 2 diabetes. the researchers notice older patients have a longer length of stay than younger patients. they have seen a a. positive correlation between age and length of stay b. negative correlation between age and length of stay c. causal relationship between age and length of stay d. homologous relationship between age and length of stayCORRECT ANSWER a. positive correlation between age and length of stay Johnston city was set upon by a swarm of killer bees. all 5,000 residents are at risk of a bee attack. if 25 residents were attacked by the bees, the incidence of bee attack a. is 5 in 1,000 b. is 5 in 5,000 c. is 25 in 1,000 d. cannot be determined at this timeCORRECT ANSWER a. is 5 in 1,000 a 335-bed hospital opened a new wing on June 1 of a nonleap year, increasing its bed count to 350 beds. the total bed count days for the year at the hospital was a. 122, 275 b. 125, 485 c. 127, 750 d. the answer cannot be calculated with the information providedCORRECT ANSWER a. 125, 485 a patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of a. 45 days b. 46 days c. 47 days d, 48 daysCORRECT ANSWER c. 47 days release of information has increased its used of part-time prn clerical support in order to respond to increased requests for release of information. the budget variance report will reflect a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area b. the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support c. both the increases in revenue and increased costs for clerical support in ROI d. neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reportsCORRECT ANSWER a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. you are heading a research study that includes a patient questionnaire. five of the questions will be answered using the following scale: a. stacked bar graph b. pie chart c. frequency table d. frequency polygonCORRECT ANSWER c. frequency table your HMO manager has requested a report on the number of patient visits per year for preschool children. which of the age groupings below will you use for your report. a. 0-1 year, 1-2 years, 2-3 years, 3-4 years, 4-5 years b. less than 12 months, 12-24 months, 25-37 months, 38-50 months, 51-63 months. c. greater than 12 months, 12-24 months, 25-37 months, 38-50 months, less than 51 months d. 0-2 years, 3-4 years, 5 yearsCORRECT ANSWER b. less than 12 months, 12-24 months, 25-37 months, 38-50 months, 51-63 months. Collins Family Hospital had a bed count of 150 for the first 6 months of the year. on june 1, it added 15 beds when it opened a new wing. if you are given the average length of stay for the year, can you calculate the annual bed turnover rate? how? a. yes, using the direct method b. yes, using the indirect method. c. yes, using the joint commision method. d. no, there is insufficient data to complete the calculationCORRECT ANSWER d. no, there is insufficient data to complete the calculation in a research study that includes a patient questionnaire, five of the questions will be answering using the following scale: 1-strongly agree 2-disagree 3-no opinion 4-agree 5-strongly agree the data collected using this scale are called a. cardinal data b. ordinal data c. nominal data d. continuous dataCORRECT ANSWER b. ordinal data gail smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. according to her sister, gail 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. EDMS system b. CPOE c. expert system d. RHIOCORRECT ANSWER d. RHIO the patients family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered a. the best utilization of the hospital's resources. b. an inappropriate use of hospital resources c. a compassionate use of the hospital's resources d. appropriate provided it is limited to a few daysCORRECT ANSWER b. an inappropriate use of hospital resources the state is considering the closure of the Arcadia Hospital. in reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? a. daily census b. percentage of occupancy c. inpatient service days d. average length of stayCORRECT ANSWER b. percentage of occupancy the census taken at midnight on August 1 showed 99 patients remaining in the hospital. on august 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. one of these patients was admitted in the morning and remained only 8 hours. how many inpatient service days were rendered on August 2? a. 94 b. 95 c. 96 d. 97CORRECT ANSWER d. 97 you are implementing a quality improvement plan that utilizes the PDSA cycle. if you correctly implement the PDSA, which pase of the project will take the most of your time a. P b. D c. S d. ACORRECT ANSWER a. P a run or line chart would be most useful for collecting data on a. waiting time in the pediatrics clinic b. patient satisfaction with the food c. delays in scheduling elective surgical procedures d. medication errors and their causesCORRECT ANSWER a. waiting time in the pediatrics clinic the ER staff has collected the data on the number of visits and corresponding wait times in the ER. the data are displayed on the chart shown above. based on this information, what kind of correlation do you see between the number of visits (variable X) and the wait times (variable y)? a. a positive correlation between variable X and variable Y b. a negative correlation between variable x and variable y c. a conjunctive correlation between variable X and variable Y d. a causative correlation between variable x and variable yCORRECT ANSWER a. a positive correlation between variable X and variable Y Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr Jones approves a two-night leave of absence (LOA). Chances are Fred is a patient in a. an acute care facility; his LOA will decrease the months average daily inpatient census b. a long-term care facility, his LOA will increase the month's percentage of occupancy c. an acute care facility; his LOA will increase the month's total discharge days d. a long term care facility; his LOA will decrease the month's total inpatient service days.CORRECT ANSWER d. a long term care facility; his LOA will decrease the month's total inpatient service days community hospital reported an average LOS in December of 3.7 days with a standard deviation of 23. this information indicates that a. there was a small variation in the LOS at the community hospital b. there was a large variation in the LOS at community hospital c. most of the patients at community hospital stay 3 to 4 days d. patients stay longer at community than at most hospitalsCORRECT ANSWER b. there was a large variation in the LOS at community hospital four HIT students are working on a LOS project at their clinical site. to describe the variability of the data, Smithson suggest using range because it is the most exact. Donaldson wants to use the mean because it is easy to calculate. franklin recommends variance because it is the most preferred and has better interpretive uses. who made the best suggestion a. smithson b. donaldson c. franklin d. howellCORRECT ANSWER d. howell [Show Less]
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RHIA Exam Prep 145 Questions with Verified Answers,100% CORRECT
RHIA Exam Prep 145 Questions with Verified Answers Source-Oriented Health Record - CORRECT ANSWER Documents organized into sections according to the pro... [Show More] vider's and departments that provide treatment (lab together, rad. together, clinical notes together) Problem-Oriented Health Record - CORRECT ANSWER Divided into four parts: database, problem list, initial plan, progress notes (SOAP) SOAP what does S stand for? - CORRECT ANSWER Subjective (patient's point of view) SOAP what does O stand for? - CORRECT ANSWER Objective (what the practitioner finds) SOAP what does A stand for? - CORRECT ANSWER Assessment (combine subjective and objective to make a conclusion) SOAP what does P stand for? - CORRECT ANSWER Plan (approach to be taken to resolve patient's problem Integrated Health Records - CORRECT ANSWER Documentation from various sources organized in strict chronological or reverse chronological order Advantage of Integrated Health Record? - CORRECT ANSWER Easy to follow course of diagnosis and treatment Disadvantage of Integrated Health Record? - CORRECT ANSWER Difficult to compare similar information (ex. lab results or oncology information) When should H&P be documented in record? - CORRECT ANSWER Within 24 hours of admission When should Operative Report be documented in record? - CORRECT ANSWER Immediately following surgery When should Verbal Orders be cosigned? - CORRECT ANSWER Within 24 hours When should Discharge Summary be documented? - CORRECT ANSWER Immediately after discharge of patient Qualitative Analysis - CORRECT ANSWER Review of record to ensure that standards are met and determine the adequacy of entries documenting the quality of care Quantitative Analysis - CORRECT ANSWER A review of health record to determine its completeness and accuracy Data Accuracy - CORRECT ANSWER Data are the correct values and are valid Data Accessibility - CORRECT ANSWER Data items are easily obtainable and legal to collect Data Comprehensiveness - CORRECT ANSWER All required data items included AND entire scope of data is collected and intentional limitations documented Data Consistency - CORRECT ANSWER Value of data is reliable and consistent across applications Data Currency - CORRECT ANSWER Data is up to date, if it is outdated it must have been up to date at the time it was presented Data Definition - CORRECT ANSWER Clear definitions provided so users know what data means, each data element should have clear meaning and accepted values Data Granularity - CORRECT ANSWER The attributes and values of data should be defined at the correct level of detail Data Precision - CORRECT ANSWER Data values should be just large enough to support the application or process and acceptable values or ranges must be defined Data Relevance - CORRECT ANSWER The data are meaningful to the performance of the process or application for which they are collected Data Timeliness - CORRECT ANSWER Determined by how the data are being used and their context Minimum Data Set (MDS) purpose? - CORRECT ANSWER Promote comparability and compatibility of data by using standard data items with uniform definitions Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER Uniform collection of data on inpatients Uniform Ambulatory Core Data Set (UACDS) - CORRECT ANSWER Improve ability to compare data in ambulatory care settings Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI) - CORRECT ANSWER Comprehensive functional assessment of long-term care patients Outcome and Assessment Information Set (OASIS) - CORRECT ANSWER Comprehensive assessment for adult home care patient and forms the basis for measuring patient outcomes Uniform Clinical Data Set (UCDS) - CORRECT ANSWER Data collection utilized by peer review organization to determine the quality of patient care Data (3 definition points) - CORRECT ANSWER 1. Collection of elements on a given subject 2. Raw facts and figures expressed in text, numbers, symbols, and images 3. Facts, ideas, or concepts that can be captured, communicated, and processed, either manually or electronically Information (2 definition points) - CORRECT ANSWER 1. Data that have been processed into meaningful form, manually or by computer in order to be valuable to user 2. Adds to a representation and tells recipient something that was not known before Data Model - CORRECT ANSWER Plan or pattern for an information system, including the database structure, known as a conceptual model, and the translation of the concept to the computer, known as the physical model Database Entities - CORRECT ANSWER Persons, locations, things, or concepts about which data can be collected and stored Database Attribute - CORRECT ANSWER Describes an entity or distinct characteristics about it Database Relationship - CORRECT ANSWER Associations between entities Database Character - CORRECT ANSWER Collection of bits make up a byte Byte - CORRECT ANSWER A character such as a number, letter, or symbol Database Field - CORRECT ANSWER Made up of several characters such as name, age, or gender Database Record - CORRECT ANSWER Made up of a series of fields about one person or thing Database File - CORRECT ANSWER Made up of fields and records about an entity such as a patient What is another word for file or entity - CORRECT ANSWER Table What are fields in a database table? - CORRECT ANSWER Columns What are records in a database table? - CORRECT ANSWER Rows Relational Model Database - CORRECT ANSWER Database management system in which data are organized and managed as a collection of tables Object Oriented Database Model - CORRECT ANSWER Uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways Hierarchical Database Model - CORRECT ANSWER Data is organized in tree's according to relationships (one to many) Network Database Model - CORRECT ANSWER Data is organized in tree's according to relationships (many to many) Open System Architecture - CORRECT ANSWER Hardware, software, transmission, media, and database industry standards allow different computer vendor systems to communicate to each other Closed System Architecture - CORRECT ANSWER Communication is possible only on one vendor's system Hardware - CORRECT ANSWER Physical equipment that makes up computers and computer systems What are the 3 types of computers? - CORRECT ANSWER Mainframes, minicomputers, microcomputers Software - CORRECT ANSWER Operating systems software and application software Local Area Network (LAN) - CORRECT ANSWER Multiple devices connected via communications media and located in a small geographical area Wide Area Network (WAN) - CORRECT ANSWER A computer network that connects separate institutions across a large geographical area Intranet - CORRECT ANSWER Private network that has its servers located inside a firewall Alphabetic Health Record Identification - CORRECT ANSWER A patient's name identifies the patient record Numeric Identification - CORRECT ANSWER A number identifies the patient record Serial Numbering - CORRECT ANSWER A new number is assigned to the patient for each new encounter at the facility Unit Numbering - CORRECT ANSWER The patient retains the same number for every encounter at the facility Serial-Unit Numbering - CORRECT ANSWER A new number is assigned to the patient for each new encounter at the facility, but the former records are brought forward and filed under the new number Centralized Filing - CORRECT ANSWER Records filed in one location Decentralized Filing - CORRECT ANSWER Records filed in multiple locations Alphabetic Filing - CORRECT ANSWER Starts with last names and then includes first name and middle initial Straight Numeric Filing - CORRECT ANSWER Filing charts in sequential order; the records start with the chart with the lowest number value and end with the chart with the highest number value Terminal Digit Filing - CORRECT ANSWER Numeric filing is divided into three parts and is read from right to left instead of left to right What does AHA recommend for record retention? - CORRECT ANSWER Minimum of 10 years When does AHA recommend record retention for a minor? - CORRECT ANSWER 10 years past the age of majority Index - CORRECT ANSWER Listing or arrangement of data in a designated order; contains special types of information, and purpose is to assist in location of desired information Master Patient Index (MPI) - CORRECT ANSWER Identifies all patients admitted to a health care facility for treatment, along with their identifying information Number Index - CORRECT ANSWER Chronological list of patient's identification numbers issued to patients Physician Index - CORRECT ANSWER Provides every physician with a list of identifying medical cases Disease Index - CORRECT ANSWER List of diseases and conditions according to the classification system used in the facility Procedure or Operation Index - CORRECT ANSWER List of surgical and procedural codes Registry - CORRECT ANSWER Created to monitor various diseases and health problems with different goals and objectives Admission and Discharge Register -- How long retained and in what order? - CORRECT ANSWER Permanent in chronological order Operating Room Register - CORRECT ANSWER Maintained for 10 years; provides statistical data for caseload analysis and administrative reports Births and Deaths Register - CORRECT ANSWER Provide accessible information about births and deaths Emergency Room Register - CORRECT ANSWER Monitors patients who enter the emergency room for services Cancer or Tumor Registry - CORRECT ANSWER System that monitors all types of cancer diagnosed or treated in an institution Health Care Information Management Systems Society (HIMSS) - CORRECT ANSWER Provides leadership in health care for the management of technology management systems International Federation of Health Record Organizations (IFHRO) - CORRECT ANSWER Supports national associations and health record professionals to improve health records International Medical Informatics Association (IMIA) - CORRECT ANSWER Promotes informatics in healthcare and bio-medical research American Medical Informatics Association (AMIA) - CORRECT ANSWER Supports information technology professionals to improve health care American Association for Medical Transcription (AAMT) - CORRECT ANSWER Largest association for medical trasncription College of Healthcare Information Management Executives (CHIME) - CORRECT ANSWER Serves needs of health care chief information officers and advocates for more effective use of information management in health care Alternate Delivery Systems - CORRECT ANSWER Health care provided by methods other than the traditional inpatient care, including home health, ambulatory, hospice, and other types of health care. Care - CORRECT ANSWER The management of, responsibility for, or attention to the safety and well-being of another person or other persons Client - CORRECT ANSWER Individual who is receiving professional services Hill Burton Act - CORRECT ANSWER Legislation enacted in 1946 that provided funding for the construction of hospitals and other health care facilities Secondary Patient Record - CORRECT ANSWER A record used for selected data elements to aid in research conducted by clinical and non-clinical people American Medical Association (AMA) was established to...? - CORRECT ANSWER Assure the quality of American medical education American Hospital Association (AHA) was established to...? - CORRECT ANSWER Promote public welfare by providing better health care in hospitals What did the Flexner Report of 1910 do? - CORRECT ANSWER Identify serious problems and inconsistencies in medical education American College of Surgeons (ACS) was established to...? - CORRECT ANSWER Develop a system of hospital standardization to improve patient care and recognize hospitals that had the highest ideals What is the Department of Health and Human Services (DHHS) responsible for? - CORRECT ANSWER Health issues, including health care and cost, welfare of various populations, occupational safety, and income security plans What did the Tax Equity and Fiscal Responsibilities Act (TEFRA) do? - CORRECT ANSWER Established a mechanism for controlling the cost of the Medicare program and set limits on reimbursement and required the development of the prospective payment system What did the Consolidated Omnibus Budget Reconciliation Act (COBRA) establish? - CORRECT ANSWER Anti-dumping statue, established criteria for the transfer and discharge of Medicare and Medicaid patients What did the Patient Self-Determination Act of 1990 establish? - CORRECT ANSWER Gave patients the right to set advance directives Hierarchical Organizational Chart - CORRECT ANSWER Individuals at the top have authority and it passes downward through a chain of command Vertical Organizational Chart - CORRECT ANSWER Governing Board has ultimate authority, followed by the CEO, Medical Staff, Department Directors, Supervisors, and Numerous Subordinates Matrix Organizational Chart - CORRECT ANSWER Supports general managers who focus on managing people and processes as opposed to strategy and structure, horizontal scheme embraces individual capabilities, employees may have two or more supervisors Product Line Management - CORRECT ANSWER Hospitals organized around product line categories (obstetrics, rehabilitation, cardiology) Health Maintenance Organizations (HMO's) - CORRECT ANSWER Managed health care that integrates health care delivery with insurance for healthcare Nursing Long-Term Care - CORRECT ANSWER Nursing care and related services for residents who need medical, nursing, or rehabilitative care provided on a 24 hour basis Domiciliary - CORRECT ANSWER Supervision, room, and board provided for those unable to live independently Mobile Diagnostic Services - CORRECT ANSWER Health care services are transported to the patients, especially diagnostic procedures Fee for Service - CORRECT ANSWER Third party payers and/ or patients issue payments to health care providers based on charges assigned to each service performed for each patient Traditional Fee-For-Service - CORRECT ANSWER Third party payers and/ or patients pay health care providers after services have been rendered Managed Fee-For-Service - CORRECT ANSWER Costs are controlled by the managed-care plan's management of members' uses of services; providers are reimbursed by fee schedules Episode of Care - CORRECT ANSWER Health care plan compensates providers with a lump-sum payment to compensate them for all services delivered to a patient for a specific illness and over a specific period of time Resource-Based Relative Value Scale (RBRVS) - CORRECT ANSWER for reimbursement of physician services of beneficiaries covered under Medicare Part B Clinical Practice Guidelines - CORRECT ANSWER Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances Clinical Protocols - CORRECT ANSWER Treatment recommendations often based on guidelines, step-by-step description of an accepted procedure Critical Paths - CORRECT ANSWER Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency Clinical Pathways - CORRECT ANSWER Structured plans of care Care Maps - CORRECT ANSWER Multi-disciplinary standards that outline the processes of care and expected outcomes within predetermined time frames Private Law (Civil Law) - CORRECT ANSWER Recognition and enforcement of the rights and duties of private individuals and organizations Tort - CORRECT ANSWER An injury or wrong committed against an individual or his property. One party asserts wrongful conduct on part of the other and seeks compensation for harm suffered Contract - CORRECT ANSWER Legally enforceable agreements between two or more individuals Public Law - CORRECT ANSWER Deals with relationships between private parties and the government (criminal law and government regulations) Criminal Law - CORRECT ANSWER Prohibits conduct considered injurious to society as a whole and provides for punishment of those found to have engaged in such conduct What is the difference between a CRIME and a TORT - CORRECT ANSWER A crime is an offense against a person or the public at large. A tort is a civil wrong against an individual Statutes - CORRECT ANSWER Statutory law written or enacted by bodies such as the U.S. Congress and state and local legislatures Common Law - CORRECT ANSWER Consists of principles that have evolved over time from court decisions resolving controversies How long does AHIMA recommend keeping an adult patient health record? - CORRECT ANSWER 10 years after most recent encounter How long does AHIMA recommend keeping a minor patient health record? - CORRECT ANSWER From the age of majority (usually 18) plus a statute of limitation governing medical malpractice lawsuits Who owns the physical health record? - CORRECT ANSWER The healthcare provider, physician, or hospital that maintains it Who owns the information within the health record? - CORRECT ANSWER The patient Privacy - CORRECT ANSWER The right of an individual to be left alone What are the three elements of privileged communication? - CORRECT ANSWER 1. Relationship between patient and provider 2. Information must have been acquired through such a relationship 3. Information must have some connection with the provider's task of treating the patient Durable Power of Attorney - CORRECT ANSWER Legal document in which patients name someone close to them to make decisions about their health care in the event they become incapacitated Subpoena - CORRECT ANSWER Court order requiring someone to appear in court to give testimony What can happen if you disregard a subpoena? - CORRECT ANSWER You can be held in contempt of court Subpoena Duces Tecum - CORRECT ANSWER A written order commanding a person to appear, give testimony, and bring all documents(records) described in the subpoena to court Subpoena Ad Testificandum - CORRECT ANSWER Court order that requires a person to appear in court to testify Drug Abuse and Treatment Act (1972) - CORRECT ANSWER Requires drug and alcohol abuse patient records to be kept confidential and not subject to disclosure except as provided by law Heath Care Quality Improvement Act (1986) - CORRECT ANSWER Established the NPDB Patient Self Determination Act (1990) - CORRECT ANSWER Requires that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their health record Privacy Act (1974) - CORRECT ANSWER Gives individuals some control over the information collected about them by the federal government Omnibus Budget Reconciliation Act (1987) - CORRECT ANSWER Created the Nursing Home Reform Act, which ensures residents of nursing homes receive quality care, requires provision of certain services, and establishes a residents' bill of rights Tax Equity and Fiscal Responsibility Act (1936) TEFRA - CORRECT ANSWER Introduced the Peer Review Organization (PRO) program as a component of Medicare law to ensure the quality of care rendered to patients Uniform Business Records as Evidence Act (1936) - CORRECT ANSWER Stipulates that records can be admitted as evidence in a court of law if they were kept in the ordinary course of business. Uniform Healthcare Information Act (1985) - CORRECT ANSWER Serves as a model for state adoption and provides rules about health information management. As of 1996, only Montana and Washington had enacted this legislation [Show Less]
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RHIA Exam Review 116 Questions with Verified Answers,100% CORRECT
RHIA Exam Review 116 Questions with Verified Answers Which one of the following actions would NOT be included int he professional obligations of the hea... [Show More] lth information practitioner that lead to responsible handling of patient health information? A. Educate consumers about their rights and responsibilities regarding the use of their personal health information. B. Extend privacy and security principles into all aspects of the data use, access, and control program adopted in the organization. C. Honor the patient-centric direction of the national agenda. D. Take a compromising position toward optimal interpretation of nonspecific regulations and laws. - CORRECT ANSWER D. Take a compromising position toward optimal interpretation of nonspecific regulations and laws If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the A. date of birth. B. date of admission. C. social security number. D. mother's maiden name. - CORRECT ANSWER A. date of birth Which of the following is NOT a step in developing a health record retention schedule? A. conducting an inventory of the facility's records B. determining the format and location of storage C. assigning all records the same retention period D. destroying records that are no longer needed - CORRECT ANSWER C. assigning all records the same retention period What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79? A. terminal digit B. straight numeric C. social security number D. middle digit - CORRECT ANSWER B. straight numeric If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? A. 2.4% B. 3.5% C. 4.6% D. 5.1% - CORRECT ANSWER A. 2.4% (3,545 x 100) divided by 15,000 = 2.36% = 2.4% Which of the following is NOT an advantage of a centralized filing system? A. There is less transportation time and effort when a facility operates from several sites. B. There is less duplication of effort to create, maintain, and store records. C. Record control and security are easier to maintain. D. There is decreased cost in space and equipment. - CORRECT ANSWER A. There is less transportation time and effort when a facility operates from several sites. In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26? A. 00-06-26 B. 02-06-26 C. 03-06-26 D. 99-99-25 - CORRECT ANSWER A. 00-06-26 The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions would be most effective in reducing the delay in retrieval of requested records? A. Offer a prize to the employee who locates the requested records first. B. Review and possibly reengineer the retrieval process to decrease retrieval time. C. Allow the requesters to retrieve the record themselves. D. Increase file area staff to include one additional file clerk devoted to pulling records for the emergency room. - CORRECT ANSWER B. Review and possibly reengineer the retrieval process to decrease retrieval time. Which one of the following is NOT an advantage of a computerized master patient index? A. It allows access to data alphabetically, phonetically, or by date of birth, social security number, medical record, or billing number. B. It solves most space and retrieval problems. C. It provides other departments with immediate access to the information maintained in the master patient index. D. Duplication of patient registration can never occur. - CORRECT ANSWER D. Duplication of patient registration can never occur. Color coding of record folders is used to assist in the control of A. record tracking. B. loose reports. C. record completion. D. misfiles. - CORRECT ANSWER D. misfiles. Information found in which of the following would not be considered secondary data? A. disease index B. implant registry C. health record D. National Practitioner Data - CORRECT ANSWER C. health record Under the Patient Self-Determination Act of 1990, evidence of advance directives A. are required to be documented in the health record. B. are not required to be documented int he health record. C. require a doctor's approval. D. must be prepared by an attorney. - CORRECT ANSWER A. are required to be documented in the health record. A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? A. 6 B. 8 C. 10 D. 12 - CORRECT ANSWER D. 12 200 units x 6 shelves per unit = 1,200 shelves total 1,200 shelves divided by 100 primary numbers (00-99) = 12 shelves per primary number A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken? A. Return inactive records to each individual patient. B. Destroy records of all deceased patients. C. Destroy inactive records that exceed the statute of limitations. D. Maintain the records indefinitely in hard copy. - CORRECT ANSWER C. Destroy inactive records that exceed the statute of limitations. Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital? A. terminal digit B. unit C. straight numeric D. serial unit - CORRECT ANSWER C. straight numeric What is the chief criterion for determining record inactivity? A. Medicare's definition of inactivity B. amount of space available for storage of newer records C. efficiency of microfilming D. preference of the medical staff - CORRECT ANSWER B. amount of space available for storage of newer records Out of 2,543 records requested from the HIM Department, 2,375 were located. What is the filing accuracy rate? A. 6.61% B. 75.33% C. 89.01% D. 93.39% - CORRECT ANSWER D. 93.39% (2,375 records retrieved from proper locations x 100) divided by 2,543 records requested = 93.39% filing accuracy Which set of records filed consecutively on a shelf displays terminal digit filing order? A. 00-79-99, 00-79-01, 99-78-99 B. 57-78-00, 57-78-01, 56-78-99 C. 99-05-26, 01-06-26, 49-04-02 D. 55-55-55, 33-33-33, 44-44-44 - CORRECT ANSWER B. 57-78-00, 57-78-01, 56-78-99 In the master patient index, which is filed by last name, Jill Thomas-Jones would be A. J-I-L-L-T-H-O-M-A-S-J-O-N-E-S B. T-H-O-M-A-S-J-O-N-E-S,J-I-L-L C. T-H-O-M-A-S,J-I-L-L-J-O-N-E-S D. J-O-N-E-S,J-I-L-L-T-H-O-M-A-S - CORRECT ANSWER B. T-H-O-M-A-S-J-O-N-E-S,J-I-L-L According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30? A. 99-98-30 B. 00-00-31 C. 01-00-31 D. 99-99-31 - CORRECT ANSWER B. 00-00-31 How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals require that patient health records be retained for at least ________ years unless a longer period is required by state or local laws. A. 3 B. 5 C. 7 D. 10 - CORRECT ANSWER B. 5 Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be A. 5 years. B. 7 years. C. 10 years. D. either 5 or 7 years, as determined by the facility. - CORRECT ANSWER B. 7 years Which of the following technologies works best with automated record-tracking systems to speed the data entry process? A. discharge lists B. bar codes C. compressible filing units D. computerized chart-out slips - CORRECT ANSWER B. bar codes A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased? A. 11 B. 12 C. 13 D. 14 - CORRECT ANSWER D. 14 2,540 + 400 = 2,940 inches needed 36 x 6 = 216 inches per unit 2,940 (inches needed) divided by 216 (inches per unit) = 13.61 shelves You must buy 14 units because you cannot purchase a 0.14 filing shelf. Microfilmed records are considered A. inadmissible evidence. B. never admissible as hearsay evidence. C. acceptable as courtroom evidence. D. not admissible as secondary evidence. - CORRECT ANSWER C. acceptable as courtroom evidence. A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2016. Which of the following indices would be the best source in locating the needed records? A. master patient index B. physician index C. disease index D. operation index - CORRECT ANSWER C. disease index Which item is collected and maintained in the organ transplant registry? A. vaccine manufacturer B. histocompatibility information C. cytogenetic results D. stage at the time of diagnosis - CORRECT ANSWER B. histocompatibility information Which of the following is NOT a mandatory disclosure according to the HIPAA Privacy Rule? A. emergencies concerning public health B. quality assurance reviews by authorized authorities C. instances concerning victims of domestic violence D. reporting of traffic fatalities - CORRECT ANSWER D. reporting of traffic fatalities Which of the following should NOT be included in the documentation of record destruction? A. statement that records were destroyed in the normal course of business B. method of destruction C. signature of the individuals supervising and witnessing the destruction D. dates not covered in destruction - CORRECT ANSWER D. dates not covered in destruction If the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number? A. 8 B. 10 C. 12 D. 100 - CORRECT ANSWER A. 8 8 shelves per unit x 100 units = 800 total shelves 800 shelves divided by 100 primary digits (00-99) = 8 shelves per primary digit Which of the following is NOT a consideration when implementing a disaster plan? A. Include disaster training in staff orientation. B. Establish a plan for conducting drills. C. Provide staff with tools needed to implement the plan. D. Test the disaster plan only once. - CORRECT ANSWER D. Test the disaster plan only once. Which of the following lists is in correct alphabetical order? A. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip; Ferlazzo, J. B. Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P. Ferlazzo, Joshua Philip C. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, J.; Ferlazzo, Joshua Philip D. Ferlazzo, Joshua A.; Ferlazzo, B.; Ferlazzo, Joshua; Ferlazzo, Joshua Philip - CORRECT ANSWER B. Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip Mary Schnering was admitted to Community Hospital on 10/3/15 and assigned a record number of 54-47-53. The patient was later admitted on 1/14/16 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/filing system is being used at Community Hospital? A. serial-unit B. serial C. unit D. terminal digit - CORRECT ANSWER A. serial-unit Capital Health Center is moving to a new facility in December 2016. The CEO is projecting a conversion to an electronic health record system by then. This new facility will not include space for filing of paper-based health records. Which of the following items would not be considered when planning this conversion? A. changing role of department functions and work flow B. challenges of maintaining records that are partially paper and partially electronic C. whether to scan older paper records D. relationship with the microfilm vendor - CORRECT ANSWER D. relationship with the microfilm vendor What microform should the HIM practitioner select if the records must be unitized and color-coded for filing purposes? A. roll microfilm B. cartridge C. jacket microfilm D. cassette - CORRECT ANSWER C. jacket microfilm What is the business of buying and selling information as a commodity? A. information brokering B. e-health consumerism C. telehealth D. competitive data - CORRECT ANSWER A. information brokering At Community Hospital the average admission will create a file that will take up 0.25 inch of file space. Each new ER record requires 0.125 inch of file space. Approximately 25,000 new patients are admitted per year and 15,000 ER patients are treated per year. The shelving cost is $1.05 per filing inch. How much money should be allocated for storage space in next year's budget? A. $8,531.25 B. $8,125.00 C. $853.25 D. $1,875.00 - CORRECT ANSWER A. $8,531.25 25,000 inpatients x 0.25 inch/record = 6,250 inches 15,000 ER patients x 0.125 inch/record = 1,875 inches 6,250 inches + 1,875 inches = 8,125 total inches of filing space/year 8,125 total inches x $1.05/filing inch = $8,531.25 budget allocation for storage space On his 12/23/16 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous number assigned to Mr. Robinson during a 9/1/16 admission was 07-10-47. In a serial numbering/filing system, how would these records be filed? A. Both records are combined under 07-10-47. B. Both records are combined under 07-23-38. C. Each admission is filed under its own number. D. Previous records are brought forward and filed under the latest number issued. - CORRECT ANSWER C. Each admission is filed under its own number. The same patient was admitted on three different occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be used given the following information? Admitted 5/04/16 Patty Miller 23-33-56 Admitted 6/05/16 P. J. Miller 25-56-88 Admitted 9/27/16 Patricia Miller 27-12-12 A. Void the first and last numbers and file all admissions under 25-56-88. B. Delete all previous numbers and assign a completely new number. C. Void the first two numbers and file all admission under 27-12-12. D. Void the last two numbers and file all admissions under 23-33-56. - CORRECT ANSWER D. Void the last two numbers and file all admissions under 23-33-56. The health care providers in an acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should A. staff the department with personnel 24 hours a day. B. be on call every evening and weekends for emergency requests. C. train security guards to retrieve records after the department closes. D. arrange for records to be retrieved at 7:00 AM every morning. - CORRECT ANSWER A. staff the department with personnel 24 hours a day. As a prerequisite in the implementation of an electronic health record, what process would facilitate automatic indexing? A. redesigning forms to include bar codes B. removing portions of the patient record that will not be scanned C. converting all microfilm to optical disk format D. scanning only emergency room records initially - CORRECT ANSWER A. redesigning forms to include bar codes Which of the following is NOT a data retrieval tool? A. light pen B. SQL C. color, animation, sound icons D. screen design - CORRECT ANSWER A. light pen A HIM Department wants to buy new open-shelf filing units for its file expansion. Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average record is 1-inch thick. How many filing units should be purchased? A. 2 B. 4 C. 6 D. 8 - CORRECT ANSWER C. 6 33 inches per shelf x 6 shelves per unit = 198 linear filing inches per unit 1,000 records x 1 inch per record = 1,000 inches of records to be filed 1,000 (inches of records needed) divided by 198 inches per unit = 5.05 filing units In order to provide for the total expansion, 6 filing units need to be purchased. Which of the following statements is FALSE when addressing characteristics of the legal health record in an electronic document management system? A. The storage media used and the format of the scanned documents must protect data from loss and damage. B. The storage format must be efficient, manageable, and in compliance with laws and regulations. C. The backup and disaster recovery process is certified to ensure that all data can be recovered. D. Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems. - CORRECT ANSWER D. Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems. Which of the following is NOT a document input device in the electronic document management system? A. scanner B. bar codes C. printer D. touch screen - CORRECT ANSWER C. printer The master patient index must, at a minimum, include sufficient information to A. summarize the patient's medical history. B. list all physicians who have ever treated the patient. C. uniquely identify the patient. D. justify the patient's hospital bill. - CORRECT ANSWER C. uniquely identify the patient. Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital? A. National Practitioner Data Bank B. Healthcare Integrity and Protection Data Bank C. MEDPAR file D. State Administrative Data Bank - CORRECT ANSWER A. National Practitioner Data Bank It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed? A. discharge summaries B. physician names C. nursing notes D. dates of admission, discharge, and encounters - CORRECT ANSWER D. dates of admission, discharge, and encounters A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors? A. statute of limitations B. volume of research C. readmission rate D. department staffing - CORRECT ANSWER D. department staffing Which of the following is NOT a benefit of the electronic document management system in the HIM department? A. online availability of information B. multiuser simultaneous access C. decreased use of computer technology D. system security and confidentiality - CORRECT ANSWER C. decreased use of computer technology Which of the following is an advantage of straight numeric filing over terminal digit filing? A. All sections of the file expand uniformly. B. The training period is short. C. Work can be evenly distributed, causing accountability for accuracy in each of the 100 sections. D. Inactive records can be purged evenly. - CORRECT ANSWER B. The training period is short. Which one of the following is NOT an electronic document management system component? A. scanner B. file server C. laser printer D. reader-printer - CORRECT ANSWER D. reader-printer Which of the following items is the health information manager primarily concerned with when purchasing file guides? A. cost and color B. durability and visibility C. cost and visibility D. color and durability - CORRECT ANSWER B. durability and visibility Palm Beach Healthcare Center has been in operation for 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admissions per year from now on. There are 2,500 linear feet of filing space available and half is being used. The facility expects a 30% readmission rate. If a unit numbering/filing system is used, how many file folders will be needed for the next year? A. 1,800 B. 1,860 C. 4,340 D. 6,200 - CORRECT ANSWER C. 4,340 6,000 admissions (year currently) + 200 additional admissions/year = 6,200 total admissions next year 6,200 total admissions x 30% readmission rate = 1,860 readmissions next year 6,200 - 1,860 readmissions = 4,340 new file folders needed for next year As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to A. install a computerized access control panel. B. hire a security guard to monitor entrance to the file area. C. convert from a terminal digit filing system to serial unit filing. D. utilize a sign-in and sign-out log for admittance to the file area. - CORRECT ANSWER A. install a computerized access control panel Which one of the following is NOT a technical security control employed by electronic health record systems? A. audit trails B. data encryption protocols C. user-based access controls D. automatic logon - CORRECT ANSWER D. automatic logon The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information? A. patient register B. disease index C. operation index D. birth defects register - CORRECT ANSWER C. operation index A major consideration in a hospital or facility closure is to A. notify all patients to pick up their original records by the date of closure. B. seek approval for destruction of all records with a last date of treatment over 3 years ago. C. ensure that authorized parties have access to the information as provided by law. D. arrange for donating the records to an HIA/HIT education program for student use. - CORRECT ANSWER C. ensure that authorized parties have access to the information as provided by law. What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program? A. 70% B. 80% C. 90% D. 100% - CORRECT ANSWER C. 90% In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing? A. who completes the list of what records are to be stored B. what are the billing terms C. who will purge inactive files for transfer D. confidentiality policies and liability concerns - CORRECT ANSWER D. confidentiality policies and liability concerns Which index is used by the HIM department to link the patient's name and number in relation to access and retention of the patient record? A. physician index B. disease index C. master patient index D. operation index - CORRECT ANSWER C. master patient index Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long? A. age of majority plus statute of limitation B. 10 years after the most recent encounter C. 10 years after the age of majority D. permanently - CORRECT ANSWER A. age of majority plus statute of limitation A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data? A. overwriting data with a series of characters B. disk reformatting C. magnetic degaussing D. overwriting the backup tapes - CORRECT ANSWER C. magnetic degaussing Which of the following statements would be found in the laboratory report section of the health record? A. BUN reported as 20 mg B. Morphine sulfate gr. 1/4 q.4h. for pain C. IV sodium Pentothal 1% started at 9:05 AM D. TPR recorded g.h. for 12 hours - CORRECT ANSWER A. BUN reported as 20 mg Which of the following is a disadvantage of terminal digit filing as compared to straight numeric filming? A. File personnel are crowded in the highest numbers. B. Inactive records are pulled from one common area. C. The training period is slightly longer. D. Files expand at the end of the umber series, requiring back shifting. - CORRECT ANSWER C. The training period is slightly longer. What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms? A. past medical history B. social and personal history C. chief complaint D. review of systems - CORRECT ANSWER D. review of systems Electronic health record built-in tools that can make data capture easier include all but which one of the following? A. data dictionaries B. flow process charts C. automated quality measures D. clinical decision support systems - CORRECT ANSWER B. flow process charts If the department staff are having trouble locating the terminal digit sections quickly, the supervisor could add more A. outguides. B. file guides. C. requisitions. D. staff. - CORRECT ANSWER B. file guides. The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should A. issue a copy of the birth certificate from the patient's record. B. direct the request to the state's office of vital records. C. direct the request to the attending physician. D. issue a copy of the newborn's record. - CORRECT ANSWER B. direct the request to the state's office of vital records. A surgeon requests the name of a patient he admitted on January 11, 2017. Which of the following would be used to retrieve this information? A. physician index B. number index C. R-ADT system D. operation index - CORRECT ANSWER C. R-ADT system Of 750 records filed during the week, 75 were not located. What is the filing error rate? A. 10% B. 90% C. 0.1% D. 0.9% - CORRECT ANSWER A. 10% Where in the health record would the following statement be located? "Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"? A. operative report B. pathology report C. anesthesia report D. radiology report - CORRECT ANSWER B. pathology report Which of the following is NOT a factor to consider when developing a record retention program? A. legal requirements as determined by statute of limitations B. record usage in the facility determined by health care provider activity C. reimbursement guidelines D. cost of space to maintain paper records - CORRECT ANSWER C. reimbursement guidelines When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data? A. audit control B. person or entity authentication C. transmission security D. access control - CORRECT ANSWER D. access control When evaluating an outside contract microfilm company, all but which of the following are important factors to rate? A. cost B. emergency returns C. storage after filming D. cache memory - CORRECT ANSWER D. cache memory Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements? A. method of destruction or disposal B. time that will elapse between acquisition and destruction or disposal C. safeguards against breaches D. the hospital's liability insurance in specified amounts - CORRECT ANSWER D. the hospital's liability insurance in specified amounts The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of? A. concurrency B. access C. integrity D. cost - CORRECT ANSWER B. access When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow? A. Security training is provided to all levels of staff. B. Patients are not educated about their right to confidentiality of health information. C. The information system encourages mass copying, printing, and downloading of patient records. D. When paper-based records are no longer needed, they are bundled and sent to a recycling center. - CORRECT ANSWER A. Security training is provided to all levels of staff. Which of the following features should NOT be considered when designing screens to capture quality health data? A. a prompt for more information B. built-in alerts to notify users of possible errors C. the use of abbreviations on data fields D. left to right and bottom to top formatting - CORRECT ANSWER D. left to right and bottom to top formatting When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT A. state laws and licensing standards. B. Communities of Practice requirements. C. needs of patients. D. Medicare requirements. - CORRECT ANSWER B. Communities of Practice requirements. Case finding methods for patients with diabetes include a review of all but which one of the following? A. health plans B. CPT diagnostic codes C. billing data D. medication lists - CORRECT ANSWER B. CPT diagnostic codes What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft? A. budget B. disaster C. case management D. patient care - CORRECT ANSWER B. disaster Which of the following is NOT an alternative storage method for paper-based records? A. microfilm B. optical imaging C. computer D. outguide - CORRECT ANSWER D. outguide Which of the following issues would be of LEAST concern when storing health records in off-site storage? A. operating hours of the storage facility B. safety and confidentiality procedures C. filing order of the records D. procedure for request of a record in an emergency - CORRECT ANSWER C. filing order of the records The HIM Department maintains 500,000 records and responds to 5,000 requests for records in a given period of time. What is the record usage rate? A. 0.01% B. 1% C. 5% D. 10% - CORRECT ANSWER B. 1% (5,000 x 100) divided by 500,000 = 1% Which one of the following is NOT a data retrieval tool? A. color B. sound C. point-and-click fields D. icons - CORRECT ANSWER C. point-and-click fields When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract? A. who performs record preparation B. provision for destruction of original records C. type of reader or printer needed to view the microfilm D. confidentiality of information being filmed - CORRECT ANSWER C. type of reader or printer needed to view the microfilm What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital? A. storing the records off-site at a cost of $25,000 per year B. scanning all 250,000 records for a cost of $195,000 C. purging and storing all death records off-site at a cost of $20,000 per year D. destroying all records older than 3 years for a cost of $50,000 - CORRECT ANSWER B. scanning all 250,000 records for a cost of $195,000 The total number of records filed during the month is 2,500 and, upon completion of a filing accuracy study, 90 records were not found. What is the accuracy rate for filing? A. 1% B. 4% C. 28% D. 96% - CORRECT ANSWER D. 96% 2,500 - 90 = 2,410 (2,410 x 100) divided by 2,500 = 96.4% filing accuracy A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the A. accuracy of analyzing records. B. number of incomplete records. C. inclusion of late reports. D. tracking of release of information requests. - CORRECT ANSWER C. inclusion of late reports. According to AHIMA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently? A. physician index B. register of births C. register of surgical procedures D. register of deaths - CORRECT ANSWER A. physician index For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which of the following elements? A. unique and serialized transaction number B. location of destruction C. patient notification D. acceptance of fiduciary responsibility - CORRECT ANSWER C. patient notification The steps in developing a record retention program include all but which of the following? A. determining the storage format and location B. notifying the courts of the destruction C. assigning each record a retention period D. destroying records that are no longer needed - CORRECT ANSWER B. notifying the courts of the destruction A health care facility as received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the A. newborn records. B. state bureau of vital statistics. C. maternal records. D. birth defects registry. - CORRECT ANSWER D. birth defects registry. An example of a primary data source is the A. physician index. B. health record. C. cancer registry. D. hospital statistical report. - CORRECT ANSWER B. health record Which of the following is NOT considered a challenge in the adoption of an electronic health record system? A. design of the work flow and processes B. physician willingness to adopt C. contribution to the quality of patient care D. individual state legal and regulatory issues - CORRECT ANSWER C. contribution to the quality of patient care Fetal monitoring strips are part of the _________ record and should be maintained _________. A. newborn's; 10 years past the age of majority B. mother's; according to the length of time required for a minor's records C. newborn's; according to the time period specified in the state's statute of limitations D. mother's; 10 years - CORRECT ANSWER B. mother's; according to the length of time required for a minor's records Which one of the following would NOT be a strategy when purchasing an electronic health record system? A. Recognize stakeholders from different organizational levels and engage them appropriately. B. Determine return on investment or cost-benefit analysis. C. Identify system requirements. D. Broaden the vendor field and select several vendors of choice. - CORRECT ANSWER D. Broaden the vendor field and select several vendors of choice. How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained? A. 5 B. 7 C. 30 D. permanently - CORRECT ANSWER C. 30 What data cannot be retrieved from the MEDPAR? A. ICD-10-CM diagnosis codes B. Charges broken down by specific types of services C. Non-Medicare patient data D. Data on the provider - CORRECT ANSWER C. Non-Medicare patient data Which of the following is NOT a major management challenge in the storage and retention of electronic health record systems? A. following state and federal laws and accreditation requirements when developing retention and destruction policies B. keeping technology updated in order to retrieve data C. ensuring that health information can be retrieved in a timely manner D. maintaining the paper-based storage system - CORRECT ANSWER D. maintaining the paper-based storage system General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity? A. desktop publishing B. word processing C. database management system D. command interpreter - CORRECT ANSWER C. database management system The Director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Director's response? A. decreased clinical documentation errors B. increased work efficiency C. faster access to health data D. elimination of the need for expensive desktop computers - CORRECT ANSWER D. elimination of the need for expensive desktop computers The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed? A. Visit corporate headquarters of the vendor. B. Perform a vendor reference check. C. Read consumer reports before buying. D. Test the software prior to purchase. - CORRECT ANSWER D. Test the software prior to purchase. Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate all but which of the following? A. security controls and access privileges of staff B. policies and procedures developed to safeguard privacy and security C. use of a back-up system D. salary for the database administrator - CORRECT ANSWER D. salary for the database administrator Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used? A. HTML B. SQL C. XML D. data dictionary - CORRECT ANSWER B. SQL The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they more through the completion process. What departmental function is this most useful for? A. release of information B. coding C. chart tracking D. transcription - CORRECT ANSWER C. chart tracking The hospital administrator is making a strategic decision by queering various institutional databases for information. What type of system is the hospital administrator using? A. electronic health record system B. results reporting system C. financial information system D. executive information system - CORRECT ANSWER D. executive information system University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using? A. intranet B. extranet C. Internet D. clinical information system - CORRECT ANSWER D. clinical information system The HIM practitioner's duty to retain health information via the archiving and storage of health data includes all but which of the following? A. strategies that consider accessibility, natural disasters, and innovations in storage technology B. strategies ensuring that inactive records are as secure as active records C. a retention plan for multiple volumes of records D. a retention plan for financial data - CORRECT ANSWER D. a retention plan for financial data As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system? A. authentication B. encryption C. disaster recovery plan D. stonewall - CORRECT ANSWER D. stonewall Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(an) A. interfaced system. B. integrated system. C. OLAP. D. standard. - CORRECT ANSWER A. interfaced system. The function of a(an) ________ is limited to data retrieval. A. electronic health record B. executive information system C. database management system D. clinical data repository - CORRECT ANSWER D. clinical data repository The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry? A. Enhanced databases will provide information for improved clinical care. B. Training will be offered by the hospital. C. Those physicians not in compliance will be denied admitting privileges. D. Multiple users will not have access to the same information simultaneously. - CORRECT ANSWER A. Enhanced databases will provide information for improved clinical care. University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs? A. application service provider model B. clinical workstation C. IBM Medical Information Systems Program D. legacy system - CORRECT ANSWER A. application service provider model A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would A. be filed in a health record created for the infant. B. be filed in the mother's record. C. be retained in a separate file in the administrative offices. D. not be retained in hospital records. - CORRECT ANSWER B. be filed in the mother's record. [Show Less]
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RHIA Exam Prep 35 Questions with Verified Answers,100% CORRECT
RHIA Exam Prep 35 Questions with Verified Answers What term is used in reference to objective descriptions of processes, procedures, people, and other... [Show More] observable objects and activities? - CORRECT ANSWER Data Which of the following processes is an ancillary function of the health record? - CORRECT ANSWER Biomedical Research What term is used in reference to electronically accessed information that provides physicians with pertinent health information beyond the health record itself? - CORRECT ANSWER Clinical Practice Guidelines To which of the following authorities do hospitals report vital statistics? - CORRECT ANSWER National Vital Statistics System An attempt to contain hospital inpatient costs and improve quality by restructuring services is called: - CORRECT ANSWER Patient-focused care What organization was established in 1847 to represent the interests of physicians across the United States? - CORRECT ANSWER American Medical Association Today, to practice medicine, medical school students must pass a test before they can obtain a: - CORRECT ANSWER License For healthcare organizations, this modern process began with the adoption of the Minimum Standards: - CORRECT ANSWER Accreditation Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? - CORRECT ANSWER Credentialing Which of the following is a mechanism that records and examines activity in information systems? - CORRECT ANSWER Audit controls Which of the following is the goal of quantitative analysis performed by HIM professionals? - CORRECT ANSWER Identifying deficiencies early so they can be completed What are LONIC codes used for? - CORRECT ANSWER Identifying test results While the focus of inpatient data collection is on the principle diagnosis, the focus of outpatient data collection is on the: - CORRECT ANSWER Reason for encounter The inpatient data set incorporated into federal law and required for Medicare reporting is the: - CORRECT ANSWER Uniform Hospital Discharge Data Set In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? - CORRECT ANSWER X12N This document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a LTCH. - CORRECT ANSWER Care Plan Which of the following is a component of the Resident Assessment Instrument? - CORRECT ANSWER A standard Minimum Data Set Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? - CORRECT ANSWER Nurse working on the unit where the patient is located Who is responsible for ensuring the quality of health record documentation? - CORRECT ANSWER Provider Of the following, what is the most likely to happen to the health records of a physician's patient when a physician leaves an office practice? - CORRECT ANSWER It will be retained by the practice Which health record format is arranged in chronological order with documentation from various sources intermingled? - CORRECT ANSWER Electronic Staff disagreements within the health record should be: - CORRECT ANSWER Avoided Mrs. Bolton is an angry patient who resents her physicians "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is: - CORRECT ANSWER Noncompliant and hostile toward staff The___is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for Long-term Care (MDS). - CORRECT ANSWER Resident Assessment Instrument One technology used for computer-assisted coding is: - CORRECT ANSWER Natural language processing A barrier to effective computer-assisted coding is the: - CORRECT ANSWER Poor quality of documentation According to the UHDDS definition, ethnicity should be recorded on a patient record as: - CORRECT ANSWER Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown A coding supervisor checks coding quality each month by having two or more coders code the same set of records and then comparing the results. This process addresses the data quality element of: - CORRECT ANSWER Reliability A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is: - CORRECT ANSWER Continuity of Care Record A consumer interested in comparing the performance of health plans should review data from: - CORRECT ANSWER HEDIS Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and: - CORRECT ANSWER CMS A computer software program that supports a coder in assigning correct codes is called a(n): - CORRECT ANSWER Encoder Diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? - CORRECT ANSWER Inpatient Patient has HIV with disseminated candidiasis; what is the correct code assignment? - CORRECT ANSWER 042, 112.5 A 65 year old woman was admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? - CORRECT ANSWER 038.11, 562.11 [Show Less]
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RHIA AHIMA practice Test 108 Questions with Verified Answers,100% CORRECT
RHIA AHIMA practice Test 108 Questions with Verified Answers Processing - CORRECT ANSWER Domain 2 Classifying, sorting, storing and retrieving data are... [Show More] all characteristics of which system component? 1. Output 2. Feedback 3.Processing 4.Input K81.2, OFT40ZZ, OFJ44ZZ - CORRECT ANSWER Domain 1 The patient is taken to the OR for a laparoscopic gallbladder removal secondary to acute and chronic cholecystitis. The surgeon encounters difficulty secondary to the patients body habitus and converts this to an open procedure. The correct code assignment is? 1. K81.0, K81.1, OFT44ZZ 2. K80.12,OFT40ZZ, 3. K81.2, OFT40ZZ, OFJ44ZZ 4. K81.2.,OFT40ZZ, OFT44ZZ E11.52, OY6X0Z0 - CORRECT ANSWER Domain 1 A patient is admitted with gangrenous changes in the right fifth toe secondary to peripheral vascular disease resulting from long standing diabetes mellitus. Amputation of this toe at the metartarsophalangeal joint occurs in an effort to halt the current disease process. 1. E11.52, OY6X0Z0 2. I70.260, E11.9, OY6X0Z0 3. I96, I73.9, E11.9, OY6X0Z0 4. E11.52, I70.261, OY6X0Z0 Unit - CORRECT ANSWER Domain 4 The Admitting Department manager at a hospital provided admitting "scenarios" for the staff. Which kind of system testing uses scenarios? 1. Unit 2. Parallel 3. Stress 4. Integrated Privacy - CORRECT ANSWER Domain 2 A patient deploys a personal health record and established an access list for the personal health record, which includes only the patient and the patient's treating healthcare providers. In limiting access, the patient has excised the right to: 1. Confidentiality 2. Security 3. Privacy 4. Integrity I50.9 I10 - CORRECT ANSWER Domain 1 A patient presents to the ER with lower extremity edema, some chest heaviness, and dyspnea. The BNP and chest x-ray performed in the ER demonstrate pulmonary edema and a grossly elevated BNP. She is admitted to the hospital with congestive heart failure and essential hypertension. The code assignment is 1. I11.9 2. I11.0, I50.9 3.R60.9, R06.00, I50.9, I10 4. I50.9, I10 Maintenance/Evaluation - CORRECT ANSWER Domain 3 Which phase of the SDLC is missing from the list below? -Analysis -List -Implementation 1. Disposition/Disposal 2. Maintenance/Evaluation 3. Acquisition/Development 4. Operations/Maintenance Data Quality - CORRECT ANSWER Domain 1 Accuracy, currency, and relevance are examples of? 1. Data accessibility 2. Data collection 3. Data Analysis 4. Data Quality Once a year - CORRECT ANSWER Domain 5 Job descriptions should be reviewed: 1. Every six months 2. Once a year 3. Every other year 4. Every two years Movement Diagram - CORRECT ANSWER Domain 4 One of the best tools to aid in the determination of the location and reduction in bottlenecks which impede the coding process is the: 1. Movement diagram 2. Gantt chart 3. Pareto chart 4. Decision grid Patient Census - CORRECT ANSWER Domain 1 A hospital staff member goes to each patient's room and physically checks to see if they are in bed. The staff member's patient head count is used to calculate the: 1. Patient census 2. Inpatient daily census 3. Outpatient service days 4. Inpatient service days Firewall systems - CORRECT ANSWER Domain 2 Which security measure is based on pre-established rules that allow or deny access to a network or exchange of information between networks? 1. Encryption technology 2. Phishing technology 3. Firewall systems 4. Cryptography Mining - CORRECT ANSWER Domain 3 The process of searching through large volumes of data for cluster patterns is known as data: 1. Mapping 2.Mining 3.Repository 4.Mart A combination of electronic and paper chart - CORRECT ANSWER Domain 1 Which of the following is the definition of a hybrid record? 1. An EHR with little access to digital ima 2. A complete electronic health record 3. A combination of electronic and paper chart 4. None of the above Pie chart - CORRECT ANSWER Domain 3 The data display tool used to show how each component contributes to the total process is a: 1. Line graph 2. Pie chart 3. Scatter diagram 4. Bar graph 60 feet - CORRECT ANSWER Domain 2 The amount of work space allocation for clerical employees in square fee is 1. 60 2. 90 3. 100 4. 120 PPS (Prospective Payment System) - CORRECT ANSWER Domain 2 The Tax Equity and Fiscal Responsibility Act (TEFRA) created which of the following organizations: 1. PPO 2. PPS 3. QIO 4. PRO Structure measure - CORRECT ANSWER Domain 3 The number of nurses per patient is a ratio that is monitored and assessed as part of an organization's performance improvement program. According to Donabedian's quality assessment model, this is an example of a(n): 1. Outcome measure 2. Process measure 3. Outlier measure 4. Structure measure Mission - CORRECT ANSWER Domain 1 An organization provides a broad statement created to set it apart from all other similar entities. This statement is known as the: 1. Vision 2 Mission 3. Opportunity 4. Value Intranet - CORRECT ANSWER Domain 2 A hospital has an internet-based system, only accessible to its employees, that lists all job vacancies. This system would be called a(n): 1. Demilitarized zone 2. Virtual private network 3. Intranet 4. Extranet Forced distribution - CORRECT ANSWER Domain 5 A method of performance appraisal of employee ranking. One of the most employed methods is "simple ranking." The other method is: 1. Forced distribution 2. Critical incident 3. Behavioral rating 4. Graphic rating scales At will - CORRECT ANSWER Domain 5 An employment contract without a specified length of time, in which either party can terminate with or without cause is known as: 1. Implied 2. At will 3. Good faith 4. Tort law Delineating privilege - CORRECT ANSWER Domain 2 The Department of Surgery at a hospital is determining if it will allow a surgeon to perform Cyberknife surgery. This process is known as: 1. Delineating privilege 2. Verifying background 3. Validating society membership 4. Processing application EMTALA- Emergency Medical Treatment and Labor Act - CORRECT ANSWER Domain 2 The legislation enacted to reduce the inappropriate transfer of patients for financial reasons is known as: 1. HIPPA 2. EMTALA 3. FMLA 4. ERISA Processing mortality statistics - CORRECT ANSWER Domain 1 In addition to promoting international comparability; the International Classification of Disease was originally designed as a means for: 1. Processing mortality statistics 2. Reimbursement method 3. Quality initiatives 4. Global health care Business associate contracts - CORRECT ANSWER Domain 2 Which of the following is an example of an administrative safeguard under the HIPAA security rule? 1. Access controls 2. Business associate contracts 3. Person authentication 4. Devices and media controls Analysis - CORRECT ANSWER Domain 3 A hospital considers purchasing a new hospital information system. The Information Systems department begins to survey system users. The hospital is is which phase of the Systems Development Life Cycle? 1. Analysis 2. Implementation 3. Design 4. Maintenance/evaluation Continuous speech input - CORRECT ANSWER Domain 2 Various levels of speech recognition attainable today. The type of input that does not require the user to pause between words to let the computer distinguish between the beginning and ending of the words is: 1. Confidential speech input 2. Normal speech input 3. Continuous speech input 4. Absolute speech input Process measure - CORRECT ANSWER Domain 3 Patient education at discharge is monitored and assessed s part of an organization's performance improvement program. According to Donabedian's quality assessment model, this is an example of a(n): 1. Process measure 2. Outlier measure 3. Outcome measure 4. Structure measure Work simplification - CORRECT ANSWER Domain 2 Eliminate, combine and improve are fundamentals objectives of: 1. Productivity 2. Benchmarking 3. Problem solving 4. Work simplification Demographic - CORRECT ANSWER Domain 1 Patient name, address, and social security number are examples of what type of information? 1. Administrative 2. Quantitative 3. Qualitative 4. Demographic Diversity training - CORRECT ANSWER Domain 5 A health care facility conducts annual education programs for creating an environment that fosters tolerance and appreciation of individual differences within the facility's workforce. This is known as: 1. Diversity training 2. Performance counseling 3. Customer service training 4. New employee orientation Notice of Privacy Practices - CORRECT ANSWER Domain 2 A patient is given a document on admission describing how the hospital may use or disclose the patient's protected health information. As required by HIPAA law, what is the name of this document? 1. Notice of privacy practices 2. Authorization of patient information 3. Request to amend the designated record 4. Consent for treatment Evaluation - CORRECT ANSWER Domain 3 EHR implementation impacts staffing in all health care organizations Studies are performed to determine the relative worth or each position in an organization. The process is called job: 1. Ranking 2. Grading 3. Evaluation 4. Significance ORYX Core Measures - CORRECT ANSWER Domain 2 A data analyst in the HIM department is abstracting data from health records with diagnoses of acute myocardial infarction, heart failure, and pneumonia for assessing organizational performance. This is to comply with: 1. Uniform Hospital Discharge Data Set (UHDDS) 2. ORYX core measures 3. Physician Quality Reporting Initiative (PQRI) 4. National Patient Safety Goals (NPSG) Accounts payable - CORRECT ANSWER Domain 4 All of the following are examples of an asset EXCEPT: 1. Accounts Receivable 2. Inventory 3. Accounts Payable 4. Buildings Monthly - CORRECT ANSWER Domain 3 A hospital is in the early stages of EHR implementation. The HIM manager has been identified as the project manager for the scanning of the paper records into the hybrid EHR system. How often should the manger report on the status of this component of the project? 1. Daily 2. Weekly 3. Monthly 4. Quarterly GEM's - CORRECT ANSWER Domain 3 The mapping tool used to transition from ICD-9 to ICD 10 is known as: 1. GEMs 2.APC's 3.RAC's 4.MS-DRGs Bridge - CORRECT ANSWER Domain 1 HIM professionals often need to explain concepts to a variety of audiences. The metaphor that is frequently used to help illustrate the technologies along the migration path to the electronic health record is a: 1. Linkage 2. Pyramid 3. Stairway 4. Bridge Defensibility - CORRECT ANSWER Domain 2 the Sherman Antitrust Act relates to which characteristic of peer review? 1. Defensibility 2. Consistency 3. Usefulness 4. Timeliness Motivation - CORRECT ANSWER Domain 5 Providing staff with a sense of ownership, opportunity to succeed, and encouraging new ideas and elements are associated with: 1. Motivation 2. Work simplification 3. Benchmarking 4. Methods improvement Audit trails - CORRECT ANSWER Domain 2 Which security measures exists in an EHR system to provide evidence of information system activity such as log-ins, log-outs, and file accesses? 1. Access controls 2. Audit trails 3. Password changes 4. Firewalls Mapping - CORRECT ANSWER Domain 3 The process of cross-referencing between a current terminology system and the new terminology system is known as data: 1. Mapping 2. Mining 3. Dictionary 4. Repository The Joint Commission - CORRECT ANSWER Domain 2 Health care facilities strive to comply with national patient safety goals in their mission to provide safe, high quality care. The organization responsible for publication and maintenance of these goals is the: 1. Office of Inspector General (OIG) 2. National Committee for Quality Assurance (NCQA) 3. Centers for Medicare and Medicaid (CMS) 4. The Joint Commission Job rotation - CORRECT ANSWER Domain 5 A new supervisor is hired in the HIM department of a large acute care hospital. The corporate HIM director has set up a schedule for the new supervisor that requires moving from job to job to learn the variety of tasks performed within the department. This style of on-the-job training is known as: 1. Job rotation 2. One-on-one 3. Informal learning 4. Classroom learning Federal register - CORRECT ANSWER Domain 1 The proactive manager follows the content and status of proposed national health information regulations by reading which of the following publications? 1. Congressional record 2. Federal register 3. Executive order 4. Regulatory bulletin Relational - CORRECT ANSWER Domain 1 A database model constructed with tables that share common data elements is called: 1. Hierarchical 2. Network 3. Object-orientated 4. Relational An integral part of the major service - CORRECT ANSWER Domain 1 CPT defines a separate change procedure when performed in conjunction with another service as: 1. An integral part of the major service 2. One that can be reported in conjunction with a service 3. Not fraudulent when integral to another service 4. A separate change Brainstorming - CORRECT ANSWER Domain 5 One idea-generated technique used in performance improvement in exploratory problem analysis is: 1. Flowcharts 2.Brainstorming 3.Affinity diagram 4. Fishbone diagram Providing healthcare instructions to a nursing home to which a patient is transferred - CORRECT ANSWER Domain 2 Which of the following disclosures of protected health information is permitted under HIPAA and does NOT require a patient's authorization? 1. Providing healthcare instructions to a nursing home to which a patient is transferred 2. Faxing health records to a prospective provider 3. Copying the health record for an attorney 4. Sending the patient's history and physical to the ER Diagnostic codes - CORRECT ANSWER Domain 4 Third party payers will deny payment for services that are considered unreasonable and unnecessary based on: 1. Diagnostic codes 2. Charges 3. Costs 4. Advanced beneficiary notices Best of fit - CORRECT ANSWER Domain 4 One year ago a hospital's Radiology department implemented a state-of-the art Radiology Information System (RIS) that met all of its requirements. The newly hired CIO expressed concerns that this system will not meet the organization's long-term goals as the RIS cannot be integrated with the hospital information system to be purchased within the next year. The information technology acquisition strategy used by the Radiology department was most likely: 1. Dual core 2. Best of breed 3. Rip and replace 4. Best of fit Interface engine - CORRECT ANSWER Domain 3 A hospital is planning for its new hospital information system. The CIO wants to make sure that all hospital patient care systems are able to efficiently share ADT information with the main system. Which of the following will ensure that is achieved? 1. Computer drive 2. Ethernet connection 3. Open system 4. Interface engine The hospital has unique information needs that cannot be met by an available vendor systems - CORRECT ANSWER Domain 3 A hospital decides to build its own information system. Which of the following reasons may have led to that decision? 1. Internally developed IT systems can be more in depth 2. Internally developed IT systems are more cost effective 3. Qualified information technology staff are easy to find 4. The hospital has unique information needs that cannot be met by an available vendor system Being investigated at the time of admission - CORRECT ANSWER Domain 1 the designation of POA assignment to an ICD-10-CM code include chronic conditions impacting care; acute conditions and those: 1. Identified within 24 hours of the admission 2. Diagnosed upon discharge 3. Being investigated at the time of admission 4. Listed in the family history PERT - CORRECT ANSWER Domain 3 The tool used to complete process management activities on time and in proper order is: 1. Pareto 2. Benchmark 3. PERT 4. Histogram 12 - CORRECT ANSWER Domain 1 The passage of FMLA in 1993 allows the employee annual unpaid time off with retained job security to attend to family healthcare needs and childbirth. The number of weeks granted annually is: 1. 6 2 .9 3. 12 4. 24 Control improper coding practices - CORRECT ANSWER Domain 1 One of the reasons Centers for Medicare and Medicaid services (CMS) developed the National Council on Compensation Insurance(NCCI) is to: 1. Control improper coding practices 2. Correct improper use of modifier 59 3. Monitor Medically Unlikely Edits (MUE) 4. Circumvent coding guidelines Business associate agreement - CORRECT ANSWER Domain 2 The HIM department in a large hospital uses a vendor for health record storage. Which of the following must be created to ensure that the vendor follows rules set forth by the hospital for handling protected health information? 1. Risk analysis plan 2. Patient authorization 3. Business associate agreement 4. Physician authorization Biometrics - CORRECT ANSWER Domain 2 Which technology supports the security of information by utilizing a patient's physical trait to verify identity? 1. Flash drive 2. Smart card 3. Picture identification 4. Biometrics Portal - CORRECT ANSWER Domain 2 A physician accesses the hospital's order entry system through a secure internet gateway called a web: 1. Protocol 2. Portal 3. Program 4. Processor Address deficiencies through education - CORRECT ANSWER Domain 2 A HIM manager developed performance measurements for the inpatient coding staff. After comparing coders' performance with the standards, the manager identified problems with the performance of one coder who is continuously making the same coding errors. What step should the manager take next? 1. Wait to see if the same mistakes reoccur 2. Reassign to ambulatory coding 3. Issue verbal warning to the coder 4. Address deficiencies through education Matrix - CORRECT ANSWER Domain 3 The most basic decision support tool is: 1. Table 2. Block 3. Matrix 4. Tree Volume - CORRECT ANSWER Domain 3 A hospital is testing the newly installed information system. All employees have been instructed to log on to the system at 11:00 am. Which system testing phase are they involved in? 1. Total system 2. Integration 3. Volume 4. Unit Granularity - CORRECT ANSWER Domain 1 When a data element cannot be further subdivided, its structure complies with which data quality characteristic? 1. Precision 2. Accuracy 3. Granularity 4. Currency History and physical - CORRECT ANSWER Domain 3 The data collection tool the physician uses to collect information regarding the patient's health care to include past and current complaints is: 1. Encounter form 2. History and physical 3. Care plan 4. Physician orders Reference check - CORRECT ANSWER Domain 5 The process of verifying information obtained about a job applicant and their past performance is called: 1. Application review 2. Reference check 3. Employment testing 4. Selection interview Data modeling - CORRECT ANSWER Domain 3 What is the process of determining the users' information needs and identifying relationships among the data? 1. Data modeling 2 .Data mining 3. Data repositories 4. Data quality Comparative - CORRECT ANSWER Domain 3 A hospital employee benchmarks with another HIM department to assess his department's performance level. What kind of data will the employee use? 1. Longitudinal 2. Aggregate 3. Discrete 4. Comparative Reduced payment to the transferring facility - CORRECT ANSWER Domain 1 The CMS transfer policy generally results in: 1. Reduced payment to the transferring facility 2. Increased payment to the transferring facility 3. Cost share 4. A decrease in patient care LOINC - CORRECT ANSWER Domain 3 The data set to facilitate and collect laboratory results for clinical care, research, and outcomes management is known as: 1. National Provider Data Base (NPDB) 2. Logical Observation Identifiers Names and Codes(LOINC 3. ORYX 4. Unified Medical Language System ( UMLS) Leading - CORRECT ANSWER Domain 5 Encouraging employees, direction others, and resolving conflicts are examples of: 1. Directing 2. Motivation 3. Leading 4. Mentoring Work simplification - CORRECT ANSWER Domain 4 The process of improving quality while reducing time and lowing costs is known as: 1. Benchmarking 2. Flow charting 3. Work distribution 4. Work simplification Resource-Based Relative Value Scale (RBRVS) - CORRECT ANSWER Domain 4 Medicare uses which of the following methodologies for physician reimbursement? 1. Resource-Based Relative Value Scale (RBRVS) 2. Ambulatory Payment Classification (APC) 3. Ambulatory Payment Group (APG) 4. Correct Coding Initiative (CCI) Need to know - CORRECT ANSWER Domain 2 What type of control is used to determine access granted to a user? 1. Need to know 2. Integrity 3. Audit 4. Authentication Job description - CORRECT ANSWER Domain 3 The most tangible output of the job analysis process is the: 1. Employee handbook 2. Performance standards 3. Skills assessment 4. Job description Dictionary - CORRECT ANSWER Domain 1 A central repository for data structure and elements is called data: 1. Charting 2. Dictionary 3. Modeling 4. Mapping Scope - CORRECT ANSWER Domain 5 The project manager records the estimated time, costs of the project, and records the team purpose. The project manager is establishing the project: 1. Scope 2. Vision 3. Sponsor 4. Accord Standardize the health record language - CORRECT ANSWER Domain 1 The primary purpose of a clinical/medical vocabulary is to: 1. Provide documentation options for health records 2.Develop reference terminologies for the physicians 3.Create a communication tool for caregivers 4. Standardize the health record language Unity of command - CORRECT ANSWER Domain 5 The DRG coordinator reports to the HIM director daily on staff performance, timeliness, and quality issues. The DRG coordinator also receives report requests and statistical assignments from the accounting manager who gives her strict 24-hour turnaround requirements. The DRG coordinator works in a position that lacks: 1. Centralization 2. Line authority 3. Unity of command 4. Span of control Job ranking - CORRECT ANSWER Domain 4 A method of comparing particular jobs with other jobs by levels of responsibility and the impact of these positions on revenue generation in organizations with limited positions is known as: 1. Job ranking 2. Factor comparison 3. Point system 4. Job grading Service provider - CORRECT ANSWER Domain 4 A hospital contracts with a company that will provide high-speed Internet connections to innovative software. This kind of enterprise is called an application: 1. Server 2. System 3. Service provider 4. Portfolio analyst One-on-one - CORRECT ANSWER Domain 5 A new HIM employee is learning how to perform deficiency analysis in an electronic health record (EHR) system. Another employee who has extensive knowledge of the EHR system is teaching the new person and asks her to explain each step as she proceeds. This style of training is known as: 1. Job rotation 2. One-on-one 3. Web-based 4. Informal learning Defining the problem and desired outcome - CORRECT ANSWER Domain 5 The first step in the problem-solving model is: 1. Brainstorming alternatives 2. Evaluating and gathering information about the problem 3. Analyzing and understanding the nature of the problem 4. Defining the problem and desired outcome The halo effect - CORRECT ANSWER Domain 4 A common rater bias can occur in a performance appraisal associated with a specific performance incident or personal characteristics is called: 1. Central tendency error 2. Personal prejudice 3. The halo effect 4. The regency effect Ergonomics - CORRECT ANSWER Domain 5 The science focused on the design of the work environment promoting a safe, comfortable and injury-free work zone are known as: 1. Work flow 2. Ergonomics 3. Economics 4. Work simplification National Committee for Quality Assurance (NCQA) - CORRECT ANSWER Domain 2 The organization responsible for accrediting MCOs and PPOs is known as the: 1. NCRA 2. NCHS 3. NCQA 4. NCVHS Bar graph - CORRECT ANSWER Domain 3 The data display tool which can be used to accommodate nominal, ordinal, discrete, and continuous data is the: 1. Histogram 2. Frequency polygram 3. Bar graph 4. Frequency distribution The condition "after study" which occasioned the admission to the hospital - CORRECT ANSWER Domain 1 The definition of "principle diagnosis" is: 1. The first listed diagnosis on the history 2. the first listed diagnosis on the discharge 3. The condition "after study" which occasioned the admission to the hospital 4. The diagnosis the patient presented to the provider Biometrics - CORRECT ANSWER Domain 2 Memorial Hospital implemented iris scanning as a new procedure for patient verification at registration. The new security technology is known as: 1. Biometrics 2. Smart card 3. Cyptography 4. Behavior metrics Design - CORRECT ANSWER Domain 4 A hospital generated an Request For Proposal (RFP) to select the vendor for its new hospital information system. In which phase of the System Development Life Cycle is the hospital involved? 1. Maintenance/evaluation 2. Implementation 3. Analysis 4. Design Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER Domain 1 The federally mandated inpatient acute care data set is: 1. DEEDS 2. MDS 3. UACDS 4. UHDDS K43.9, B20, K21.9 - CORRECT ANSWER Domain 1 Patient A presents for a ventral hernia repair. A review of the H&P indicates HIV disease and GERD. The diagnosis code assignment is: 1. K43.9, B20, K21.9 2. B20, K43.9, K21.9 3 Z21 K43.9, K21.9 4. K43.9, Z21, K21.9 Rule-based - CORRECT ANSWER Domain 1 A hospital's new outpatient scheduling system ensures that patients are scheduled for barium studies after and not before nuclear medicine gastric emptying studies because barium interferes with gastric emptying studies. This is an example of which kind of clinical decision support? 1. Process-based 2. System-based 3. Patient-based 4. Rule-based Productivity - CORRECT ANSWER Domain 5 The process of converting organizational resources into products and services as a means to meet the organization's goals is known as: 1. Productivity 2. Flowcharting 3. Performance 4. Benchmarking Senior manager or physician - CORRECT ANSWER Domain 3 Complex projects, such as the migration of the electronic health record, benefit from having a "champion", who believes in the change and promotes support. The manager seeking such a key ally, would most likely develop a relationship with an individual in which of the following roles? 1. Senior manager or physician 2. Major stakeholder representative 3. Public relations specialist 4. Subject matter expert Re-engineering - CORRECT ANSWER Domain 4 Reducing costs and risks are main objectives of: 1. Policies 2. Re-engineering 3. Procedures 4. Work flow De-identifying - CORRECT ANSWER Domain 2 A HIM data analyst prepares patient charts for scanning into a database for peer review. The analyst must remove certain data elements such as the patient's name, address and date of birth. What process is the analyst performing to protect the health information? 1. Distributing 2. De-identifying 3. Disclosing 4. Delineating Healthcare Effectiveness Data and Information Set (HEDIS) - CORRECT ANSWER Domain 3 The data set designed to allow consumers to compare the performance of various managed care plans is: 1. ANSI 2. NCQA 3. HEDIS 4. DEEDS Work distribution chart - CORRECT ANSWER Domain 3 The coding department has identified problems related to its work processes. Coding staff are spending too much time on unrelated coding tasks, duplication of effort and task assignment is uneven in quality of volume. The coding manager has asked each coding professional to complete a form identifying the amount of time he/she spends each day on various tasks. This tool is known as: 1. GANTT chart 2. Work distribution chart 3. Check sheet 4. Process sheet Root cause analysis - CORRECT ANSWER Domain 4 A patient has had surgery performed on the wrong knee. As part of the risk management program in a Joint Commission accredited organization, the facility should perform a(n): 1. Root cause analysis 2. Performance improvement study 3. External agency review 4. Review of operating room scheduling Phishing - CORRECT ANSWER Domain 2 Which type of security threat consists of an e-mail message that appears to come from a legitimate business and requests personal information such as an account number? 1. Computer worm 2. Phishing 3. Malware 4. Cookie Request for Information (RFI) - CORRECT ANSWER Domain 4 An HIM manager wants to screen vendors to identify which vendor's products meet the department's Tumor Registry System needs. The manager sends the vendors an: 1. RFP 2. RFI 3. RFQ 4. RFC Decomposition diagram - CORRECT ANSWER Domain 3 The purpose of this type of chart is breaking down problems into smaller details by identifying all the tasks in the process and grouping them hierarchical levels. 1. Dialogue design diagram 2. Decomposition diagram 3. Fishbone diagram 4. Data structure diagram Defensibility - CORRECT ANSWER Domain 4 As the HIM Director you are concerned about ensuring your staff does not make errors in compiling the physician delinquency list so physicians will not be suspended in error. On which of the following characteristics or review is your concern based? 1. Consistency 2. Usefulness 3. Defensbility 4. Timeliness Access controls - CORRECT ANSWER Domain 2 Which method uses the employees' role to determine their system security level? 1. Access controls 2. Password assignments 3. Single-ones 4. Biometric devices Policies - CORRECT ANSWER Domain 1 Guides used by management to make decisions for a variety of reasons are: 1. Procedures 2. Policies 3. Objectives 4. Evaluations Ordinal - CORRECT ANSWER Domain 3 The CFO asks your to rank physician admissions during the past quarter. The type of data best used to accomplish this task is: 1. Ordinal 2. Nominal 3. Interval 4. Ratio [Show Less]
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RHIA Prep Test 110 Questions with Verified Answers,100% CORRECT
RHIA Prep Test 110 Questions with Verified Answers This committee makes recommendations to the governing board for appoints to the medical staff - COR... [Show More] RECT ANSWER executive physicians who deliver most of the medical care in hospitals and who site on committees are - CORRECT ANSWER active staff accreditation organization which accredits health information educational programs is - CORRECT ANSWER CAHIIM which component, group has ultimate authority and is responsible for providing quality care to patients? - CORRECT ANSWER governing board which organization was the first to require a medical record on each patient and developed standards for its content? - CORRECT ANSWER American college of surgeons what documents specify the principles and policies by which both medical staff and governing board agree to abide by - CORRECT ANSWER bylaws which hospital department is responsible for arranging a transfer to a nursing home? - CORRECT ANSWER social service which professional association organized to resolve inconsistencies and standardized medical education for the practice of medicine? - CORRECT ANSWER AMA physicians are licensed to practice by... - CORRECT ANSWER the state in which they practice which organization currently sets voluntary standards for hospitals pertaining to quality health care? - CORRECT ANSWER JC cost of care is based on the patient's ability to pay - CORRECT ANSWER sliding scale numbering system will generate gaps in filing space when records are pulled forward to the most recent medical record number assigned to patient - CORRECT ANSWER serial-unit numbering What is the format of the progress notes of a problem oriented medical record? - CORRECT ANSWER SOAP ASTM developed a standard to provide guidance for collection of data for the purpose of.. - CORRECT ANSWER computerizing the patient record primary purpose of quantitative analysis - CORRECT ANSWER to have a complete medical record what resource provides standard definitions for inpatient data commonly collected in acute care hospitals? - CORRECT ANSWER UHDDS What is aggregate data? - CORRECT ANSWER data combined from several measurements ex: data the media uses to report on health info of epidemiological interest to the public when records are analyzed for deficiencies on the unit while the patient is still in house, this is called? - CORRECT ANSWER concurrent analysis confirmation of the diagnosis and treatment options from another physician within the same specialty is called? - CORRECT ANSWER a second opinion cancer registries can be accredited by? - CORRECT ANSWER ACS case files of cancer patients are abstracted when - CORRECT ANSWER patient is diagnoses and/or treated a graph most frequently used to present continuous data? - CORRECT ANSWER histogram the filing system used in an electronic environment? - CORRECT ANSWER straight numeric assessment of nursing productivity is usually based on - CORRECT ANSWER inpatient service days full time responsibility for the operation of a hospital is delegated by the governing board to the - CORRECT ANSWER CEO the system of numbering in which a patient receives a number on his first admission to the hospital and retains that number on all subsequent admissions to the hospital is - CORRECT ANSWER unit what is the function of CAHIIM - CORRECT ANSWER accrediting college educational programs quantitative analysis purpose - CORRECT ANSWER complete medical record qualitative analysis purpose - CORRECT ANSWER consistent medical record standards are published by the JC for all types of facilities except? - CORRECT ANSWER public health purpose of a two digit modifier - CORRECT ANSWER 1. append to either CPT or HCPCS level II services 2. they indicate a service or procedure that has been altered but doesn't change description Coding rule for coding outpatient dx documented as probable, suspected, rule out conditions - CORRECT ANSWER it should not be coded as if they are established. first organization to implement minimum standards for hospitals - CORRECT ANSWER ACS What are three things HITECH has encouraged/required the use of - CORRECT ANSWER 1. meaningful use 2. Health Information Exchanges 3. EHRs what is benchmarking - CORRECT ANSWER comparing something against a certain standard NPDB - CORRECT ANSWER national practitioner data bank maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed health providers HIPDB - CORRECT ANSWER healthcare integrity and protection data bank maintains reports on civil judgement, criminal conventions of licensed healthcare providers, federal and state licensing and certification actions, and exclusions from participation in federal or state healthcare programs HEDIS - CORRECT ANSWER healthcare effectiveness data and information set measures performance on important dimensions of care and service. allows health plans to see where they need to focus their improvement efforts NCQA - CORRECT ANSWER National committee for quality assurance non profit organization dedicated to improving healthcare quality physician query - CORRECT ANSWER requesting clarification for inconsistent, ambiguous, or incomplete documentation for coding nomenclature - CORRECT ANSWER naming system controlled by rules clinical interface technology - CORRECT ANSWER systematic collection of health care related phrases that can be converted to structured data elements recognized between computer programs UMLS - CORRECT ANSWER unified medical language system converts terms from one vocabulary to another to enable information exchange between databases and systems how length of stay can affect the hospital's finances under PPS - CORRECT ANSWER the longer the patient stays, the more money the hospital loses. if the patient's stay is less than average LOS the hospital will not make as much money as they expect encoder - CORRECT ANSWER converts information from one code to another and keeps standardization groupers - CORRECT ANSWER computer programs that assign patients to case-mix groups and have an algorithm that determines the patient groups RAC - CORRECT ANSWER recovery audit contractor they ensure correct payments are made to providers and facilities by Medicare part A&B claims COLA - CORRECT ANSWER cost of living adjustment DSH - CORRECT ANSWER disproportionate share hospital GAF - CORRECT ANSWER geographical adjustment factor AHRQ - CORRECT ANSWER agency for healthcare research and quality a US government agency that functions as a part of the dept of Health & Human Services to support research to help improve the quality of healthcare When defining the LHR in a healthcare entity, it is best practice to establish a policy statement of the LHR along with? - CORRECT ANSWER health record matrix the insured party's member identification number is an example of what kind of data - CORRECT ANSWER financial data what type of information makes it easy for hospitals to compare and combine the contents of multiple patient records - CORRECT ANSWER uniform data sets in a LTC setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items - CORRECT ANSWER resident assessment protocols (RAPs) decision making and authority over data-related matters is known as: - CORRECT ANSWER data governance abbreviations in the health record... - CORRECT ANSWER should have only one meaning In ICD 10, what value is used if there is a character that doesn't apply to a given code? - CORRECT ANSWER Z primary responsibility of a coder - CORRECT ANSWER ensure quality of coded data what is the data model most widely used to illustrate a relational database structure? - CORRECT ANSWER entity-relationship diagram name the proper ways to destroy paper records - CORRECT ANSWER pulverize, shred, burn, pulp examples of metadata - CORRECT ANSWER name of element definition application in which the data element is found locator key ownership entity relationships what are LOINC codes used for? - CORRECT ANSWER identifying test results the inpatient data set incorporated into federal law and required for Medicare reporting is the - CORRECT ANSWER UHDDS What is the desired outcome of analyzing data for a specific purpose? - CORRECT ANSWER information root operation - extirpation - CORRECT ANSWER taking or cutting out solid matter from a body part penalties for HIPAA violations can be: - CORRECT ANSWER civil and criminal how long does the hospital have to respond to request for information? - CORRECT ANSWER 30 days when ownership of a physician practice changes.. - CORRECT ANSWER the health records of the practice may be transferred as assets When should adoption records only be released? - CORRECT ANSWER by court order HIPAA retention standard for maintaining a record on a deceased patient is - CORRECT ANSWER 50 years Stark Law/Federal Physician Self-Referral Statute - CORRECT ANSWER prohibits physicians ordering services for Medicare patients from entities in which the physician or an immediate family member has a financial relationship What are reported to the medical examiner? - CORRECT ANSWER accidental deaths Type of technology that focuses on data security - CORRECT ANSWER firewalls a visitor sign-in sheet to a computer area is an example of what type of control? - CORRECT ANSWER facility access ensuring that data have been access or modified only by those authorized to do so is a function of: - CORRECT ANSWER data integrity firewall - CORRECT ANSWER controls external access to a network authorization management involves: - CORRECT ANSWER limiting user access to a database authorization management - CORRECT ANSWER protecting the security and privacy of data in the database user access control, usage monitoring name an administrative safeguard action - CORRECT ANSWER documentation retention guidelines under HIPAA, these types of safeguards have to do with protecting the environment: - CORRECT ANSWER physical one of the four requirements a CE must adhere to in order to be in compliance with HIPAA - CORRECT ANSWER ensure the: confidentiality integrity availability of ePHI Rank the next-of-kin in the following order for medical decision making purposes - CORRECT ANSWER Spouse adult child parent adult sibling Per HITECH, breach notification requirements, what is the threshold for the immediate notification of each individual? - CORRECT ANSWER 500 individuals affected Per HITECH, an accounting of disclosures must include disclosures made during the previous: - CORRECT ANSWER 3 years What does not have to be included in a CE's NPP - CORRECT ANSWER patient's signature and email let the master answer - CORRECT ANSWER respondeat superior employees in the hospital business office may have legitimate access to patient health info without patient authorization based on what HIPAA principle - CORRECT ANSWER minimum necessary CEs must retain documentation of their security policies for at least: - CORRECT ANSWER 6 years from the date when last in effect regarding an individual's right of access per HIPAA, a CE... - CORRECT ANSWER may require individuals to make their requests in writing Administrative Simplification portion of Title II of HIPAA addresses which of the following? - CORRECT ANSWER uniform standards for transactions and code sets An original goal of HIPAA administrative simplification was to standardize: - CORRECT ANSWER the electronic transmission of health data technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: - CORRECT ANSWER technical safeguards name a "public interest and benefit" exception to the authorization requirement - CORRECT ANSWER PHI regarding victims of domestic violence most common method for implementing entity authentication - CORRECT ANSWER password systems what is a two factor authentication system - CORRECT ANSWER something you know, have, are Ex: password and swipe card when should an e discovery response team be formed? - CORRECT ANSWER well in advance of any litigation a subpoena duces tecum compels the recipient to - CORRECT ANSWER bring records to a legal proceeding Business record exception - CORRECT ANSWER the rule under which a record is determined to not be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge if a breach occurs, which of the following must be provided to the individual whose PHI has been breached? - CORRECT ANSWER the types of unsecured PHI that were involved e-discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended which legislation? - CORRECT ANSWER Federal Rules of Civil Procedure a valid subpoena duces tecum seeking health records does not have to - CORRECT ANSWER be signed by the plaintiff and defendant which landmark legal case established the responsibility of the hospital for the quality of care given by its physician? - CORRECT ANSWER Darling vs Charleston Community Memorial Hospital what type of safeguards compromise over half of all of the safeguards included in the Security Rule? - CORRECT ANSWER administrative safeguards within context of data security, protecting data privacy means defending or safeguarding: - CORRECT ANSWER access to information what is the most constant threat to health information integrity? - CORRECT ANSWER humans res ipsa loquitur - CORRECT ANSWER the thing speaks for itself Safe Medical Devises Act requires the reporting of injuries due to medical devices to whom? - CORRECT ANSWER FDA components of a late entry - CORRECT ANSWER should be documented as late entry should include date/time entry was made should be documented ASAP which doctrine do courts apply indicating that they are unwilling to revisit issues of previously settled cases? - CORRECT ANSWER res judicata [Show Less]
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RHIA Mock Exam Practice 138 Questions with Verified Answers,100% CORRECT
RHIA Mock Exam Practice 138 Questions with Verified Answers Authorizations are always required for the use or disclosure of psychotherapy notes except i... [Show More] n which of the following situations: - employee and employment-related activities - health insurance carrier -media-related activities -carry out payment, treatment and operations - CORRECT ANSWER carry out payment, treatment and operations Steve has submitted a written authorization to request a copy of his medical chart. However, Steve's psychiatrist has determined that access to his PHI might endanger his life or safety. What should the covered entity do concerning the request? -release requested information to Steve's legal guardian -confirm the psychiatrist decision and deny the request -release requested information to Steve -provide an appeals process to Steve for the denial - CORRECT ANSWER -provide an appeals process to Steve for the denial A health information technician wants to obtain a chronological list of all patients admitted to the facility during the third quarter with a diagnosis of appendicitis. Which database should the technician utilize? accession register (is a unique and irreplaceable official administrative document that establishes the museum's legal right of ownership) disease index (an alphabetical list of diseases with information about each condition, such as the CDC's Diseases & Conditions A-Z Index.) master patient index ( is a patient database used by healthcare organizations to maintain accurate medical data across its various departments.) patient register (is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes.) - CORRECT ANSWER patient register Which of the following organizations is responsible for developing standards and conducting investigations to determine compliance in matters related to occupational safety and health? COBRA (Consolidated Omnibus Budget Reconciliation Act. It gives employees the right to pay premiums for and keep the group health insurance) CMS DHHS ( a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services.) OSHA ( Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.) - CORRECT ANSWER OSHA Warren, a 12 year old Boy Scout breaks his leg while hiking with the troop. Which type of facility might Warren's Boy Scout leader take him to for emergent treatment? Ambulatory care clinic (is an outpatient facility for medical, surgical and diagnostic procedures) non emergent situations Surgicenter General hospital Specialty hospital - CORRECT ANSWER General hospital Tristan Vo brings a lawsuit against Houston Hospital for damages done to his knee during surgery. What term best describes Tristan? bailiff attorney plaintiff defendant - CORRECT ANSWER plaintiff Which of the following is an example of a government agency that has an interest in the standardization of records and data collection? -Department of Health and Human Services (HHS) - the Joint Commission -American Medical Association (AMA) -American Health Information Management Association (AHIMA) - CORRECT ANSWER Department of Health and Human Services (HHS) The health record may be used for personal and nonpersonal reasons. Which is an example of personal use of the health record? -patient reviews record with provider for understanding of health status - health information professional assigns ICD-10-CM codes -employer reviews healthcare data to evaluate job injuries -accrediting agency reviews record to assure quality health care - CORRECT ANSWER -patient reviews record with provider for understanding of health status Place the following in terminal digit order: 01-34-54, 01-35-55, 02-05-49, 02-66-48 02-05-49, 01-34-54, 01-35-55, 02-66-48 02-66-48, 02-05-49, 01-34-54, 01-35-55 01-34-54, 01-35-55, 02-05-49, 02-66-48 02-66-48, 02-05-49, 01-35-55, 01-34-54 - CORRECT ANSWER 02-66-48, 02-05-49, 01-34-54, 01-35-55 As director of health information of a newly established acute-care facility, where would you expect to find directives concerning the minimum health record contents? - Benchmarks from area acute-care facilities -Medical record committee meeting minutes -The Joint Commission -Credential committee meeting minutes - CORRECT ANSWER The Joint Commission Upon discharge analysis of a patient's record, the analyst does not see a discharge order written by the physician. What can the analyst assume? the family members requested hospice care the patient left against medical advice the patient will continue treatment on an outpatient basis the patient died prior to discharge - CORRECT ANSWER the patient left against medical advice The Hill-Burton Act of 1946: assured the provision of health care for the indigent. (ACA) provided health care to Americans 65 years of age and older (Medicare) enacted legislation funding the construction of hospitals and other healthcare facilities. established the retrospective payment system. - CORRECT ANSWER enacted legislation funding the construction of hospitals and other healthcare facilities. Dr. Thomas made an error in recording the progress notes in a patient's medical record. What is the first thing he should do to correct the error? draw a single line through the error obliterate the error and enter correct entry remove the page on which he made the error tell the nursing staff to ignore the statement - CORRECT ANSWER draw a single line through the error A patient is hospitalized for less than 48 hours. Which of the following is permissible in lieu of a discharge summary? final diagnosis discharge order final progress note discharge diagnosis - CORRECT ANSWER final progress note Who is responsible for developing bylaws governing physicians' completion of medical records? chief executive officer governing board chief of medicine medical staff - CORRECT ANSWER medical staff Which system avoids assigning a new number for each patient encounter? serial-unit numbering straight numerical serial numbering unit numbering - CORRECT ANSWER unit numbering By signing a consent for treatment, the patient agrees to: take all medications prescribed and dispensed by healthcare providers treatments and procedures to be performed by healthcare providers allow hospital to dispose of property and values in the case of death allow the hospital to release information to his or her insurance company - CORRECT ANSWER treatments and procedures to be performed by healthcare providers Reviewing the record to assure the presence of a discharge summary is referred to as: legal analysis ( refers to a statement by a court, judicial officer, or legal expert as to the legality or illegality of an action, condition, or intent.) quantitative analysis (analysis of a situation or event) documentation analysis ( a form of qualitative research in which documents are interpreted by the researcher to give voice and meaning around an assessment topic ) qualitative analysis ( documents are interpreted by the researcher to give voice and meaning around an assessment topic ) - CORRECT ANSWER quantitative analysis (analysis of a situation or event) A major advantage of the source-oriented medical record is the: strict chronology that keeps episode of care clearly defined by date ease with which healthcare providers can follow the course of one problem forms are designed to support numbering and tracking of problems speed at which individual sheets can be located - CORRECT ANSWER speed at which individual sheets can be located Which of the following would be most beneficial in locating a charged out medical record? master patient index requisition slip ( lists the items to be picked from inventory and used in the production process or in the provision of a service to a customer, Charge-out procedures should be followed regardless of who removes the medical record from the files, for what reason, or for how long. ) transfer notice outguide - CORRECT ANSWER requisition slip Which of the following filing systems would be most affected in the event of a divorce? family serial serial-unit unit - CORRECT ANSWER Family filing system A patient had an appendectomy due to appendicitis. This operative report must be completed when? within 15 days of discharge within 24 hours of surgery immediately after surgery within 48 hours of surgery - CORRECT ANSWER immediately after surgery A post-anesthesia note is required when? within 15 days of discharge within 24 hours of surgery within 48 hours of surgery immediately after surgery - CORRECT ANSWER within 24 hours of surgery A discharge summary: is not required when death occurs within 48 hours or less may be completed in lieu of a clinical resume is not required for a stay of 48 hours or less must be dictated and typed for ease of readability - CORRECT ANSWER is not required for a stay of 48 hours or less (CSR&I 108) A PEG tube would most likely be done to facilitate eating breathing urination none of the above - CORRECT ANSWER eating (CSR&I 11) A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are: congestive heart failure and diabetes mellitus. The code should query the physician about adding the diagnosis of laryngitis bronchitis arthritis glaucoma - CORRECT ANSWER laryngitis CSR&I 12) The patient is diagnosed with congestive heart failure. A drug of choice is digoxin oxytocin ibuprofen haloperidol - CORRECT ANSWER digoxin (CSR&I 4) A system of preferred terminology for naming disease processes is known as: classification system (grouping together of similar items) set of categories diagnosis listing medical nomenclature (preferred terminology) - CORRECT ANSWER medical nomenclature (CSR&I 41) A cancer program is surveyed for approval by the Joint Commission on Accreditation of Healthcare Organizations American Cancer Society State Department of Health Commission on Cancer of the American College of Surgeons - CORRECT ANSWER Commission on Cancer of the American College of Surgeons The transcription are has an opening for a transcriptionist with demonstrated skill in medical and surgical reports. Which of the following types of tests should be administered? aptitude ( determine a person's ability in a particular skill or field of knowledge) performance (skill) intelligence stress - CORRECT ANSWER performance (CSR&I 5) A patient who is taking the drug Antivert may have a diagnosis of arthritis dizziness (treats Vertigo) urinary tract infection congestive heart failure - CORRECT ANSWER dizziness (CSR&I 56) A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a master patient index disease index admissions register disease registry - CORRECT ANSWER disease registry (CSR&I 6) Which of the following is NOT included as a part of the minimum data maintained in the MPI? full name (last, first, and middle) patient medical record number date of birth principal diagnosis - CORRECT ANSWER principal diagnosis (HDC 10) As a new CTR you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility's patient's index physician's index disease index number control index - CORRECT ANSWER disease index (HDC 11) Joint Commission requires the attending physician to countersign health record documentation that is entered by consulting physicians midwives interns or medical students physician partners - CORRECT ANSWER interns or medical students (HDC 3) A good first step toward protecting the security of data contained in a health information computer system would be to establish a good record tracking system define levels of security for different types of information, depending on sensitivity provide internet access to facility records provide remote terminals for improved access to the record - CORRECT ANSWER define levels of security for different types of information, depending on sensitivity (HDC 5) 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 doctor's progress notes nurse's notes incident report integrated progress notes - CORRECT ANSWER incident report 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 obstetrical records. The best place in the record to locate this information is the labor and delivery record discharge summary prenatal record postpartum record - CORRECT ANSWER prenatal record Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the risk manager peer review organization Health Plan Employer Data and Information Set National Practitioner Data Bank - CORRECT ANSWER National Practitioner Data Bank Rules and principles determined by legislative bodies constitute which type of law? case law (the law as established by the outcome of former cases.) common law (derived from custom and judicial precedent rather than statutes) administrative law (law that regulates the operation and procedures of government agencies.) statutory law (written laws, usually enacted by a legislative body. ) - CORRECT ANSWER statutory law Your job description states that as Assistant Director of the Health Information Management Department, you will supervise day-to-day operations for the transcription, release of information, and coding areas. What principle of management is described? span of control delegation specialization centralized authority (organizational management structure where most of the major decision-making power and authority rests in the hands of a concentrated group of leaders) - CORRECT ANSWER span of control Gary's primary concern is providing food and housing for his large family. What level of Maslow's hierarchy of needs does Gary operate from? self-actualization ("the full realization of one's potential", and of one's "true self") physiological (survival needs like need for sleep, food, air, and reproduction.) esteem (needs refer to the need for respect, self-esteem, and self-confidence.) safety (need for security and protection) - CORRECT ANSWER physiological Under the ADA, prior to employment it is illegal to require a math aptitude test coding proficiency test typing skill test pre-employment physical exam - CORRECT ANSWER pre-employment physical exam Jason, an HIM director, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. He will describe which of the following? Wagner Act (stablished the National Labor Relations Board and addressed relations between unions and employers in the private sector.) Labor Management Relations Act ( United States federal law that restricts the activities and power of labor unions.) AKA Taft hartley act Taft-Hartley Law OSHA - CORRECT ANSWER OSHA Color coding of record folders is used to assist in the control of misfiles record tracking loose reports record completion - CORRECT ANSWER misfiles A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? 10 6 12 8 - CORRECT ANSWER 12 If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to social security number date of admission mother's maiden name date of birth - CORRECT ANSWER date of birth What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, 14-32-79? terminal digit social security number middle digit straight numeric - CORRECT ANSWER straight numeric If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? 2.4% (3545/150,000*100) 3.5% 5.1% 4.6% - CORRECT ANSWER 2.4% in a terminal digit filing system, what would be the record number immediately in front of number 01-06-26? 03-06-26 00-06-26 99-99-25 02-06-26 - CORRECT ANSWER 00-06-26 (IR&A 91) According to AHIMA's recommended retention standards, which one of the following types of health information does NOT need to be retained permanently? physician index register of surgical procedures register of births register of deaths - CORRECT ANSWER physician index (MB&RS 12) A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n) case-mix analyzer DRG creeper encoder grouper - CORRECT ANSWER grouper (MB&RS 16) Currently, payment to the physician for outpatient surgery performed on a Medicare patient is based upon which prospective payment system? MS-DRGs ASCs APGs RBRVS - CORRECT ANSWER ASCs How to calculate case mix index - CORRECT ANSWER Acute Inpatient PPS. This file contains hospitals case mix indexes (CMI) for discharges. A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. (MB&RS 24) All of the following elements are found in the charge description master, EXCEPT for narrative description HCPCS/CPT code ICD-9-CM code charge - CORRECT ANSWER ICD-9-CM code (MB&RS 3) __________ indicates that the claim has been released as complete for submission to the insurer for payment. Bill hold Accounts receivables Bill drop Concurrent review - CORRECT ANSWER (MB&RS 4) All of the following items are packaged under the Medicare outpatient prospective payment system, EXCEPT for recovery room anesthesia medical visits supplies - CORRECT ANSWER (MB&RS 60) There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by calling the physician's office leaving notes in the chart using physician query form emailing physician - CORRECT ANSWER using physician query form (MB&RS 65) Under APCs, payment status indicator "C" means significant procedure, discounted ancillary service inpatient procedure significant procedure, nondiscounted - CORRECT ANSWER (MB&RS 87) This accounting method attributes a dollar figure to every input required to provide a service. charge accounting reimbursement contractual allowance cost accounting - CORRECT ANSWER cost accounting The cause of aplastic anemia is chronic blood loss inadequate iron intake bone marrow failure acute blood loss - CORRECT ANSWER Each of the following pertains to COPD EXCEPT chronic bronchitis pneumonia smoking emphysema - CORRECT ANSWER A diagnostic test for meningitis usually involves stool C&S testing urine cerebrospinal fluid analysis blood cultures - CORRECT ANSWER cerebrospinal fluid analysis (O&M 11) In a filing system containing a total of 1,255 records, 48 records are identified as misfiles. What is the percentage of filing accuracy for this area? 26.14% 3.82% 96% 74% - CORRECT ANSWER 96% (O&M 16) Anna Claire is attending budget training for new supervisors. The representative from Finance explains that ________ costs will vary in direct proportion to changes in the volume of care provided. variable periodic semi-variable fixed - CORRECT ANSWER fixed (O&M 2) Strong lateral relationships within a facility are most likely when individual departments cooperate together to achieve organizational goals individual departments are only interested in their internal goals individual departments avoid one another vertical relationships are less than adequate - CORRECT ANSWER individual departments cooperate together to achieve organizational goals (O&M 32) In preparing a capital budget request, the first priority will be to document the cost of the new equipment where the new equipment will be located the specific type of equipment requested the need for the new equipment - CORRECT ANSWER (O&M 37) The most important consideration in planning the office layout for a HIS department is the types of furniture to be purchased workflow cost the number of employees - CORRECT ANSWER O&M 8) A rule is helpful to both managers and the employees in the decision-making process. A rule requires interpretation allows judgments to be made pre-decides issues provides the necessary details - CORRECT ANSWER (Q&PI 11) Most health care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay. severity of illness/intensity of service criteria (SI/IS) Joint Commission defined and developed criteria HEDIS measures critical pathways - CORRECT ANSWER severity of illness/intensity of service criteria (SI/IS) (Q&PI 12) The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality is referred to as focused review peer review occurrence screening benchmarking - CORRECT ANSWER benchmarking (Q&PI 13) With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory? risk management quality assessment quality improvement utilization review - CORRECT ANSWER utilization review (Q&PI 31) Joint Commission requires that medical record review by performed to evaluate adequacy, accuracy, completeness, and quality of documentation annually quarterly every 2 years on an ongoing basis - CORRECT ANSWER on an ongoing basis (Q&PI 32) Which of the following established legal liability for hospitals in 1965? Darling v. Charleston Community Memorial Hospital Health Care Financing Administration (HCFA) P.L. 92-603 Joint Commission - CORRECT ANSWER Darling v. Charleston Community Memorial Hospital A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? either of the patient's parents the patient's parent or legal guardian the patient's wife the patient - CORRECT ANSWER A 19 year old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the Army. The release of informaiton clerk should send a letter informiong him that faxed requests are not accepted. inform the young man that specific reports must be identified in his request. send the records as requested. deny the request. - CORRECT ANSWER A __________ uses a private tunnel through the Internet as a transport medium between locations for secure access and transmission. VPN TCPIP protocol hub firewall - CORRECT ANSWER VPN A clerical level employee reports an incident in which the clerk felt the first-line supervisor discriminated on the basis of the clerk's gender. The best action for you to take at this time is to ask the clerk to provide objective evidence of the discrimination talk with the first-line supervisor to determine what happened thoroughly investigate the matter and document your findings ask the other clerical level staff if they had similar experiences - CORRECT ANSWER thoroughly investigate the matter and document your findings A common goal of the ONC for HIT, RHIO's and a national infrastructure for information is sharing information among providers transferring health information within a hospital system translating images into a digital format promoting telemedicine - CORRECT ANSWER sharing information among provider A patient initially consulted with Dr. Vince at the request of Dr. Matthews, the patient's primary care physician. Dr. Vince examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vince's office for continuing care would be assigned from which E/M section? office and other outpatient services, established patient confirmatory consultations, new or established patient office or other outpatient consultations, new or established patient office and other outpatient services, new patient - CORRECT ANSWER office and other outpatient services, established patient A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? "W" "U" "Y" "N" - CORRECT ANSWER N A piece of objective data collected upon initial assessment of the patient is the chief complaint vital signs review of systems history of present illness - CORRECT ANSWER A section of a job description states that the incumbent will handle day-to-day operations in the transcription and ROI areas. This section defines the authority associated with the job skills required to perform the job scope of responsibility in the job time required for each function - CORRECT ANSWER scope of responsibility in the job A supervisor reviews a job to determine the required content, skils, knowledge, abilities and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job detail process description analysis - CORRECT ANSWER description A technique that uncovers new information from existing information by probing data sets is known as SQL data mining neural network analysis data warehousing - CORRECT ANSWER data mining A tool that is used to illustrate the various applications, support structures, and sequencing of implementation phases for a system is a PERTT diagram milestone chart migration path work flow diagram - CORRECT ANSWER A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc). The quality improvement tool most likely to help collect these data would be flowchart force field analysis check sheet decision matrix - CORRECT ANSWER A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that you are opposed to the union. wages will increase if the union is defeated. you need the names of those involved in union activities. a strike is inevitable if the union wins. - CORRECT ANSWER Access to radiologic images has been improved through the use of which of the following? PACS CPOE EDMS LOINC - CORRECT ANSWER PACS According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is percutaneous incisional excisional punch - CORRECT ANSWER An effective means of protecting the security of computerized health information would be to install a system that would require fingerprint scanning and recognition for data access develop clear policies on data security that are supported by the top management of the facility require all facility employees to change their passwords at least once a month write detailed procedures for the entry of data into the computerized information systems - CORRECT ANSWER As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most effecient way to retrieve this information would be to use accession register patient index patient abstracts follow-up files - CORRECT ANSWER As the Director of a HIT program, your community college has been selected to participate in the workforce development of EHR specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of which governmental agency? OSHA ONC CMS CDC - CORRECT ANSWER ONC As the information security officer at your facility, you have been asked to provide examples of technical security safeguards adopted as a result of HIPAA legislation. Which of the following would you provide? evidence of security awareness training surge protectors workstation use and location audit controls - CORRECT ANSWER Authentication is one of the components necessary to produce a legal document in an EHR. This means identifying who created a document and when creating audit trails tracking changes in the EHR system establishing access controls for individual employees - CORRECT ANSWER Based on the information below, what was the net deah rate at Seaside Hospital in January? Seaside Hospital Selected Statistics (January) Admissions 280 Discharged to Home 212 Discharge Transfers 28 Death <48hours 8 Deaths >48 hours 6 2.8% 2.4% 3.8% 5.8% - CORRECT ANSWER (6 x 100)/(212 + 28+ 6)= 2.4% Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of sta for the year, can you calculate the annual bed turnover rate? How? yes, using the direct method no, there is insufficient data to complete the calculation yes, using the Joint Commission method yes, using the indirect method - CORRECT ANSWER Encoding software was installed at your hospital 2 years ago. The coders are well trained on it and like using it. It functions well and only requires ICD code updates yearly. In terms of the Information System Life Cycle phases, the coding system is likely in the operation and maintenance phase design phase obsolescence or decline phase implementation phase - CORRECT ANSWER operation and maintenance phase Everyone in the HIM Department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not salaried nonexempt employees hourly employees temporary employees salaried exempt employees - CORRECT ANSWER In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to nationally known facilities facilities within your corporation larger facilities facilities with superior performance - CORRECT ANSWER facilities with superior performance In order to perform their jobs, facility employees should have full and timely access only to the information they need to complete the task at hand. This is similar to HIPAA's provision for An informed consent a Notice of Privacy Practices (NOPP) Amending a record Accessing need to know information only - CORRECT ANSWER Accessing need to know information only In preparation for conversion to a computerized patient record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data edits feasibility reasonableness dictionary - CORRECT ANSWER In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post surgery. Thee is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the nurses' notes lab report operative report pathology report - CORRECT ANSWER In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to a health care provider interested in the case the patient's spouse the quality assurance committee for review purposes a third-party payer with a direct interest in the case - CORRECT ANSWER the quality assurance committee for review purposes 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 use of prohibited or "dangerous" abbreviations. flagrant use of specialty-specific abbreviations prohibited use of any abbreviations. use of abbreviations used in the final diagnosis - CORRECT ANSWER use of prohibited or "dangerous" abbreviations. Joanie Howell presents to Dr. Franklin requesting rhinoplasty. Because Howell is covered by Medicare, Dr. Franklin must provide Howell with an ABN, because Howell's rhinoplasty may not be medically necessary a Notice of Exclusion, because rhinoplasty is not a Medicare covered service. an ABN, because rhinoplasty is not a Medicare covered service a Notice of Exclusion, because Howell's rhinoplasty may not be medically necessary. - CORRECT ANSWER an ABN, because Howell's rhinoplasty may not be medically necessary Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is capturing every data item required by UHDDS consistent formatting of each page of each form providing instructions when necessary for appropriate data fields giving each form or view an identifiable name, number, and revision data - CORRECT ANSWER giving each form or view an identifiable name, number, and revision data Oryx is a program that was developed by Joint Commission to ink patient outcomes to accreditation NIH to track communicable diseases AMA to allow for rapid CPT updates CMS to track Medicare costs - CORRECT ANSWER Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound stie that was treated with antibiotics. When making decision about sequencing the codes for this case, the coder should rely on definitions found in the UHDDS Coding Clinic Federal Registrar CMS Coding Guidelines - CORRECT ANSWER Part of your job description is to educate physicians regarding proper documentation policies and standards. You are the Information Security Manager Clinical Data Specialist Health Information Manager Risk Manager - CORRECT ANSWER 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 procedures and dates personal identification cognitive patterns principal diagnosis - CORRECT ANSWER Release of information has increased its use of part-time prn clerical support in order to respond to increased requests for release of information. The budget variance report will reflect both the increases in revenue and increased costs for clerical support in ROI the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area - CORRECT ANSWER Stage I of MU focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? Establish critical pathways for complex, high-dollar cases Appropriate use of HL7 standards Smoking cessation counseling for MI patients Use of CPOE for medication orders - CORRECT ANSWER Appropriate use of HL7 standards The CFO of your facility asks you to prepare a budget for the fiscal year based on the past volume and expected capacity for the coming year. This process is an example of using the "__________" budgeting method. flexible or statistics budget zero-based budget fixed budget rolling budget - CORRECT ANSWER The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to et the administrative departmental staff get training. The Joint Commission only expects involvement from clinical staff If you can talk him into training his staff, you can let him skip the training This will not do because it violates Joint Commission standards and CQI philosophy This level of involvement is enough to meet Joint Commission standards - CORRECT ANSWER The Credentialing Committee discovered problems with Dr. Hernandez performing hip replacements by reviewing Dr. Hernandez's physician profile querying the National Physician Data Bank sampling and reviewing Dr. Hernandez's patient records interviewing the Chief of Surgery - CORRECT ANSWER The census taken at midnight on August 1 showed 99 patients remaining in the hospital. On August 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on August 2? 94 97 95 96 - CORRECT ANSWER Remaining at midnight 8/1 99 Admissions +4 Discharges -7 In & out same day +1 Inpatient service days on 8/2 97 *Fetal deaths and DOA have NO impact on inpatient service days The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. The supervisor is particularly weak in which management function? controlling planning organizing budgeting - CORRECT ANSWER The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure all alternatives/vendors are evaluated subjectively the personalities of individual vendors will not influence the decision., consistent criteria are used to evaluate the alternatives/vendors the level of software support will be considered in the decision - CORRECT ANSWER consistent criteria are used to evaluate the alternatives/vendors The difference between the IRB and a hospital's Ethics Committee is that The Ethics Committee reviews ethics complaints and the IRB focuses on developing policies and procedures The IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary. the IRB focuses on patient care only and the Ethics Committee addresses both patient care and business practices. The IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. - CORRECT ANSWER The discharge diagnosis for this inpatient encounter is "rule out myocardial infarction." The coder would assign a code for the patient's symptoms. no code for this condition. a code for an impending myocardial infarction. a code for myocardial infarction. Code "rule out" as if it were a confirmed diagnosis. - CORRECT ANSWER The emergency department staff has complained that the clerical staff in your department is delaying stat reports. You decide to meet with your staff and develop a cause and effect diagram to determine possible reasons for the delay. You have explained the issue to your staff and have set up a blank cause & effect diagram. The next step is to discuss the importance of prompt delivery of stat reports brainstorm possible reasons for delays in deliverying the reports design a new system that will support prompt report delivery determine whether there are internal conflicts in the area - CORRECT ANSWER The most sophisticated level of interoperability of an EHR and other such systems is the __________ level. exchange functional basic semantic - CORRECT ANSWER semantic The purpose of the Correct Coding Initiative is to increase fines and penalties for bundling services into comprehensive CPT codes teach coders how to unbundle codes restrict Medicare reimbursement to hospitals for ancillary services detect and prevent payment for improperly coded services - CORRECT ANSWER detect and prevent payment for improperly coded services The use of public and private keys is part of what type of data protection? phishing biometrics firewalls encryption - CORRECT ANSWER When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only, the primary neoplasm is coded as the principal diagnosis, and the secondary neoplasm is coded as an additional diagnosis. code only the primary neoplasm as the principal diagnosis. code only the secondary neoplasm as the principal diagnosis. the secondary diagnosis is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis. - CORRECT ANSWER Which of the following are considered late effects regardless of time? congenital defect poisoning nonhealing fracture nonunion - CORRECT ANSWER Which of the following would be coded as a poisoning? Coumadin intoxication due to a cumulative effect. Idiosyncratic reaction to Artane. Intersection between Aldomet and a vasodilating agent. Reaction between Coumadin and an over-the-counter-medication. - CORRECT ANSWER You are a new supervisor in the HIM department and find it difficult to deal with performance issues. Laney, an employee in the ROI section has been late several times this month. She has already been given a verbal warning. She was late again today. According to the progressive discipline process, your next step will be to issue a written warning reinforce the institution's policies suspend the employee reissue the verbal warning - CORRECT ANSWER issue a written warning You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM for billing purposes. You find this "theoretically" reasonable because DSM codes are also valid ICD-10-CM codes is the industry standard for psychiatric billing systems codes are also valid CPT codes is a widely used and accepted classification system - CORRECT ANSWER You have been asked to reduce your department's operating budget by 20%. In order to do so, you will have to effect reductions in your largest budget line. You will have to make cuts in supplies contracts equipment personnel - CORRECT ANSWER personnel You supervise five clerical employeess who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for 250 square feet of space for your clerical staff. 350 square feet of space for your clerical staff. 200 square feet of space for your clerical staff. 300 square feet of space for your clerical staff. *You can't use Professor's Bond's approach of letting the administrative assistant "take care of this". Master every task of the Department. - CORRECT ANSWER 300 square feet of space for your clerical staff Your HIM Department is moving to a new location and in order to arrange your employees and functions for optimal work flow efficiency and to decide which employees need to be placed close to each other, the tool you decide to use is a PERT chart proximity chart or movement diagram data flow diagram flow process chart - CORRECT ANSWER our HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report? <12 months 12-24 months 25-37 months 38-50 months 51-63 months 0-2 years 3-4 years 5 years >12 months 12-24 months 25-37 months 38-50 months <51 months 0-1 year 1-2 years 2-3 years 3-4 years 4-5 years - CORRECT ANSWER 0-2 years 3-4 years 5 years Your facility has decided to purchase an integrated patient information system. Your part in the initial work plan is the develop system specifications that will ultimately be sent out to vendors who will potentially submit a bid on your system. You are working on the systems specs that will become part of the RFP CPR CRS IRB - CORRECT ANSWER Your facility is storing scanned records for long-term storage on optical disk. The Risk Management Committee's Disaster Task Force has recommended that copies of the disks be stored at a facility across town. The administrator is concerned that records may be altered on the disks stored off-site. You tell the administrator this is a legitimate concern; perhaps the committee should consider storing duplicates in two locations in this facility. this is not a concern; there is really no need to make and store duplicate disks as they are difficult to damage. this is not a concern because WORM technology makes it impossible to alter the documents. this is a legitimate concern; it should be addressed in the contract written with the storage facility. - CORRECT ANSWER this is a legitimate concern; perhaps the committee should consider storing duplicates in two locations in this facility. Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with regular in-service presentations on documentation, including its importance and tips for improvement the UHDDS and informaiton on where each data element is collected and/or verified in your facility feedback on specific instances where improved documentation would improve coding a copy of the facility coding guidelines, along with written informaiton on improved documentation - CORRECT ANSWER regular in-service presentations on documentation, including its importance and tips for improvement Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be professional standards statutory requirements provider preferences space considerations - CORRECT ANSWER [Show Less]
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RHIA Exam Prep 101 Questions with Verified Answers,100% CORRECT
RHIA Exam Prep 101 Questions with Verified Answers HL7 - CORRECT ANSWER A set of international standards for transfer of clinical and administrative dat... [Show More] a between software applications used by various healthcare providers. These standards focus on the application layer, which is "layer 7" in the OSI model. Data Validity - CORRECT ANSWER Accuracy of data Data Comprehensiveness - CORRECT ANSWER All data items are included. Data Granularity - CORRECT ANSWER (a) The attributes and values of data should be defined at the correct level of detail. (b) When a data element cannot be further subdivided Data Precision - CORRECT ANSWER Data values are just large enough to support the application of process For ex: Setting up a drop down menu to make sure that the clerk collects "gender" as "male, female, or unknown" is an example of ensuring data Data Reliability - CORRECT ANSWER Consistency of data Data Timeliness - CORRECT ANSWER Data being available within a time frame helpful to the user Fuzzy Logic - CORRECT ANSWER A branch of logic designed to allow degrees of imprecision in reasoning and knowledge, typified by terms such as `very', `quite possibly', and `unlikely', to be represented in such a way that the information can be processed by computer Quantitative Analysis - CORRECT ANSWER Quantitative analysis involves checking for the presence or absence of necessary reports and/or signatures, Qualitative Analysis - CORRECT ANSWER Qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record. HIM - CORRECT ANSWER Is responsible (in an acute care facility) for educating physicians and other health care providers regarding proper documentation policies 5 years - CORRECT ANSWER How long do CMS regulations require health records to be maintained (unless a longer period is required by other state or local law) AHIMA recommends that PHI for minors be retained for this long unless a longer period is required by other state or federal law - CORRECT ANSWER Age of majority plus statute of limitation Fetal monitoring strips are part of the (blank) record and should be maintained (blank) - CORRECT ANSWER Mother's record; according to the length of time required for minor's records What item is collected and maintained in the organ transplant registry? - CORRECT ANSWER Histocompatibility information Level I CPT codes - CORRECT ANSWER AMA Level II (HCPCS) codes are maintained by - CORRECT ANSWER CMS APC's - CORRECT ANSWER The PPS system used to reimburse hospitals for Medicare hospital outpatient is called Indemnity - CORRECT ANSWER (a) security or protection against a loss or other financial burden. (b) security against or exemption from legal responsibility for one's actions. Hard coding - CORRECT ANSWER HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill Primary Key - CORRECT ANSWER It must contain a unique value for each row of data Risk Assessment - CORRECT ANSWER (a) Reviewing your privacy and security policies, procedures, training programs, and so on, and comparing them to HIPPA and ARRA regulations (b) The security management process Authentication - CORRECT ANSWER Before a user is allowed to access health information the system confirms that the person is who they say they are 60/30 days - CORRECT ANSWER A request to addend a record must be acted on within 60 days. A request to view a record must be acted on within 30 days. 3 Components of a security program - CORRECT ANSWER Protecting the privacy of data, ensuring integrity of data, and ensuring the availability of data System Characterization - CORRECT ANSWER Before you can go any further with your risk analysis you need to determine what systems/info need to be protected. This step is known as Information Systems Review - CORRECT ANSWER Reviewing audit logs, access reports and security incident reports daily Digital Signature - CORRECT ANSWER (a) Signature that uses encryption (b) authentication may be achieved by this in an EHR Brainstorming - CORRECT ANSWER (a)One idea-generated technique used in performance improvement in exploratory problem analysis (b) QI tool useful in sharing input and various recommendations for problem solving Work simplification - CORRECT ANSWER Eliminate, combine, and improve are fundamental objectives of: Audit Trails - CORRECT ANSWER Which security measure exists in an EHR system to provide evidence of information system activity such as log ins, log outs, and file access? Need to Know - CORRECT ANSWER What type of control is used to determine access granted to a user? Re-engineering - CORRECT ANSWER Reducing costs and risks are main objectives of: Design - CORRECT ANSWER A hospital generated an RFP to select the vendor for its new hospital information system. In which phase of the System Development Life Cycle is the hospital involved? ORYX Core Measures - CORRECT ANSWER A data analyst in the HIM department is abstracting data from records with diagnoses of acut MI, HF, and PNA for assessing organizational performance. This is to comply with the: Job Description - CORRECT ANSWER The most tangible output of the job analysis process is the: Intranet - CORRECT ANSWER A hospital has an internet-based system, only accessible to it's employees, that lists all job vacancies. This system would be called a(n): Job Ranking - CORRECT ANSWER A method of comparing particular jobs with other job levels of responsibility and the impact of these positions on revenue generation in organization with limited positions is known as: Relational - CORRECT ANSWER A database model constructed with tables that share common data elements is called: HEDIS - CORRECT ANSWER The data set designed to allow consumers to compare the performance of various managed care plans. It consists of 71 measures across 8 domains of care Productivity - CORRECT ANSWER The process of converting organizational resources into products/services as a means to meet the organization's goals Comparative - CORRECT ANSWER A hospital employee benchmarks with another HIM department to assess his department's performance level. What kind of data will the employee use? Decomposition Diagram - CORRECT ANSWER The purpose of this chart is breaking down problems into smaller details by identifying all the tasks in the process and grouping them into hierarchical levels Joint Commission - CORRECT ANSWER Health care facilities strive to comply with national patient safety goals in their mission to provide safe, high quality care. The organization responsible for publication and maintenance of these goals is the: Defensibility - CORRECT ANSWER The Sherman Antitrust Act (outlawed monopolies) relates to which characteristic of peer review? Scope - CORRECT ANSWER The project manager records the estimated time, costs of project, and records the team purpose. The project manager is establishing the: Analysis - CORRECT ANSWER A hospital considers purchasing a new hospital information system. The IS department begins to survey system users. The hospital is in which phase of the Systems Development Life Cycle? Privacy - CORRECT ANSWER A patient deploys a personal health record and established an access list for the PHR. In limiting access, the patient has exercised the right to: UHDDS - CORRECT ANSWER Federally mandated inpatient acute care data set Unit - CORRECT ANSWER The admitting department manager at a hospital provided admitting scenarios for the staff. Which kind of system testing uses scenarios? Business Associate Agreement - CORRECT ANSWER The HIM department in a hospital uses a vendor for health record storage. What must be created to ensure that the vendor follows rules set forth by the hospital for handling protected health information? Rule Based - CORRECT ANSWER A hospital's outpatient scheduling system ensures that patients are scheduled for barium studies after and not before nuclear medicine gastric emptying studies because barium interferes with gastric emptying studies. This is an example of which kind of clinical decision support? Bar Graph - CORRECT ANSWER The data tool which can be used to accommodate nominal, ordinal, discrete, and continuous data is the: Resource Based Relative Value Scale - CORRECT ANSWER Medicare uses which of the following methodologies for physician reimbursement? Policies - CORRECT ANSWER Guides used by management to make decisions for a variety of reasons are: Access Control - CORRECT ANSWER Which method uses the employee's role to determine their system security level? Data Mining - CORRECT ANSWER The process of searching through large volumes of data for cluster patterns is known as data: Processing - CORRECT ANSWER Classifying, sorting, storing, and retrieving data are all characteristics of which system component? NCQA - CORRECT ANSWER The organization responsible for accrediting MCOs and PPOs is known as the: RFI - CORRECT ANSWER A HIM manager wants to screen vendors to identify which vendor's products meets the department's system needs. The manager sends the vendors an: EMTALA - CORRECT ANSWER The legislation enacted to reduce the inappropriate transfer of patients for financial reasons is: Movement - CORRECT ANSWER One of the best tools to aid in the determination of the location and reduction of bottlenecks which impede the coding process is the: Data Modeling - CORRECT ANSWER What is the process of determining the user's information needs and identifying relationships among the data? Donabedian's Model - CORRECT ANSWER Structure, then process, then outcome Business Associate Contracts - CORRECT ANSWER An example of an administrative safeguard under HIPPA Data Mapping - CORRECT ANSWER The process of cross-referencing between a current terminology system and the new terminology system is: PERT - CORRECT ANSWER The tool used to complete process management activities on time and in proper order Libel - CORRECT ANSWER A written false statement damaging to someone's reputation Slander - CORRECT ANSWER A spoken false statement damaging to someone's reputation Institution - CORRECT ANSWER Traditionally medical records are accepted as being the property of the: Patient - CORRECT ANSWER The ownership of the information contained in the physical medical record is considered property of the: Hearsay; inadmissable - CORRECT ANSWER Under traditional rules of evidence a medical record is considered (blank) and is (blank) into evidence Informed - CORRECT ANSWER The ideal consent for medical treatment obtained by the physician Average Daily Census - CORRECT ANSWER This includes adult and pediatric patients but NOT newborns Inpatient Service Day - CORRECT ANSWER The day of admission is counted as an inpatient service day but the day of discharge is not Births - CORRECT ANSWER Multiple births are one delivery and fetal deaths are counted as deliveries Total Inpatient Deaths - CORRECT ANSWER Fetal deaths and outpatient deaths are not included in this calculation Line Graph - CORRECT ANSWER (a) The best form/graph for demonstrating trends over time (b) Used for a large number of observations to compare services on one data display Histogram - CORRECT ANSWER (a) Will allow the reader to compare the results of Group A with those of Group B on one graphic display (b) Commonly used to display frequency distribution with continuous data Frequency polygon or histogram - CORRECT ANSWER Data display for frequency distribution Type I Error - CORRECT ANSWER When the null hypothesis is rejected and is actually true Kurtosis - CORRECT ANSWER The flatness/peakedness of one distribution in relation to another distribution Performance Improvement - CORRECT ANSWER Process of continuously looking at ways that problems develop and seeking ways to prevent them from happening in the future 2 Years - CORRECT ANSWER Clinical privileges are granted to a physician for this interval of time Utilization Review - CORRECT ANSWER With the passage of Medicare in 1965 this function became mandatory Loss Prevention and Reduction - CORRECT ANSWER Major responsibilities of the Risk Manager Risk Management - CORRECT ANSWER Promoted by the medical malpractice crisis of the 1970's Decision Matrix - CORRECT ANSWER Quality improvement tool that uses criteria to weigh different alternatives Flowchart - CORRECT ANSWER Visual tool used to best identify all of the logical steps and sequence of each procedure during comparison Fishbone - CORRECT ANSWER (a) Visual quality improvement tool that is helpful in identifying the outcome variables and the major/root causes (b) Use of metrics to conduct root cause analysis Affinity Diagram - CORRECT ANSWER Feedback is provided through brainstorming that is compiled on flip charts and organized into categories Crosby - CORRECT ANSWER Quality management theorist who focused on zero defects as the goal of performance improvement Deming - CORRECT ANSWER Quality management theorist who believed that merit raises, formal evaluations and quotas established through benchmarking hinder productivity and growth Annually - CORRECT ANSWER Joint Commission requires facilities manage the environment of care by implementing seven safety plans which must be evaluated: Control Chart - CORRECT ANSWER Best tool for differentiating between common cause variation and special cause variation Serial-Unit Number System - CORRECT ANSWER Patient is issued a different number for each admission and records of past episodes of care are brought forward to be filed under the last number issued Variable Budget - CORRECT ANSWER Costs will vary in direct proportion to changes in the volume of care provided Capital Budget and Operational/Revenue and Expense Budget - CORRECT ANSWER Two budgets that are often prepared by HIM department managers Gantt Chart - CORRECT ANSWER A scheduling tool useful in displaying steps and completion schedule for each phase of a conversion Critical Path - CORRECT ANSWER Series of specific tasks that determine the overall project duration Storytelling - CORRECT ANSWER A strategic thinking tool [Show Less]
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RHIA Exam 292 Questions with Verified Answers,100% CORRECT
RHIA Exam 292 Questions with Verified Answers An audit trail is a good tool for which of the following? - CORRECT ANSWER Reconstructing electronic event... [Show More] s The kids foundation related to children's hospital is mailing fundraising information to the families of all patients who have been treated at children's in the past three years. based on the facts given: - CORRECT ANSWER children's hospital must have notified the patients or patients guardians of this disclosure in the notice of privacy practices A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes: - CORRECT ANSWER Spoliation A breach occurs when unsecured protected health information is accessed or released. The secretary of HHS and local media must be notified if this threshold of patient records breached has been met or exceeded - CORRECT ANSWER 500 The security rule leaves the method for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be - CORRECT ANSWER its own characteristics and environment Mary Smith has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry? - CORRECT ANSWER DEEDS- Data Elements for ER Department Who owns the health records of patients treated in a healthcare facility? - CORRECT ANSWER the facility In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation? - CORRECT ANSWER Precision The HIM manager is concerned with a backlog in transcription of surgical reports. The medical staff rules and regulations stipulate that the surgeon should: - CORRECT ANSWER Write a detailed postoperative progress note about the procedure performed. 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 less than _ hours. - CORRECT ANSWER 30 days, 24 hours, 48 hours Which of the following statements does not pertain to paper-based health records? - CORRECT ANSWER They have a built in access control mechanism. A number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year (for ex 03-0001) is a _ number - CORRECT ANSWER Accession Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking? - CORRECT ANSWER Reliability In ICD 10 CM this note means "not coded here"? - CORRECT ANSWER Excludes 1 When an entity relational diagram is implemented as a relational database, an entity will become an: - CORRECT ANSWER Table A procedure that attempts to obstruct the blood flow to a malignant tumor would be coded to which root operation in ICD 10 PCS? - CORRECT ANSWER Occlusion Under what access security mechanism would an individual be allowed access to ePHI if he or she has a proper login and password, belongs to a specified group, and his or her workstation is located in a specific place within the facility? - CORRECT ANSWER Context-based Which of the following is a rule established by an administrative agency of government? - CORRECT ANSWER Regulation The computer notified the compliance officer that a user accessed the PHI of a patient with the same last name as the user. This is an example of a - CORRECT ANSWER Trigger The Security Incident Procedures Standard has one required implementation specification centered on: - CORRECT ANSWER Identifying and responding to security events Dr. Smith an OB-GYN specialist has just become a staff member at Medical Center Hospital, where she may offer care and treatment related to obstetrics and gynecology including performing deliveries and gynecological surgery. The process of defining what services she may perform is called: - CORRECT ANSWER Granting privileges Under the HIPAA privacy standard, which of the following types of protected health information PHI must be specifically identified in an authorization? - CORRECT ANSWER Psychotherapy notes If a data breach caused by willful neglect is corrected within 30 days from the date of the covered entity or business associate becoming aware of it, what level of violation of the HIPAA Omnibus Rule is this breach? - CORRECT ANSWER Tier 3 Per the HIPAA Privacy Rule, which of the following requires authorization for research purpose? - CORRECT ANSWER Use of Mary's individually identifiable information related to her asthma treatments City Hospitals HIPAA committee is considering a change in policy to allow hospital employees who are also hospital patients to access their own patient information in the hospitals EHR system. A committee member notes that HIPAA provides rights to patients to view their own health information. However, another member wonders if this action might present other problems. In this situation what suggestion should the HIM director provide? - CORRECT ANSWER Allowing employees to access their own records using their job-based access rights appears to violate HIPAAs minimum necessary requirement; therefore, allow employees to access their records through normal procedures. An employee forgot his user ID badge at home and uses another employees badge to access the computer system. What control should have been in place to minimize this security breach? - CORRECT ANSWER Security incident procedures A visitor walks through the work area and picks up a flash drive from an employees desk. What security controls should have been implemented to prevent this security breach? - CORRECT ANSWER Facility access controls The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: - CORRECT ANSWER Physician Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, Susan is a - CORRECT ANSWER Workforce member Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremys medical information is: - CORRECT ANSWER Not protected by the NPP because it is part of a personnel record If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: - CORRECT ANSWER Comply with the patients request and keep the information private (omnibus rule) The Person or entity authentication standard requires methods for verifying that a person is who he or she claims to be. Any of the following meets this standard except: - CORRECT ANSWER Unit level password 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: - CORRECT ANSWER Health record matrix 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 residents care? - CORRECT ANSWER Minimum Data Set Which of the following is an example an example of a M:M relationship? - CORRECT ANSWER Patients to consulting physicians Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of potential breach of: - CORRECT ANSWER Authorship integrity The legal health record for disclosure consists of: - CORRECT ANSWER The data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings A clinic has a contract with the city government to perform all new employee physicals and work injury evaluations. Is it appropriate that a patients family history of cancer be reported to the employer? - CORRECT ANSWER Yes, unless the employer has allowed for such exclusion. Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician? - CORRECT ANSWER Privileged communication An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system? - CORRECT ANSWER Role-based The privacy rule generally requires documentation related to its requirements to be retained: - CORRECT ANSWER 6 years Mrs Davis is preparing to undergo hernia repair surgery at Deconess Hospital. Select the best statement of the following options. - CORRECT ANSWER The surgeon should obtain Mrs. Davis informed consent Which legal doctrine was established by the Darling v. Charleston Community hospital case of 1965? - CORRECT ANSWER Corporate negligence Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers? - CORRECT ANSWER National Practitioner Data Bank Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room. - CORRECT ANSWER Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record. The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as: - CORRECT ANSWER Confidentiality Which of the following is an identifier under the Privacy Rule? - CORRECT ANSWER Vehicle license plate Which type of identity theft occurs when a patient uses another persons name and insurance information to receive healthcare benefits? - CORRECT ANSWER medical The term "hard coding" refers to: - CORRECT ANSWER ICD-10 codes that appear in the hospitals chargemaster The relationship between patient gender and readmission to the hospital is best displayed using a: - CORRECT ANSWER Contingency table This analytic technique is being used by CMS to assist in prepayment audits? - CORRECT ANSWER Predictive modeling Which of the following is included in a request for proposal (RFP)? - CORRECT ANSWER The timeline for implementation Which data collection program is the basis for the CMS value-based purchasing program? - CORRECT ANSWER Hospital Compare HIPPA mandated that healthcare business partners and covered entities implement a common standard for data and information transfer. That standard is: - CORRECT ANSWER ASC X12 N Physician use the _ to access multiple sources of patient information within the healthcare organizations network. - CORRECT ANSWER clinician portal The key to an effective retention and retrieval system of health records in a facility is: - CORRECT ANSWER Master patient index Which of the following health record numbers are in correct terminal digit order? - CORRECT ANSWER 12-25-62, 11-25-68, 18-20-69, 00-24-69 As a preliminary step in designing an IS strategy, it is important for the steering committee to conduct a scan of the external environment and to: - CORRECT ANSWER Conduct an internal environment assessment If an analyst wishes to determine the root cause of claim denials during June via a random sample, what is the sampling unit? - CORRECT ANSWER Claims In which stage of the system life cycle would data be collected from system users regarding their needs? - CORRECT ANSWER Analysis What architectural model of health information exchange allows participants to access data in point to point exchange? - CORRECT ANSWER Federated- inconsistent databases Which of the following represents the correct sequence from low to high of levels of interoperability? - CORRECT ANSWER Basic, functional, semantic There were 25 inpatient deaths, including newborns, at Community Memorial Hospital during the month of June. The hospital performed five autopsies during the same period. The gross autopsy rate for the hospital for June was: - CORRECT ANSWER 20% (5/25= 0.2*100) In purchasing an EHR system from a vendor, what does due diligence refer to? - CORRECT ANSWER Checking references The MPI includes which of the following? - CORRECT ANSWER Patients date of birth, gender, and health record number The director of the health information department wanted to determine the level of the physicians satisfaction with the departments services. The director surveyed the physicians who came to the department. What type of sample is this? - CORRECT ANSWER Convenience Working with the healthcare entity's integration team to ensure that ADT interfaces are properly built and tested is the responsibility of the: - CORRECT ANSWER MPI Manager In which of the following examples does the gender of the patient constitute information rather than a data element? - CORRECT ANSWER In a study comparing the incidence of myocardial infarctions in black males as compared to white females The HIPAA methods titled Expert Determination and Safe Harbor are ways in which the following can be achieved legally - CORRECT ANSWER Deidentification large hospital is planning for an EHR but wants to ensure it has adequate source systems in place to support it. Each of the ancillary departments has a separate information system, and each has claimed that the product is the best on the market and that the vendor has promised the system will interface with any EHR on the market. Identify the PM mistake in this situation - CORRECT ANSWER Lack of sponsorship An HIM professional who accurately reports HIV status of an audit that indicates health problems meets the ethical standards for: - CORRECT ANSWER Public health A distance learning method in which groups of employees in multiple classroom locations may listen to and see the material presented at the same time via satellite or telephone is called: - CORRECT ANSWER Videoconferencing As an EHR implementation project proceeds, additional hospital departments add requirements for the system, and the project becomes more complex. This is known as - CORRECT ANSWER Scope creep Fifty percent of our HIM staff have a nationally recognized credential. This is an example of what type of indicator? - CORRECT ANSWER System Based on the financial data listed what was Triads total net assets before posting net income for the year? - CORRECT ANSWER (assets-liability=net assets) (cash+A/R+building+land)-(A/R+mortgage)= 1,500,000 Based on the financial data, what was Triads net income? - CORRECT ANSWER Revenue - Expenses 25000000-2250000= 250,000 For a contract to be valid, it must include three elements. Which of the following is one of those elements? - CORRECT ANSWER Consideration Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? - CORRECT ANSWER Constructive confrontation Distributing work duties to others along with the right to make decisions and take action is called - CORRECT ANSWER Delegation The performance standard to assign the correct health record number to a returning patient with 99 percent accuracy is an example of a - CORRECT ANSWER Quality standard The process icon symbol (rectangle) is used in flowcharting to indicate: - CORRECT ANSWER A process in which actions are being performed by humans Outpatient programs designed to provide employees immediate access to psychological counseling on a limited basis that may be provided on site or through local providers are called - CORRECT ANSWER Employee Assisted programs In order to expedite basic performance improvement team functioning, the team should: - CORRECT ANSWER Establish ground rules The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called - CORRECT ANSWER Environmental assessment 1000 records per day, 3 FTE, 88% productive, 12% unproductive PFD - CORRECT ANSWER 1000 rpd * 3 88%*8= 7 333/7 = 48 records per hour A comprehensive retrospective review should be conducted at least once a year of what aspect of CDI program? - CORRECT ANSWER All query opportunities The facilities Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding audit review should be performed? - CORRECT ANSWER Focused audit A polyp was removed from a patients colon during a colonoscopy procedure. The physician and pathologist document the polyp as probable adenocarcinoma of the colon. Which of the following actions should the coding professional take to code this encounter? - CORRECT ANSWER Code "polyp" All of the following are goals for a clinical documentation improvement program except - CORRECT ANSWER Preventing billing for bundled services What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals? - CORRECT ANSWER State licensure agencies Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER Date the claim drops Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for - CORRECT ANSWER Spouses or widowers of veterans meeting specific criteria Which of the following accreditation categories would the JC assign to a hospital that did not meet all of the standards at the time of initial on site survey, had a level of standards in noncompliance, had requirements for improvements (RFIs) in excess of the published level for a year and subsequently underwent an additional onsite follow-up survey? - CORRECT ANSWER Contingent accrediation Which of the following lists contains only entities that have roles in the various Medicare improper payment review processes? - CORRECT ANSWER MAC (Medicare Audit Contactor), RAC (Recovery Audit Contractors), and QIO (Quality improvement Organization) Physician normal charge $340 Medicare fee schedule $300 Patient has met his deductible - CORRECT ANSWER $240 (80% of 300) What is the benefit of comparing the coding assigned by coders to the coding that appears on the claim? - CORRECT ANSWER May find claim generation issues that cannot be found in other ways Which of the following is not true of a PHR? - CORRECT ANSWER It will replace the legal records of providers How are hospital compare measures used by CMS - CORRECT ANSWER Hospitals that report all measures receive the full payment update Technology that electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print stream originated is called - CORRECT ANSWER Computer output laser disk (COLD) technology What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document? - CORRECT ANSWER Digital signature It is impossible to have health information interoperability or health information exchange without the following: - CORRECT ANSWER Complete, publicity available standards The JC and CMS identify core measures that provide an indication of a healthcare facility's performance. Some of the core measure data sets include which of the following? - CORRECT ANSWER Pneumonia, congestive heart failure, and myocardial infarction Medical identity thefts are situations in which the following occurs: - CORRECT ANSWER When demographic and financial information is used to acquire medical services The technology commonly utilized for automated claims processing (sending bills directly to third party payers) is: - CORRECT ANSWER Electronic data interchange Which of the following healthcare entities mission is to reduce medicare improper payments through detection and collection of overpayments, identification, identification of underpayments, and implementation of actions that will prevent future improper payments? - CORRECT ANSWER Recovery audit contractor Which of the following conditions would be the most likely to fall into the category of notifiable diseases as defined by the National Notifiable Diseases Surveillance System? - CORRECT ANSWER HIV infection A technique for measuring healthcare entity performance across the four perspective of customer, financial, internal process, and learning and growth is called: - CORRECT ANSWER Balanced scorecard methodology A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called: - CORRECT ANSWER Orientation Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? - CORRECT ANSWER Derived What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? - CORRECT ANSWER Clinical practice guidelines The patient has a biopsy of the colon followed by a hemicolectomy. In the ICD 10 PCS coding system, which procedure(s) are coded? - CORRECT ANSWER Both the biopsy and the hemicolectomy What is the first step a healthcare entity should take when developing a data dictionary? - CORRECT ANSWER Design a plan Which of the following processes is an ancillary function of the health record? - CORRECT ANSWER Biomedical research While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: - CORRECT ANSWER Reason for encounter Unstructured data may be preferred over structured data because: - CORRECT ANSWER It provides greater detail Inadequate functions that make it impossible to detect when an entry was modified or borrowed from another source and misrepresented as an original entry by an authorized user is an example of a potential breach of ____________. - CORRECT ANSWER Auditing integrity Which health record format is arranged in chronological order with documentation from various sources intermingled? - CORRECT ANSWER Integrated To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following? - CORRECT ANSWER Resident Assessment Instrument A barrier to effective computer-assisted coding is the: - CORRECT ANSWER Poor quality of documentation A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is the correct root operation? - CORRECT ANSWER Extirpation Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and who? - CORRECT ANSWER CMS Who is responsible for ensuring the quality of health record documentation? - CORRECT ANSWER Provider Which of the following is an example of a 1:1 relationship? - CORRECT ANSWER Patients to hospital beds According to the UHDDS definition, ethnicity should be recorded on a patient record as: - CORRECT ANSWER Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown Which of the following is a component of the resident assessment instrument? - CORRECT ANSWER A standard Minimum Data Set (MDS) HIM professionals sometimes monitor the records of current inpatients as well as closed records after the patients have been discharged or transferred. What is this process called? - CORRECT ANSWER Ongoing record review Which of the following is a graphical display of the relationship between tables in a database? - CORRECT ANSWER ERD (Entity Relationship Diagram) Which of the following keywords precedes the listing of variables to be returned from an SQL query? - CORRECT ANSWER SELECT The process of providing proof of the authorship of health record documentation is called: - CORRECT ANSWER Authentication Regardless of the healthcare setting, accreditation and Regulatory standards require a separate Healthcare record for each: - CORRECT ANSWER Individual patient Which of the following is a business role with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? - CORRECT ANSWER Data definition steward Record consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: - CORRECT ANSWER Hybrid health records Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered: - CORRECT ANSWER Patient data source What is the traditional paper format for a hospital patient care record? - CORRECT ANSWER Source-oriented Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______. - CORRECT ANSWER UHDDS Quality has several components, including appropriateness, technical excellence, acceptability, and: - CORRECT ANSWER Accessibility Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons? - CORRECT ANSWER Physician What tool is used to sort data in a variety of ways to assist in the study of certain data elements? - CORRECT ANSWER Indexes In a long-term care, the resident's care plan is based on data collected in the: - CORRECT ANSWER MDS- Minimum Data Set The name of the government agency that has led the development of basic data sets for health records and computer databases is the: - CORRECT ANSWER National Committee on Vital and Health Statistics Which of the following is a concept designed to help standardize clinical content for sharing between providers? - CORRECT ANSWER Continuity of care record A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR_ - CORRECT ANSWER maintenance plan Why is it important to extract individual patient information and enter it into a database? - CORRECT ANSWER To reveal patterns Where can you find guidelines for the retention and destruction of healthcare information? - CORRECT ANSWER Accreditation standards Community hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? - CORRECT ANSWER Each physcian practice should obtain a business associate agreement with the hospital. [Show Less]
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RHIA Exam 70 Questions with Verified Answers,100% CORRECT
RHIA Exam 70 Questions with Verified Answers To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base... [Show More] payment rate by the - CORRECT ANSWER relative weight for the MS-DRG. These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments. - CORRECT ANSWER hold harmless Under APCs, payment status indicator "T" means - CORRECT ANSWER ancillary services Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT - CORRECT ANSWER changes in coding productivity ________ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist. - CORRECT ANSWER Fraud How many major diagnostic categories are there in the MS-DRG system? - CORRECT ANSWER 25 Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group. - CORRECT ANSWER 150% The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator is - CORRECT ANSWER U = Documentation is insufficient to determine if condition was present at the time of admission. This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs). - CORRECT ANSWER inpatient rehabilitation facilities The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS) - CORRECT ANSWER cancer hospital All of the following items are "packaged" under the Medicare outpatient prospective payment system, EXCEPT for - CORRECT ANSWER medical visits Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true? - CORRECT ANSWER Each facility is accountable for developing and implementing its own methodology. The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ________ years, unless state law specifies a longer period. - CORRECT ANSWER six All of the following statements are true of MS-DRGs, EXCEPT - CORRECT ANSWER a patient claim may have multiple MS-DRGs. This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service. - CORRECT ANSWER Medicare Physician Fee Schedule (MPFS) Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's nonPAR fee is $57.00. How much reimbursement will the physician receive from Medicare? - CORRECT ANSWER $45.60 What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care? - CORRECT ANSWER home health resource groups Once all data are posted to a patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have internal auditing systems. The auditing systems run each claim through a set of edits specifically designed for the various third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction. These "internal" auditing systems are called - CORRECT ANSWER scrubbers A patient is admitted for a diagnostic workup for cachexia. The final diagnosis is malignant neoplasm of lung with metastasis. The present on admission (POA) indicator is - CORRECT ANSWER Y = Present at the time of inpatient admission. In a global payment methodology, which is sometimes applied to radiological and similar types of procedures that involve professional and technical components, all of the following are part of the "technical" components EXCEPT - CORRECT ANSWER physician services. In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation," EXCEPT - CORRECT ANSWER each service is paid based on the actual charges Under APCs, payment status indicator "C" means - CORRECT ANSWER inpatient procedures/services Under the inpatient prospective payment system (IPPS), there is a 3-day payment window (formerly referred to as the 72-hour rule). This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for - CORRECT ANSWER both diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services. The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology. - CORRECT ANSWER clinical lab services Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are - CORRECT ANSWER physician work, practice expense, and malpractice insurance expense Health plans that use ________ reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time. - CORRECT ANSWER episode-of-care (EOC) When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service. - CORRECT ANSWER CPT Code 99291 (critical care) CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital - CORRECT ANSWER will not receive additional payment for these conditions when they are not present on admission. Accounts Receivable (A/R) refers to - CORRECT ANSWER cases that have not yet been paid. When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital - CORRECT ANSWER absorbs the loss. The term "hard coding" refers to - CORRECT ANSWER HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill. Under the APC methodology, discounted payments occur when - CORRECT ANSWER there are two or more (multiple) procedures that are assigned to status indicator "T", and modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started. Under APCs, payment status indicator "V" means - CORRECT ANSWER clinic or emergency department visit (medical visits). This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS'Web site. - CORRECT ANSWER the OIG's Workplan The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called - CORRECT ANSWER APCs. A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR Medicare fee schedule amount for this service is $190.00. - CORRECT ANSWER $66.50. Under APCs, payment status indicator "S" means - CORRECT ANSWER significant procedure, multiple procedure reduction does not apply. Under APCs, the payment status indicator "N" means that the payment - CORRECT ANSWER is for ancillary services. The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called - CORRECT ANSWER Resource Utilization Groups (RUGs). A fiscal year is a yearly accounting period. It is the 12-month period on which a budget is planned. The federal fiscal year is - CORRECT ANSWER October 1st through September 30 of the next year The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement. - CORRECT ANSWER ICD-9-CM codes Commercial insurance plans usually reimburse health care providers under some type of ________ payment system, whereas the federal Medicare program uses some type of ________ payment system. - CORRECT ANSWER retrospective, prospective ________ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. - CORRECT ANSWER Never events The present on admission (POA) indicator is required to be assigned to the ________ diagnosis(es) for ________ claims on ________ admissions. - CORRECT ANSWER principal and secondary, Medicare, inpatient To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the - CORRECT ANSWER DNFB (discharged, no final bill) A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR Medicare fee schedule amount for this service is $190.00. If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is - CORRECT ANSWER $200.00. A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR Medicare fee schedule amount for this service is $190.00. If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is - CORRECT ANSWER $40.00. If a participating provider's usual fee for a service is $700.00 and Medicare's allowed amount is $450.00, what amount is written off by the physician? - CORRECT ANSWER $250.00 A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by - CORRECT ANSWER home health agencies (HHA) and inpatient rehabilitation facilities (IRF) The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the nonPAR fee schedule amount. The limiting charge is - CORRECT ANSWER 15% When payments can be made to the provider by EFT, this means that the reimbursement is - CORRECT ANSWER sent to the provider by check. The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that the patient was not admitted with, but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as - CORRECT ANSWER present on admission To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the - CORRECT ANSWER relative weight for the MS-DRG. This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms. - CORRECT ANSWER National Provider Identifier (NPI) CMS assigns one ________ to each APC and each ________ code. - CORRECT ANSWER payment status indicator, HCPCS This is the amount collected by the facility for the services it bills - CORRECT ANSWER reimbursement In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the - CORRECT ANSWER geographic practice cost indices. When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called - CORRECT ANSWER abuse. This accounting method attributes a dollar figure to every input required to provide a service. - CORRECT ANSWER cost accounting CMS adjusts the Medicare Severity DRGs and the reimbursement rates every - CORRECT ANSWER fiscal year beginning October 1 Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient? - CORRECT ANSWER RBRVS This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda. - CORRECT ANSWER LCD (Local Coverage Determinations) Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT - CORRECT ANSWER lifetime reserve days are paid under Medicare Part B. Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services? - CORRECT ANSWER The provider cannot bill the patients for the balance between the MPFS amount and the total charges LCDs and NCDs are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors. LCD and NCD are acronyms that stand for - CORRECT ANSWER local coverage determinations and national coverage determinations. A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. The charge for the office visit was $125. The Medicare beneficiary had already met his deductible. The Medicare Fee Schedule amount is $100. Dr. Zachary does not accept assignment. The office manager will apply a practice termed as "balance billing," which means that the patient is - CORRECT ANSWER financially liable for charges in excess of the Medicare fee schedule, up to a limit A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR Medicare fee schedule amount for this service is $190.00. If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total receive is - CORRECT ANSWER $218.50 The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. DNFB is an acronym for ________. - CORRECT ANSWER discharged not final billed When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a - CORRECT ANSWER Corporate Integrity Agreement The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from - CORRECT ANSWER OASIS (Outcome and Assessment Information Set) [Show Less]
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AHIMA RHIA Exam Prep (7th Edition) 158 Questions with Verified Answers,100% CORRECT
AHIMA RHIA Exam Prep (7th Edition) 158 Questions with Verified Answers 17. A patient requests copies of her medical records in an electronic format. T... [Show More] he hospital maintains a portion of the designated record set in a paper format and a portion of the designated record set in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically - CORRECT ANSWER c. Provide the patient with both paper and electronic copies of the record The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be delivered electronically (Thomason 2013, 102). 15. For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - CORRECT ANSWER If an EHR is to provide clinical decision support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364). 14. Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN - CORRECT ANSWER c. Password and swipe card The three methods of two-factor authentication are something you know, such as a password or PIN; something you have, such as an ATM card, token, or swipe/smart card; and something you are, such as a biometric fingerprint, voice scan, iris, or retinal scan (Sayles and Trawick 2014, 219). Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems - CORRECT ANSWER Each Resource-Based Relative Value Scale (RBRVS) comprises three elements: physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register (Casto and Forrestal 2015, 150). 12. The predefined process icon is used in flowcharting to indicate: a. A process in which actions are being performed by humans b. A point in the process at which participants must evaluate the status of the process c. Formal procedures that participants are expected to carry out the same way every time d. A point in the process at which the participants must record data in paper-based or computer- based formats - CORRECT ANSWER The rectangle with double lines on the side in a flowchart is a predefined process icon. This symbol represents the formal procedure that participants are expected to carry out the same way every time (Shaw and Carter 2015, 198). . A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? a. Content analysis b. Effect size review c. Psychometric assay d. Secondary analysis - CORRECT ANSWER Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586). In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has COPD d. Assign a code from the abnormal findings to reflect the condition - CORRECT ANSWER A query is routine communication and education tool used to advocate for complete and compliant documentation. The intent is to clarify what has been recorded, not to call into question the provider's clinical judgment or medical expertise. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS and whether the COPD does is not clear (Hunt 2016, 276-277). Per the HITECH breach notification requirements, which of the following is the threshold in which the media and the Secretary of Health and Human Services should be notified of the breach? a. more than 1,000 individuals affected b. more than 500 individuals affected c. more than 250 individuals affected d. Any number of individuals affected requires notification - CORRECT ANSWER Reporting requirements mandate notification to the individual whose information was breached, and in the case of breaches of more than 500 individuals' information, to the media and the Secretary of Health and Human Services (Biedermann and Dolezel 2017, 401). Determining costs associated with EHR hardware and software acquisition, implementation, and ongoing maintenance represents which type of analysis? a. Benefits realization study b. Goal-setting exercise c. Cost-benefit feasibility study d. Productivity improvement study - CORRECT ANSWER Cost-benefit feasibility is used to determine if an EHR initiative is appropriate for the organization at this time; it measures the costs associated with acquisition of hardware and software, installation, implementation, and ongoing maintenance (Amatayakul 2016, 104-105). Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service. - CORRECT ANSWER If a service is hard-coded into the charge description master (CDM), it is important that this decision is communicated to the coding staff. If the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and Forrestal 2015, 253). Which health record format is arranged in chronological order with documentation from various sources intermingled? a. Electronic b. Source-oriented c. Problem-oriented d. Integrated - CORRECT ANSWER The integrated health record is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse-chronological order. The advantage of the integrated format is that it is easy for caregivers to follow the course of the patient's diagnosis and treatment (Russo 2013b, 305). The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and that only the number be announced. - CORRECT ANSWER The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is not to interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure and, therefore, allowed in the Privacy Rule (Thomason 2013, 37). 4. Which of the following is a graphical display of the relationships between tables in a database? a. RDMS b. SQL c. ERD d. SAS - CORRECT ANSWER An entity relationship diagram (ERD) is used to describe how the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool (White 2016a, 46). What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? a. Core measures b. Enhanced discharge planning c. Data mining d. Clinical practice guidelines - CORRECT ANSWER Clinicians use health record information to develop clinical pathways and other clinical practice guidelines, which help clinicians make knowledge- and experience-based decisions on medical treatment. These guidelines make it easier to coordinate multidisciplinary care and services (Fahrenholz 2013b, 78). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). Which of the following is a kind of technology that focuses on data security? a. Clinical decision support b. Bitmapped data c. Firewalls d. Smart cards - CORRECT ANSWER Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders (Sandefer 2016a, 366). 9. What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts approved by Medicare, amount Medicare paid, and amount the patient must pay? a. EOB b. MSN c. EOMB d. ABN - CORRECT ANSWER Correct Answer: B For Medicare patients, the fiscal intermediary and carriers prepare Medicare summary notices or MSNs. The MSN details amounts billed by the provider, amounts approved by Medicare, how much Medicare reimbursed the provider, and what the patient must pay the provider by way of deductible and copayments (Casto and Forrestal 2015, 256). 20. Secondary data sources provide information that is ________ available by looking at individual health records. a. not easily b. easily c. often d. never - CORRECT ANSWER Correct Answer: A Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2013c, 159). Use of a variety of content delivery methods to accommodate different types of learners is called: a. Blended learning b. Programmed learning c. Classroom learning d. Online learning - CORRECT ANSWER Correct Answer: A Blended learning uses several delivery methods thereby gaining the advantages and reducing the disadvantages of each method alone (Patena 2016, 772). 22. In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? a. DICOM b. IEEE 1073 c. LOINC d. X12N - CORRECT ANSWER Correct Answer: D X12N refers to standards adopted for electronic data interchange. In order for transmission of healthcare data between a provider and payer, both parties must adhere to these standards (Sayles and Trawick 2014, 175). Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time? a. Prevalence b. Incidence c. Frequency d. Distribution - CORRECT ANSWER Correct Answer: A The prevalence rate is the proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time. The prevalence rate describes the magnitude of an epidemic and can be an indicator of the medical resources needed in a community for the duration of the epidemic (Edgerton 2016, 503). 15 8 Correct15 Wrong8 Unanswered 1. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff - CORRECT ANSWER Correct Answer: D In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff. Coding is based primarily on physician documentation, so nursing staff would not be included in the education process (Hunt 2016, 288). 18 5 Correct18 Wrong5 Unanswered 2. A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a: a. Problem-oriented health record b. Patient-centric record c. Longitudinal health record d. Health record - CORRECT ANSWER Correct Answer: C A longitudinal health record maintains information throughout the lifespan of the patient, ideally from birth to death (Fahrenholz 2013a, 45). 3. 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. This data is called a(n): a. Indicator b. Measurement c. Assessment d. Outcome - CORRECT ANSWER Correct Answer: A An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2015, 153). The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue. - CORRECT ANSWER Correct Answer: B The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Hunt 2016, 275). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Correct Answer: B Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). For a contract to be valid, it must include three elements. Which of the following is one of those elements? a. Assumption of risk b. Consideration c. Statute of limitations d. Notice of liability - CORRECT ANSWER Correct Answer: B The elements of a contract must be stated clearly and specifically. A contract cannot exist unless all the following elements exist: there must be an agreement between two or more persons or entities and the agreement must include a valid offer, acceptance, and exchange of consideration (Rinehart-Thompson 2016, 56). For Medicare patients, how often must the home health agency's assessment and care plan be updated? a. At least every 60 days or as often as the severity of the patient's condition requires b. Every 30 days c. As often as the severity of the patient's condition requires d. Every 60 days - CORRECT ANSWER Correct Answer: A Home health agencies are expected to conduct an assessment that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires (White 2013, 558). Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: a. Never allowed b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment c. Allowed only if Jennifer's mother is declared incompetent by a court of law d. Allowed access to PHI; any family member is always allowed access to PHI - CORRECT ANSWER Correct Answer: B The Privacy Rule lists two circumstances where protected health information (PHI) can be used or disclosed without the individual's authorization (although the individual must be informed in advance and given an opportunity to agree or object). One of these circumstances is disclosing PHI to a family member or a close friend that is directly relevant to his or her involvement with the patient's care or payment. Likewise, a covered entity may disclose PHI, including the patient's location, general condition, or death, to notify or assist in the notification of a family member, personal representative, or some other person responsible for the patient's care (Rinehart-Thompson 2017d, 225-226). 10. Using the data in the following graph, we can see changes in this hospital's profile. What concerns might the hospital's quality council need to address based on these changes in their customer base? a. Staffing changes might be necessary to accommodate patients who have cultural differences. b. Data collection has improved. c. No changes in staffing are necessary because the patient mix is appropriate. d. The quality council should ask for more detailed data. - CORRECT ANSWER Correct Answer: A The graph shows that the Asian population has increased in the last five years, so the organization may need to adjust staffing, offer a wider variety in dietary choices, and ensure patient rights and safety are appropriate in the face of possible language barriers and cultural differences (Shaw and Carter 2015, 95-97) A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called: a. Strategy map b. Process innovations c. Balanced scorecard methodology d. SWOT analysis - CORRECT ANSWER Correct Answer: C Balanced scorecard methodology is a technique for measuring organization performance across the four perspectives of customer, financial, internal processes, and learning and growth (McClernon 2016, 951). The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of: a. Assisting coders to read physician handwriting b. Preventing potential medication errors due to misinterpretation c. Making terminology consistent in preparation for electronic records d. Identifying physicians who are dispensing large quantities of drugs - CORRECT ANSWER Correct Answer: B Healthcare organizations need to be very clear about which abbreviations are not acceptable to use when writing or communicating medication orders. The organization's policy should also define whether or when the diagnosis, condition, or indication for use is included on a medication order (Shaw and Carter 2015, 248-249). Which of the following is true of the median? a. It is a measure of variability. b. It is difficult to calculate. c. It is based on the whole distribution. d. It is sensitive to extreme values. - CORRECT ANSWER Correct Answer: C The median offers the following three advantages: relatively easy to calculate; based on the whole distribution and not just a portion of it, as is the case with the mode; and unlike the mean, it is not influenced by extreme values or unusual outliers in the frequency distribution (Horton 2016, 222). 4. This type of data display tool is a plotted chart of data that shows the progress of a process over time. a. Bar graph b. Histogram c. Pie chart d. Line graph or plot - CORRECT ANSWER Correct Answer: D A line graph or plot may be used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the values of the variable being plotted (Marc 2016, 546). Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given: a. No information due to the highly sensitive nature of his illness b. Admission date and location in the facility c. General condition and acknowledgment of admission d. Location in the facility and diagnosis - CORRECT ANSWER Correct Answer: C A facility may maintain a facility directory of patients being treated. HIPAA's Privacy Rule permits the facility to maintain in its directory the following information about an individual if the individual has not objected: name, location in the facility, and condition described in general terms. This information may be disclosed to persons who ask for the individual by name (Rinehart-Thompson 2017d, 227). 17. If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? a. Survey sampling b. Systematic sampling c. Cluster sampling d. Stratified sampling - CORRECT ANSWER Correct Answer: B A systematic random sample is a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample (White 2016a, 140). . If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: a. Release the information to the health insurance provider b. Get special patient consent to release the information c. Comply with the patient's request and keep the information private d. Request permission from HHS to release the information - CORRECT ANSWER Correct Answer: C The 2013 HIPAA Omnibus Rule finalized regulations give patients the right to request that their PHI not be disclosed to a health plan if they pay out of pocket in full for the services or items. A provider who accepts the payment and provides the service is compelled to abide by this request (Rinehart-Thompson 2017d, 220-221). Which of the following would be the best approach in starting a data governance program? a. Focus on one or a few small business imperatives b. Begin with developing policies and procedures c. Identify HIPAA requirements d. Establish success metrics - CORRECT ANSWER Correct Answer: A Data governance is an iterative process. It initially prioritizes initiatives and focuses on small select business imperatives that quickly deliver value and expand as the program matures (Johns 2016, 88). 18 5 Correct18 Wrong5 Unanswered Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Utilization management b. Patient access c. Health information management d. Patient accounts - CORRECT ANSWER Correct Answer: C Resolving failed edits is one of many duties of the health information management (HIM) department. Various medical departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Schraffenberger and Kuehn 2011, 237-238). The legal health record for disclosure consists of: a. Any and all protected health information data collected or used by a healthcare entity when delivering care b. Only the protected health information requested by an attorney for a legal proceeding c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings d. All of the data and information included in the HIPAA Designated Record Set - CORRECT ANSWER Correct Answer: C The concept of legal health records was created to describe the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings. Understanding legal health records requires knowledge of not only what comprises business records used as legal health records, but also the processes as well as the physical and electronic systems used to manage these records (Biedermann and Dolezel 2017, 424). [Show Less]
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RHIA EXAM 25 Questions with Verified Answers,100% CORRECT
RHIA EXAM 25 Questions with Verified Answers Quantitative analysis - CORRECT ANSWER HIM professionals analyze medical records for any missing reports,... [Show More] forms, or required signatures and deletions. Which of the following is not usually a component of acute care patient records? medical history nurse assessment problem list progress notes - CORRECT ANSWER problem list The attending physician is responsible for which of the following types of acute care documentation? consultation report Discharge summary Laboratory report Pathology report - CORRECT ANSWER Discharge summary Which of the following is an example of clinical data? Admitting diagnosis Data and time of admission Insurance information Health record number - CORRECT ANSWER admitting diagnosis A nurse is responsible for which of the following types of acute care documentation? Operative report Medication record Radiology report Therapy assessment - CORRECT ANSWER Medication record The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the _____. Anesthesia report Progress notes Operative report Recovery room report - CORRECT ANSWER Operative report Which type of specialized record includes care provided prior to arrival at a healthcare setting and time and means of arrival Ambulatory care record Emergency care record Ambulatory surgery record Pediatric record - CORRECT ANSWER Emergency care record Documentation standards and guidelines are published by a variety of private and public organizations, including the __________ for the purpose of accreditation - The Joint Commission - American Health Information Management Association - National Committee for Quality Insurance - American Association of Professional Coders - CORRECT ANSWER The Joint Commission Which of the following is true of computer-based records? usually supported by all healthcare providers can be accessed by multiple end users simultaneously has a clear definition and technological standards permits minimal risks to healthcare privacy and security - CORRECT ANSWER can be accessed by multiple end users simultaneously Which of the following represents documentation of the patient's current and past health status? Physical exam Medical history Physician orders Patient consent - CORRECT ANSWER Medical history Which of the following contains the physician's findings based on an examination of the patient? Physical exam Discharge summary Medical history Patient insurance - CORRECT ANSWER Physical exam What is the function of a consultation report? Provides a chronological summary of the patient's medical history and illness Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care Concisely summarizes the patient's treatment and stay in the hospital Documents the physicians instructions to other parties involved in providing care to the patient - CORRECT ANSWER Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care What is the function of physician's orders? - CORRECT ANSWER To document the physician's instructions to other parties involved in providing care to a patient an example of an advance directive? - CORRECT ANSWER Living will In a medical history, which of the following is a detailed chronological description of the development of the patient's illness? - CORRECT ANSWER History of present illness Patient history questionnaires are most often used in: - CORRECT ANSWER Ambulatory care Which of the following may be managed in an electronic document management system (EDMS): - CORRECT ANSWER Document images, email, PACS A critical element of data retrieval planning is designing: - CORRECT ANSWER Screen layout Discrete data may be entered into an EHR via: - CORRECT ANSWER Macro Point and click Voice command Natural language processing: - CORRECT ANSWER Converts narrative information to discrete data A local area network using Internet-based protocols is: - CORRECT ANSWER Ethernet As part of an EHR system selection, due diligence should be done: - CORRECT ANSWER prior to contracting for an EHR product Our team has written a plan that describes what systems will be implemented in what order in our transition to the EHR. We completed our: - CORRECT ANSWER migration path Removing health records from storage area to allow space for more current records is called_____. - CORRECT ANSWER purging records The services provided by HIM departments in acute care hospitals usually include all the following except: - CORRECT ANSWER Medical billing [Show Less]
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RHIA EXAM PREP 169 Questions with Verified Answers,100% CORRECT
RHIA EXAM PREP 169 Questions with Verified Answers A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is no... [Show More] w removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Fragmentation d. Release - CORRECT ANSWER b. Extirpation ***Taking or cutting out solid matter from a body part Which type of data consists of *factual details* a *aggregated or summarized* from a group of health records that provides *no means to identify specific patients*? a. Orginal b. Source c. Protected d. Derived - CORRECT ANSWER d. Derived Which of the following data management domains would be responsible for establishing standards for data retention and storage? a. Data architecture management b. Metadata management c. Data life cycle management d. Master data management - CORRECT ANSWER c. Data life cycle management When a healthcare entity destroys the health records after the acceptable retention period has been met, a *certificate of destruction* is created. How long must the healthcare entity maintain the the certificate of destruction? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER d. Permanently Which of the following processes is an ancillary function of the health record? a. Admitting and registration information b. Billing and reimbursement c. Patient assessment and care planning d. Biomedical research - CORRECT ANSWER d. Biomedical research ***Ancillary function- medical services or supplies that are not provided by acute care hospitals, doctors, or healthcare professionals What are LOINC codes used for? a. Identifying test results b. Reporting test results c. Identifying tests unique to a specific company d. Reporting a code for reimbursement - CORRECT ANSWER a. Identifying test results Logical Observation Identifiers, Names and Codes (LOINC) is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results. While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Activities of daily living c. Discharge diagnosis d. Reason for encounter - CORRECT ANSWER d. Reason for encounter The inpatient data set that has been incorporated into federal law and is *required for Medicare reporting* is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-term Care d. Health Plan Employer Data and Information Set - CORRECT ANSWER b. Uniform Hospital Discharge Data Set Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete - CORRECT ANSWER b. It provides greater detail What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)? a. Face sheet b. Care plan c. Diagnosis plan d. Flow sheet - CORRECT ANSWER b. Care plan ***Care plan is required for patients in a LTCH Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin are all examples of: a. Auto-authentication fields b. Metadata c. Data d. Information fields - CORRECT ANSWER b. Metadata Data content standards are used to: a. Share data in the same way the users interpret data b. Share data in a unique way c. Share data between disparate systems d. Modify data - CORRECT ANSWER a. Share data in the same way the users interpret data A barrier to effective computer-assisted coding is the: a. Resistance of physicians b. Resistance of HIM professionals c. Poor quality of documentation d. Reduction of consistency without human coders - CORRECT ANSWER c. Poor quality of documentation Personal information about patients such as their names, ages, and addresses is considered what type of information? a. Clinical b. Administrative c. Operational d. Accreditation - CORRECT ANSWER b. Administrative To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual - CORRECT ANSWER a. Digital Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professionals - CORRECT ANSWER c. Provider A diagnosis described as "possible," "likely," or "rule out" is reported as if present for which type of patient records? a. Outpatient b. Inpatient c. Emergency room d. Physician office - CORRECT ANSWER b. Inpatient Identify the level in the data model that describes how the data is stored within the database: a. Conceptual data model b. Physical data model c. Logical data model d. Data manipulation language - CORRECT ANSWER b. Physical data model The purpose of the data dictionary is to _________________ definitions and ensure consistency of use. a. Identify b. Standardize c. Create d. Organize - CORRECT ANSWER b. Standardize A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: a. Spreadsheet b. Database c. File d. Data table - CORRECT ANSWER b. Database A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n): a. Implementation plan b. Information technology plan c. Migration plan d. Transition strategy - CORRECT ANSWER c. Migration plan Which of the following is the appropriate method for destroying electronic data? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing Which of the following is a *business role* with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? a. Chief data officer b. Data definition steward c. Data production steward d. Auditing integrity - CORRECT ANSWER b. Data definition steward Because a health record contains *patient-specific data* and information about a patient that has been documented by the professionals who provided care or service to that patient, it is considered: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source - CORRECT ANSWER c. Primary data source Ensuring that only the most recent report is available for viewing is known as: a. Documentation integrity b. Authorship c. Validation d. Version control - CORRECT ANSWER d. Version control Secondary data source provide information that is _____ available by looking at individual health records. a. Not easily b. Easily c. Often d. Never - CORRECT ANSWER a. Not easily In long-term care, the resident's comprehensive assessment is based on data collected in the: a. UHDDS b. OASIS c. MDS d. HEDIS - CORRECT ANSWER c. MDS ***MDS- federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents The practices or methods that *defend against charges* questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation What tool is used to sort data in a variety of ways to assist in the study of certain data elements? a. Registries b. Indexes c. Clinical trials d. Statistical reports - CORRECT ANSWER b. Indexes A critical step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary - CORRECT ANSWER d. Data dictionary ***Data dictionary- descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source - CORRECT ANSWER a. Secondary data source The name of the government agency that has led the *development of basic data sets* for health records and computer databases is: a. The Centers for Medicare and Medicaid Services (CMS) b. The National Committee on Vital and Health Statistics (NCVHS) c. The American National Standards institute (ANSI) d. The National Institute of Health (NIH) - CORRECT ANSWER b. The National Committee on Vital and Health Statistics (NCVHS) Which of the following is a concept designed to help standardize *c*linical *c*ontent for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED - CORRECT ANSWER a. Continuity of care record Which of the following makes the indexing of scanned health records more efficient by *entering metadata automatically*? a. Barcodes b. Backscanning c. OCE d. CPOE - CORRECT ANSWER a. Barcodes Where can you find guidelines for the *retention and destruction* of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards To practice medicine, medical school students must pass a test before they can obtain a: a. Degree b. Licensure c. Residency d. Specialty - CORRECT ANSWER b. Licensure Which of the following is a mechanism that *records and examines activity* in information systems? a. eSignature laws b. Security audits c. Minimum necessary rules d. Access controls - CORRECT ANSWER b. Security audits The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. The care provided to the patient b. Identification of the record as the one subpoenaed c. The qualifications of the treating physicians d. Identification of the standard of care used to treat the patient - CORRECT ANSWER b. Identification of the record as the one subpoenaed Ensuring that data have been modified or accessed only by individuals who are authorized to do so, is a function of data: a. Data integrity b. Data quality c. Data granularity d. Logging functions - CORRECT ANSWER a. Data integrity Mr Martin has asked his physician's office to review a copy of his PHI. His request must be responded to no later than _________ after the request is made. a. 90 days b. 60 days c. 30 days d. 6 weeks - CORRECT ANSWER c. 30 days The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI: a. For as long as it is maintained b. For six years c. Forever d. For 12 months - CORRECT ANSWER a. For as long as it is maintained Under the HIPAA Security Rule, these types of safeguards have to do with *protecting the environment*: a. Administrative b. Physical c. Security d. Technical - CORRECT ANSWER b. Physical Which of the following controls external access to a network? a. Access controls b. Alarms c. Encryption d. Firewall - CORRECT ANSWER d. Firewall Which of the following must be reported to the medical examiner? a. Burns b. Accidental deaths c. Causes of injury d. Morbidity - CORRECT ANSWER b. Accidental deaths A visitor sign-in sheet to a computer area is an example of what type of control? a. Administrative b. Audit c. Facility access d. Workstation - CORRECT ANSWER c. Facility access Which of the following is an *administrative safeguard* action? a. Facility access control b. Documentation retention guidelines c. Maintenance control d. Media reuse - CORRECT ANSWER b. Documentation retention guidelines Authorization management involves: a. The process used to protect the reliability of a database b. Limiting user access to a database c. Allowing unlimited use of the database d. Developing definitions for database elements - CORRECT ANSWER b. Limiting user access to a database Per HITECH an *accounting of disclosures* must include disclosures made during the previous: a. 10 years b. 6 years c. 3 years d. 1 year - CORRECT ANSWER c. 3 years The age of majority in most states is: a. 16 and older b. 17 and older c. 18 and older d. 21 and older - CORRECT ANSWER c. 18 and older Employees in the Hospital Business Office may have legitimate access to patient health information *without patient authorization* based on what HIPAA standard/principle? a. Minimum necessary b. Compound authorization c. Accounting of disclosures d. Preemption - CORRECT ANSWER a. Minimum necessary Generally, policies addressing the confidentiality of quality improvement (QI) committee data (minutes, actions, and so forth) state that this kind of data is: a. Protected from disclosure b. Subject to release with patient authorization c. Generally available to interested parties d. May not be reviewed or released to external reviewers such as the Joint Commission - CORRECT ANSWER a. Protected from disclosure Covered entities must retain documentation of their security policies for at least: a. Five years b. Five years from the date of origination c. Six years from the date when last in effect d. Six years from the date of the last incident - CORRECT ANSWER c. Six years from the date when last in effect Under HIPAA, when is the patient's written authorization required to release their healthcare information? a. For purposes related to treatment b. For purposes related to payment c. For administrative healthcare operations d. For any purpose unrelated to treatment, payment, or healthcare operations - CORRECT ANSWER d. For any purpose unrelated to treatment, payment, or healthcare operations The confidentiality of incident reports is generally protected in cases when the report is filed in: a. The nursing notes b. The patient's health record c. The physician's progress notes d. The hospital risk manager's office - CORRECT ANSWER d. The hospital risk manager's office Which one of the following has access to personally identifiable data *without authorization* or subpoena? a. Law enforcement in a criminal case b. The patient's attorney c. Public health departments for disease reporting purposes d. Workers' compensation for disability claim settlement - CORRECT ANSWER c. Public health departments for disease reporting purposes An original goal of HIPAA Administrative Simplification was to standardize: a. Privacy notices given to patients b. The electronic transmission of health data c. Disclosure of information for treatment purposes d. The definition of PHI - CORRECT ANSWER b. The electronic transmission of health data Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN - CORRECT ANSWER c. Password and swipe card Which of the following is a "public interest and benefit" exception to the authorization requirement? a. Payment b. PHI regarding victims of domestic violence c. Information requested by a patient's attorney d. Treatment - CORRECT ANSWER b. PHI regarding victims of domestic violence Under the Privacy Rule, which of the following must be included in a patient accounting of disclosures? a. State-mandated report of a sexually transmitted disease b. Disclosure pursuant to a patient's signed authorization c. Disclosure necessary to meet the national security or intelligence requirements d. Disclosure for payment purposes - CORRECT ANSWER a. State-mandated report of a sexually transmitted disease What information process must be the legal counsel of Smithville Hospital perform in order to prepare for a lawsuit against the hospital? a. Information governance b. E-discovery c. Transparency d. Enterprise information management - CORRECT ANSWER b. E-discovery What is the most common method for implementing entity authentication? a. Personal identification number b. Biometric identification systems c. Token systems d. Password systems - CORRECT ANSWER d. Password systems A _____ helps a healthcare entity proactively ensure that the information they store and maintain is only being accessed in the *normal course of business*. a. Contingency plan b. Workflow analysis c. Documentation audit d. Security audit - CORRECT ANSWER d. Security audit E discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended with legislation? a. Federal Rules of Evidence b. State Rules of Evidence c. Federal Rules of Civil Procedure d. State Rules of Civil Procedure - CORRECT ANSWER c. Federal Rules of Civil Procedure Which of the following presents the greatest risk of large-scale health information breaches? a. Unlocked rooms b. Computer monitors positioned toward high-traffic areas c. Unattended computer workstations d. Laptop theft - CORRECT ANSWER d. Laptop theft What type of safeguards comprise over half of all the safeguards included in the security rule? a. Physical safeguards b. Technical safeguards c. Administrative safeguards d. Security safeguards - CORRECT ANSWER c. Administrative safeguards What is the most constant threat to health information integrity? a. Natural threats b. Environmental threats c. Internal disaster d. Humans - CORRECT ANSWER d. Humans This data collection tool is used when one needs to gather data on sample observations in order to detect patterns. a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool - CORRECT ANSWER a. Check sheet To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of *reliability check* is called: a. Precision b. Recheck c. Interrater d. Construct - CORRECT ANSWER c. Interrater Which of the following terms is defined as the *proportion of people* in a population who have a particular disease at a specific point in time or over a specified period of time? a. Prevalence b. Incidence c. Frequency d. Distribution - CORRECT ANSWER a. Prevalence This type of chart is used to *focus attention on any variation in the process* and helps the team to determine whether that variation is normal or a result of special circumstances. a. Pareto chart b. Pie chart c. Control chart d. Line chart - CORRECT ANSWER c. Control chart ***Control chart- measures key processes over time Which application uses statistical techniques to *determine the likelihood of certain events occurring together*? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering - CORRECT ANSWER a. Predictive modeling This statistical inference measure both the *strength* of a *relationship* between two variables and the functional relationship between them. a. Correlation b. T-test c. Simple linear regression d. Standard deviation - CORRECT ANSWER c. Simple linear regression This type of data display tool is used to illustrate *frequency distributions* of *continuous variables*, such as *age and length of stay (LOS)* a. Bar graph b. Histogram c. Pie chart d. Scatter diagram - CORRECT ANSWER b. Histogram How long should the master patient index be maintained? a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently - CORRECT ANSWER d. Permanently A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the: a. Mean b. Mode c. Standard deviation d. Standard variance - CORRECT ANSWER c. Standard deviation A current key function in the health information field whereby *data is turned into useful information* is: a. Data mining b. Decision analysis c. Clinical decision support d. Data analytics - CORRECT ANSWER d. Data analytics What tern is used for a *centralized database* that captures, sorts, and processes patient data and then sends it back to the user? a. Clinical data repository b. Data exchange standard c. Central processor d. Digital system - CORRECT ANSWER a. Clinical data repository The _____ is a standardized assessment of *consumer perspectives* regarding healthcare access and quality in hospitals. a. HCAHPS b. CG-CAHPS c. AHRQ-CAHPS d. ONC-CAHPS - CORRECT ANSWER a. HCAHPS Hospital Consumer Assessment of Healthcare Providers The Administrative Simplification portion of Title II of HIPAA addresses which of the following? a. Creating standardized forms for release of information throughout the industry b. Computer memory requirements for health plans maintaining patient health information c. Security regulations for personal health records d. Uniform standards for transaction and code sets - CORRECT ANSWER d. Uniform standards for transaction and code sets A ____ is a *range of values*, such that the probability of that range covering the true value of a parameter is a set of probability or confidence. a. Confidence interval b. Hypothesis c. Proportion d. Median - CORRECT ANSWER a. Confidence interval Which index, often considered the *most important resource in a healthcare facility*, is a database of patients within a facility or associated group of facilities? a. Facility-specific index b. Disease index c. Master patient index d. Operation index - CORRECT ANSWER c. Master patient index According to the Medicare Conditions of Participation, how long must health records be retained? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER b. Five years Change management includes: a. Identifying problems b. Being available to listen to staff c. Redesigning processes d. Educating staff on new processes - CORRECT ANSWER b. Being available to listen to staff Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors - CORRECT ANSWER a. Achieving legitimate optimization The purpose of Regional Extension Centers is to: a. Implement meaningful use b. Support providers in adopting EHR with technical assistance c. Develop standards for HI systems d. Provide funding for expanding the adoption of HI technology - CORRECT ANSWER b. Support providers in adopting EHR with technical assistance Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area? a. Serial-unit filing system b. Serial filing system c. Unit filing system d. Terminal-digit filing system - CORRECT ANSWER d. Terminal-digit filing system Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards [Show Less]
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RHIA Exam 309 Questions with Verified Answers,100% CORRECT
RHIA Exam 309 Questions with Verified Answers A discharge summary must be completed within____days after discharge for most patients but within ___for... [Show More] patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ___ - CORRECT ANSWER 30 days/24 hours/48 hours systematic random sample - CORRECT ANSWER a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample. Example: If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use. Systematic sampling Entity relationship modeling - CORRECT ANSWER is a type of conceptual modeling. Conceptual models are abstract and encourage high-level problem structing; they help establish a common ground for communication between users and developers. The entity-relationship diagram was developed to depict relational database structures. The emergency health record should include - CORRECT ANSWER time and means of arrival, treatment rendered, and instruction at discharge. Facilities are required to do a pertinent history, including the chief complaint and onset of illness or injury but not a complete medical history of the patient Minimum Data set - CORRECT ANSWER a component of the resident assessment instrument (RAI) and is used to collect information about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long-term care facility. many-to-many relationship - CORRECT ANSWER occurs only in a data model developed at the conceptual level. In this case, the relationship between patients and consulting physicians is a many-to-many. For each instance of patient, there could be many instances of consulting physician because patients can be seen by more than one consulting physicians. For each instance of consulting physician, there could be many patients because the physician sees many patients. metadata - CORRECT ANSWER data about data. metadata are structured information used to increase the effective use of data. One of the most familiar types of metadata is used to describe data in databases. Data element name, data type, and field length are examples of this kind of metadata. Health Record Matrix - CORRECT ANSWER Identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR. The documentation of the LHR may physically exist in separate and multiple paper-based or electronic systems. This complicates the process of pulling the entire legal record together in response to authorized requests to produce the complete patient record. The legal health record for disclosure consists of: - CORRECT ANSWER the data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings. Understanding legal health records requires knowledge of not only what comprises business records used as legal health records, but also the processes as well as the physical and electronic systems used to manage these records. privileged communication - CORRECT ANSWER information held confidential within a protected relationship as delineated by state law. Example: Mary goes to her doctor to discuss her current medical conditions. Firewall - CORRECT ANSWER a part of a computer system or network that is designed to block unauthorized access while permitting outward communication. A firewall can limit internal users from accessing various portions of the internet The most common place to find a firewall is between the healthcare entity's internal network and the internet It supports access control policy between two networks. It cannot prevent all types of attacks How long does the privacy rule use for the period of time which privacy rule-related documents must be retained? - CORRECT ANSWER Six years. The six-year time frame refers to the date the document was created or the last effective date of the document. Such documents include policies and procedures, the notice of privacy practices, complaint dispositions, and other actions, activites, and designations that must be documented per privacy rule requirements. corporate negligence - CORRECT ANSWER a legal doctrine that was established by a judicial decision handed down in the 1965 court case Darling v Charleston Community hospital. The court in this case ruled specifically that hospital governing boards have a duty to institue a means to evaluate and council medical staff who personally perform services on a patient that results in harm due to unreasonable risk. Hospitals may be held liable when a member of the medical staff fails to meet established standards of patient care. the privacy rule requires covered entities to - CORRECT ANSWER arrange a convenient time and place for the individual to inspect his or her record. However, the covered entity also has an obligation to protect the records integrity. Therefore, it is within the covered entitiys right to provide an authorized HIM staff member to be present when the individual reviews the record. fundraising activities - CORRECT ANSWER Those that benefit the CE, the covered entity may use or disclose to a BA or an institutionally related foundation without authorization, demographic information and dates of healthcare provided to the individual. Must have an option to Opt Out from receiving the material. If a fundraising activity targets individuals based on their diagnosis, prior authorization is required The privacy rule - CORRECT ANSWER establishes a patients right to receive an accounting of disclosures of their PHI made by a covered entity. first step in conducting the security risk analysis - CORRECT ANSWER consider their own characteristics and environment and implement reasonable and appropriate measures to protect against reasonably anticipated threats and hazards to the security of PHI. The security risk analysis process provides covered entities and business associates with the structural framework up on which to bulid their securty plan Addressable Implementation Specifications - CORRECT ANSWER Addressable specifications allow a covered entity flexibility when: (1) it is determined that the specification is not reasonable or appropriate for the covered entity's environment (2) the covered entity documents why the specification is not reasonable or appropriate and implements an equivalent alternative measure as appropriate. (3) Implementing "security measures to reduce risks and vulnerabilities to a reasonable and appropriate level" is a required specification, while encryption of electronic PHI is an addressable specification The breach notification rule requires - CORRECT ANSWER covered entities and business associates to establish policies and procedures to investigate an authorized use or disclosure of PHI to determine if a breach occured to Record locator service (RLS) - CORRECT ANSWER A process that seeks information about where a patient, once identified, may have a health record available to the HIO. It manages the pointers to the information on the servers of the HIE participants. The pointers in a RLS can include a person identification number and metadata. The RLS does NOT provide information about the record, it merely points to where it might be found. Data are not stored in a centralized database and records are only provided when queried. Qualitative standards - CORRECT ANSWER specify the level of service from a function such as accuracy rate, error rate, turnaround time and response time. In this case, timely response to release of information requests can indirectly impact patient care. To properly communicate performance standards, managers need to make the distinction between quantitative and qualitative standards and identify examples of each for the health information systems functions. A possible justification for building an information system in-house rather than purchasing one from a vendor - CORRECT ANSWER the facility has development teams that they do not want to give up gross death rate - CORRECT ANSWER the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. It is calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including deaths, for the same time period. 25/500=0.05x100=5% work distribution chart - CORRECT ANSWER A matrix that depicts the work being done in a particular workgroup in terms of specific tasks and activities, time spent on tasks, and the employees performing the tasks is initially completed by each employee and includes all responsible task content. Can help when problems have been identified with work proceses such as too much time spent on unimportant tasks. pie chart - CORRECT ANSWER a chart that shows the relationship of a part to a whole. pie charts can be used to show the component parts of a single group or variable. incidence rate - CORRECT ANSWER a computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same period. a hospital is looking to cut cost on a vendors proposal for health IT should consider - CORRECT ANSWER acquiring it's own hardware Boolean Search - CORRECT ANSWER A Boolean operator is a computer-programming term for conjunctions like, AND, OR, and NOT which can be used to construct more complex search conditions. Usually found under the advanced options. Structured Query Language (SQL) - CORRECT ANSWER A language used to create and manipulate databases. Truncation - CORRECT ANSWER In metric verse, the omission of an unaccented syllable at either end of a line Wildcard search - CORRECT ANSWER search that uses characters such as * or ? to replace letters in a search term Monitoring Results - CORRECT ANSWER enables a hospital to understand if the present system is currently supporting the needs of the organization and whether the next step, identify needs will set in motion new or further development or acquisition of health IT Discrete Data (Quantitative) - CORRECT ANSWER Numerical data values that can be COUNTED. whole numbers that may or may not be related. A bar graph is the best data display tool to use Application Service Provider (ASP) - CORRECT ANSWER A company that provides the software, support, and computer hardware on which to run the software from the user's facilities over a network. There is much less upfront captial outlay and fewer IT staff required in house. The ASP acquisition strategy may be considered essentially a financing model Case Mix Index - CORRECT ANSWER The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system The weight of each ms-drg is multiplied by the number of discharges for that ms-drg. Total weights are summed and divided by the number of toal discharges to arrive at the case-mix index Data provenance - CORRECT ANSWER Record of where data originated and have moved refers to the ablitiy to track the source of data super users - CORRECT ANSWER individuals with normal jobs who happen to be skilled at learning new information technology and can help others master new technology; they are not intended to replace scribes, trainers, or technicians Pareto Chart - CORRECT ANSWER a bar graph whose bars are drawn in decreasing order of frequency or relative frequency a type of bar graph that uses data to determine priorities in problem solving. Best way to ensure that elements of a HIS work together is to - CORRECT ANSWER ensure standards are applied to software development that support interoperability Haldol - CORRECT ANSWER Haloperidol (antipsychotic) used for behavior or mental conditions division - CORRECT ANSWER Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Clustering - CORRECT ANSWER the practice of coding or charging one or two middle levels of service codes exclusively under the philosophy that, although some will be higher and some lower, the charges will average out over an extended period. Capitated rate - CORRECT ANSWER a method of payment for health services in which the third-party payer reimburses providers a fixed, per capita amount for a period. Per capita means per head or per person. A common phrase in capitated contracts is per member per month. The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs. Workers Compensation - CORRECT ANSWER is a payer that pays for healthcare services due to work-related incidents. Because workers compensation is paying the bill, they are the third-party. Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors for which of the following Code of Ethics principle? A. Advocate and uphold the right to privacy B. Put service before self-interest C. Represent the profession accurately to the public D. Respect the inherent dignity and worth of every person - CORRECT ANSWER put service before self-interest What is the payment reduction for facilities that fail to successfully meet the requirements of medicare's quality reporting programs - CORRECT ANSWER 2 percent reduction Integrated Delivery System (IDS) - CORRECT ANSWER A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced. collaboration integration of healthcare providers. The goal of the IDS isa seamless delivery of care along the continuum of care, so one bill would be generated. (even if the care provided is over a 10 month period) Value-based care - CORRECT ANSWER includes 4 domains: safety, clinical care, efficiency and cost reduction, and person and community engagement. Each domain has measures that must be reported to CMS HCAHPS - CORRECT ANSWER Hospital Consumer Assessment of Healthcare Providers and Systems part of the person/community engagement domain strategy - CORRECT ANSWER a plan of action or policy designed to achieve a major or overall aim. characteristics of strategy: an action or set of actions, a description of how one intends to achieve the goals, a plan to improve the organizations fit within the external environment implementation plan is critical to the successful execution, it is not a characteristic of strategy. tracer methodology - CORRECT ANSWER A process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; an evaluation that follows (traces) the hospital experiences of specific patients to assess the quality of patient care; part of the new Joint Commission survey processes (LaTour 953-954) Profitability Index - CORRECT ANSWER Net Present Value / Investment Required divide the present value of the cash inflows by the present value of the cash outflows. data steward - CORRECT ANSWER An individual responsible for the management of critical data elements, including identifying and acquiring new data sources; creating and maintaining consistent reference data and master data definitions; and analyzing data for quality and reconciling data issues. are embedded within an organizations business unit and responsible for monitoring the data quality of the unit Accession number - CORRECT ANSWER A number assigned to each case as it is entered in a cancer registry consists of the first digits of the year the patient was first seen in the facility, with the remaining digits assigned sequentially throughout the year. Healthcare Effectiveness Data and Information Set (HEDIS) - CORRECT ANSWER a set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need to for comparing the performance of managed healthcare plans. breach notification laws - CORRECT ANSWER do not exist in numerous states, but they often are not tailored to medical information Context-based access control (CBAC) - CORRECT ANSWER The most stringent type of access control, which takes into account the person attempting to access the data, the type of data being accessed, and the context of the transaction in which the access attempt is made. Omnibus Rule - CORRECT ANSWER Set of regulations enhancing patients' privacy protections and rights to information and the government's ability to enforce HIPAA created a new fine structure for civil monetary penalities based on a four tier system for HIPAA violations. Tiers 3 and 4 are based on violations that have been determined to be due to willful neglect. If a breach is corrected within 30 days from the date of discovery it would fall into Tier 3. If it wasn't corrected it would be a tier 4. a patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond - CORRECT ANSWER common practice for covered entities is to accept the request, but not to agree to the restriction because of legal implications to the covered entity should the restriction be violated the privacy rule lists two circumstances where phi can be used or disclosed without the individuals authorization - CORRECT ANSWER 1.disclosing PHI to a family member or close friend that is directly relevant to his or her involvement with the patients care or payment. Facility access controls - CORRECT ANSWER A visitor walks through the computer department and picks up a CD from an employee's desk. What security controls should have been implemented to prevent this security breach? technical safeguards - CORRECT ANSWER identification and authorization, encryption, firewalls, malware protection, application design includes automatic log-off, which ensures electronic processes that terminate an electronic session after a predetermined time of inactiviy Covered entities are responsible for their workforce, which consists not only of employees, but also volunteers, student interns and trainees. Workforce members are not limited to those who receive wages from the CE - CORRECT ANSWER a volunteer is a workforce member in relation to the hospital employees are not covered by - CORRECT ANSWER privacy rule the privacy rule permits individuals to request that a covered entity amend a PHI record about the individual in a designated record set unless - CORRECT ANSWER the report was erroneously placed in the record. It is not part of the designated record set. One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of patients' medical records is considered healthcare - CORRECT ANSWER operations there is the least amount of interoperability between - CORRECT ANSWER EHR in a physician office and revenue cycle management MPI: Master Patient Index manager - CORRECT ANSWER is responsible for ensuring that registration interfaces are properly built and tested line/plot graph - CORRECT ANSWER displays trends over time Normal Bell Curve - CORRECT ANSWER the normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. It is bell shaped and symmetrical about the mean. because it is symmetrical, 50% of the observations fall above the mean and 50% fall below it. In a normal distribution, the mean, median and mode are equal. Histogram - CORRECT ANSWER A graph of vertical bars representing the frequency distribution of a set of data. (nominal or ordinal data) Levels of interoperability - CORRECT ANSWER basic--functional--semantic basic relates to the ability to successfully transmit and receive data from one computer to another functional refers to sending messages between computers with a shared understanding of the structure and format of the message. The use of clinical terminologies in EHRs to provide standardized data is essential to achieving semantic interoperability. the ICU bed count in the state has relaized a decrease of 20% bed count is a component needed to calculate occupancy rates for any facility. - CORRECT ANSWER reduction of ICU beds at any healthcare facility in the state has the potential to increase the volume of patients in this hospitals ICU Federated inconsistent databases - CORRECT ANSWER Model for HIE includes multiple enterprises agreeing to connect and share specific info in a point to point manner information warehouse - CORRECT ANSWER Allows organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities. the master patient index - CORRECT ANSWER Permanent database including every patient ever admitted to or treated by the facility. the MPI must be kept permanently it is the key to an effective retention and retrieval system of health records in a facility. results management application - CORRECT ANSWER enables results of a diagnostic study to be compared and displayed with other data. character and symbol recognition technologies - CORRECT ANSWER include bar coding, optical character recognitions and gesture recognition technologies. clinician web portal - CORRECT ANSWER used by physiciaans to access multiple sources of patient information within the healthcare organizations network. predictive modeling - CORRECT ANSWER applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are applied to historical data to learn the patterns in the data. These patterns are used to create models of what is most likely to occur. contingency table - CORRECT ANSWER displays the relationship between two categorical variables. They are often referred to by the number of rows and columns. Discharged Not Final Billed (DNFB) - - CORRECT ANSWER A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. a bill cannot be generated until the coding is complete, so organizations routinely monitor the DNFB days. Hospital Compare - CORRECT ANSWER A website created by CMS and the Hospital Quality Alliance to promote reporting on hospital quality of care. Reports on 139 measures of hospital quality of care for heart attack, heart failure, pneumonia and the prevention of surgical infections. The data available on Hospital Compare is reported by hospitals to meet the requirements of the medicare value based purchasing program. how do providers benefit from the health insurance exchanges created under the ACA - CORRECT ANSWER Providers should see an increase in reimbursement both from newly insured patients and from patients who are now eligible for medicaid under the expanded programs Aging of accounts standard incrememnt - CORRECT ANSWER 30 days what benefit of comparing the coding assigned by coders to the coding that appears on the claim - CORRECT ANSWER may find claim generation issues that cannot be found in other ways Medicare participating physicians - CORRECT ANSWER payments are 80% of medicare fee schedule. noPAR payments are 95% of the 80%. Focused reviews on lower weighted MS-DRGs from triples and pairs - CORRECT ANSWER indicats areas of risk related to lower weighted MS-DRGs from triple and pair combinations which may be the result of a coder missing secondary diagnosis. A focused audit based on this specific potential problem area could help to identify these cases. Optimization seeks the most accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive Dr. Smith, a surgeon at Community Hospital, is trying to understand how she can help the hospital improve reimbursement from Medicare. The HIM manager explains to Dr. Smith that reducing catheter-associated UTIs and surgical site infections would improve the hospital's scores in which of the following domains of the Medicare Value-Based Purchasing program? - CORRECT ANSWER safety Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER date the claim drops three competencies common to all successful change - CORRECT ANSWER Leadership, change management and strategic development state licensure agencies - CORRECT ANSWER What type of organization works under contract with the CMS to conduct Medicare/Medicaid certification surveys for hospitals? Three ways to address conflict - CORRECT ANSWER compromise, control and constructive confrontation constructive confrontation - CORRECT ANSWER a method of conflict resolution in which both parties meet with an objective third party to explore their perceptions and feelings. The desired outcome is to produce a mutual understanding of the issues and to create a win-win situation Hay Guide Chart-profile Method (Hay plan) - CORRECT ANSWER Refined version of the point method used by approx. 8000 public and private sector organizations worldwide to evaluate clerical, trade, technical, professional, managerial, and/or executive-level jobs. used as a job evalutaion tool Contract Elements - CORRECT ANSWER agreement, offer, acceptance, consideration DURSA - CORRECT ANSWER data use and reciprocal support agreement, legal binding contract that draws from federal and local laws and defines requirements for participation in eHealth exchange national network, agreement also addresses sanctions for violations of contract Net Income Equation - CORRECT ANSWER Net Income = Revenues - Expenses Net assets - CORRECT ANSWER Non current assets + net current assets - long term liabilities work sampling technique - CORRECT ANSWER a statistical method that reviews a select portion of tasks performed and provides baseline data for further job performance assessment. work distribution chart - CORRECT ANSWER is initially completed by each employee and includes all responsible task content. (LaTour 801) the him manager tasked the coding manager to development a dashboard that shows the discharges pending final billing so that she can plan staffing. Because this data changes throughout the day, what analysis technique is needed. - CORRECT ANSWER real time analysis a physician on your staff asked you to help her collect information about the effects of smoking during pregnancy on the birth weight of the babies. You were asked to collect the following information: whether or not the mothers smoke during pregnancy, birth weight of the babies, apgar scores at one minute and apgar scores at 5 minutes. The scales of these variables would be: - CORRECT ANSWER nominal (yes or no question), ordinal (apgar--because the order of the numbers is meaningful), interval, ratio (birth weight--scaled data--unit of measure) a pattern used in computer based patient records to capture data in a structured manner is a called a _______. One benefit of using a ______ is to ensure data integrity upon data entry. - CORRECT ANSWER template ____ is a statistic that is used to describe the association or relationship between 2 variables. - CORRECT ANSWER correlation quantitative analysis - CORRECT ANSWER is conducted to determine whether documentation is complete and accounted for in the medical record. If information is missing or incomplete, it is flagged for the provider to review and complete. It is generally conducted retrospectively. when an entity relational diagram is implemented as a relational database, the entity will become a ____ - CORRECT ANSWER table. It becomes a table because it is the person, place or thing about which you are collecting the data in your database. alternative hypothesis - CORRECT ANSWER the compliment of the null hypothesis and typically requires some action to be taken. In this scenario, the analyst is comparing emergency department wait times between weekends and weekdays. The alternative hypothesis would be that the average wait time is longer on weekends. Metadata - CORRECT ANSWER data contained in the data dictionary. Metadata are descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. source systems - CORRECT ANSWER Systems that provide a source of organizational data. information systems that capture and feed data into the EHR. Source systems include the electronic medication administration record, laboratory information system radiology information systems, hospital information system, nursing information systems, and more. biomedical research - CORRECT ANSWER basic and applied research aimed at increasing medical knowledge and understanding is considered the ancillary function of the health record. Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients. name of element, definition, application in which the data element is found, locater key, ownership, entity relationships, date first entered system, date terminated from system and system of orgin - CORRECT ANSWER examples of metadata scatter diagram - CORRECT ANSWER A correlation chart that uses a regression line to explain or to predict how the change in an independent variable will change a dependent variable. whenever a scatter diagram indicates that the points are moving together in one direction or another, conclusions about the variables relationship, either positive or negative become evident. a data analysis tool used to plot points of two variable suspected of being related to each other in some way. Resident Assessment Instrument (RAI) - CORRECT ANSWER a federally mandated standard assessment used to collect demographic and clinical data on residents in a Medicare- or Medicaid-certified long-term care facility. It consists of three components: the Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process, and the RAI utilization guidelines (LaTour 199) How do healthcare providers use the administrative data they collect? - CORRECT ANSWER for regulatory, operational and financial purposes what is the most secure signature type - CORRECT ANSWER the digital signature is similar to the electronic signature except that is uses encryption to provide nonrepudiation to prove the authenticators identity, who is responsible for the quality of documentation of the record - CORRECT ANSWER The provider identify the level in the data model that describes how the data is being stored in the database - CORRECT ANSWER physical data model. The users are not involved with this level of the database because of its technical complexity Entity Relationship Diagram (ERD) - CORRECT ANSWER A diagram that depicts an entity relationship model's entities, attributes, and relations. describes how the tables work together. The diagram is a graphic representation of the entities, attributes and relationships that are part of a database and is a data modeling tool. Disaster Recovery Plan (DRP) - CORRECT ANSWER a plan to restore an organization's IT capability in the event that its data center is destroyed The technological aspect of business continuity planning. HIM professionals assist in designing disaster recovery plans that address documenting information in the health record during down time or a disaster. Skewness - CORRECT ANSWER A measure of the shape of a data distribution. Data skewed to the left result in negative skewness; a symmetric data distribution results in zero skewness; and data skewed to the right result in positive skewness. If the longer tail is on the right, the curve is skewed to the right. If the longer tail is on the left, the curve is skewed to the left. Hybrid health records - CORRECT ANSWER mixture of paper and electronic, or multiple electronic systems that do not communicate or are not logically architected for record management. these records are increasingly seen as the most common transition points between fully paper and completely electronic records Uniform discharge data set (UDDS) - CORRECT ANSWER adopted in 1974 by the federal government as the standard for collecting data for the medicare and medicaid programs. When the prospective payment act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing drgs. A key component was the incorporation of the definitions of principal dx, principal procedure and other significant procedures, into the DRG algorithm. minimum data set for long term care - CORRECT ANSWER is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. an assessment form used to collect demographic and clinical data on nursing home residents. it consists of a core set of screening and assessment elements based on common definitions. To meet federal requirements, long-terms facilites must complete an MDS for every resident at the time of admission and at designated reassessment points throughout the residents stay. physician index - CORRECT ANSWER categorizes patients by primary physician. It guides the retrieval of cases treated by a particular physician. This index is created simply by sorting patients by physician [Show Less]
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RHIA EXAM: INFORMATION GOVERNANCE (practice exam 1) 74 Questions with Answers,100% CORRECT
RHIA EXAM: INFORMATION GOVERNANCE (practice exam 1) 74 Questions with Answers Information Governance - CORRECT ANSWER Refers to the overall management... [Show More] of the availability, usability, integrity, and security of company data Data Governance - CORRECT ANSWER Establishes the processes and responsibilities that ensure the quality and security of the data used across a business or organization A method of documenting a nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: - CORRECT ANSWER Charting by exception Charting by exception - CORRECT ANSWER a method of documenting only abnormal or unusual findings or deviations from the prescribed plan of care - the purpose of CBE is to reduce repetitive record keeping and documentation of normal events chief compliant - CORRECT ANSWER The nature and duration of the symptoms that caused the patient's illness and caused the patient to seek medical attention as stated in the patient's own words - reason for the visit data accuracy - CORRECT ANSWER An important aspect of data quality. It indicates whether data collected for an item are accurate. Data consistency - CORRECT ANSWER The extent to which the healthcare data are reliable and the same across all applications Data accessibility - CORRECT ANSWER Refers to a user's ability to access or retrieve data stored within a database. Data comprehensiveness - CORRECT ANSWER Means that all the required data elements are included in the health record. The record is complete. 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? - CORRECT ANSWER Data consistency Which of the following is an acceptable means of authentication a record entry? - CORRECT ANSWER The physician personally signs the entry electronically If an analyst is studying the wait times at a clinic and the only list of patients available is hard copy, which sampling technique is the easiest to use? - CORRECT ANSWER systemic sampling systemic sampling - CORRECT ANSWER The process of selecting a sample of subjects for a study by drawing every nth unit on a list - ex: every 5th patient in a waiting room cluster sampling - CORRECT ANSWER A probability sampling technique in which clusters of participants within the population of interest are selected at random, followed by data collection from all individuals in each cluster. stratified sampling - CORRECT ANSWER A type of probability sampling in which the population is divided into groups with a common attribute and a random sample is chosen within each group Resident Assessment Instrument (RAI) - CORRECT ANSWER A comprehensive tool that includes the minimum data set, resident assessment protocols, and guidelines for functional assessment of the resident resident assessment protocols (RAPs) - CORRECT ANSWER A summary of a long-term care resident's medical condition and care requirements utilization guidelines (UG) - CORRECT ANSWER specified in state operation manuals that direct when and how to use the RAI minimum data sets (MDS) - CORRECT ANSWER Part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Usually done by registered nurses. in a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items - CORRECT ANSWER resident assessment protocols (RAPs) entity-relationship diagram (ERD) - CORRECT ANSWER a technique for documenting the entities and relationships in a database environment object model - CORRECT ANSWER The end product of object-oriented analysis relational model - CORRECT ANSWER uses a two-dimensional table of rows and columns of data. Rows are records (also called tuples), and columns are fields (also referred to as attributes). unified medical language system (UMLS) - CORRECT ANSWER a program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies what data model is most widely used to illustrate a relational database structure? - CORRECT ANSWER entity-relationship diagram Alex, an HIM analyst reviews the record of Patty, a patient in the facility, to ensure that all documents are complete and signatures are present. this is an example of a: - CORRECT ANSWER concurrent review concurrent review - CORRECT ANSWER review for medical necessity of tests and procedures ordered while a patient is still an inpatient in the hospital qualitative review - CORRECT ANSWER may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record. what type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records - CORRECT ANSWER uniform data sets uniform data sets - CORRECT ANSWER a defined list of recommended data elements with uniform definitions that are relevant for a particular use time-out - CORRECT ANSWER The Joint Commission defines as "an immediate pause by the entire surgical team to confirm the correct patient, procedure, and site," serious event - CORRECT ANSWER Important medical events that may not be immediately life threatening or result in death or hospitalisation but may jeopardise the patient or require intervention to prevent one of the other outcomes sentinel event - CORRECT ANSWER an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof near miss - CORRECT ANSWER Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance Before Pam administers the medication, she scans both the medication and the newborns bracelet and learns that she has the incorrect medication for this patient. Pam does not administer that medication but goes back to the order and through the proper steps, administers the correct medication. Based on this scenario, which of the following occurred? - CORRECT ANSWER near miss which of the following materials are required elements in an emergency care record? - CORRECT ANSWER time and means of arrival, treatment rendered, 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: - CORRECT ANSWER indicator indicator - CORRECT ANSWER a performance measure that enables healthcare organizations to monitor a process to determine wether it is meeting process requirements unique identifier - CORRECT ANSWER Way of uniquely identifying each record in the database case management - CORRECT ANSWER optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services outcomes and assessment information set (OASIS) - CORRECT ANSWER a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients. 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 residents care? - CORRECT ANSWER minimum data set dr collins admitted mr smith to university hospital. BCBS insurance will pay mr smith's hospital bill. Upon discharge from the hospital, who owns the health record of mr smith? - CORRECT ANSWER university hospital, the healthcare provider integrated format - CORRECT ANSWER Chronological order (MR in which info is organized in a strict chronological order) chronological - CORRECT ANSWER Arranged in order of time of occurrence source-oriented - CORRECT ANSWER organized by the entity that supplied the data Ex: all lab reports are in the lab report tab, all x-ray reports are in the radiology tab - CORRECT ANSWER source-oriented comparative performance data - CORRECT ANSWER When healthcare organizations evaluate their Joint Commission core measure data with similar organization master patient index - CORRECT ANSWER the primary index used for HIM recordkeeping, which includes a unique record for each patient within a healthcare organization Jane emailed her physician to express concern about a lab result. Her physician responded and explained the result as well as offered various treatment options. How should this email correspondence be handled? - CORRECT ANSWER Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patients medical record The insured party's member identification number is an example of this type of data: - CORRECT ANSWER financial data financial data - CORRECT ANSWER health care providers use this data to complete claims forms that will be submitted to third-party payers demographic data - CORRECT ANSWER information collected at the time of registration such as age, gender, race and ethnicity; becomes a part of the patient's medical record in a relational database, which of the following is an example of a many-to-many relationship? - CORRECT ANSWER patients to consulting physicians - patients can see many physicians - physicians can see many different patients borrowing records entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of: - CORRECT ANSWER authorship integrity the process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data within is called: - CORRECT ANSWER authentication Anywhere Hospital has mandated that the social security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a: - CORRECT ANSWER mask decision making and authority over data-related matters is known as: - CORRECT ANSWER data governance data management - CORRECT ANSWER A process that focuses on data collection, storage, and retrieval. Common data management functions include addition, deletion, modification, and listing. data administration - CORRECT ANSWER Responsible for specific policies and procedures through which data can be managed as a resource data modeling - CORRECT ANSWER The process of creating a specific data model for a determined problem domain. sue is updating the data dictionary for her organization. in this data dictionary, the data element name is considered which of the following? - CORRECT ANSWER metadata metadata - CORRECT ANSWER data that describes other data ex: data type, data element name, field length structured data - CORRECT ANSWER Data that are organized and easily retrievable and interpreted by traditional databases and data models unstructured data - CORRECT ANSWER data that do not have a predefined data model or are not stored in a traditional database structure free-text data - CORRECT ANSWER data that are narrative in nature; unstructured narrative data the data elements in a patients automated laboratory result are examples of: - CORRECT ANSWER structured data Data that are collected on large populations of individuals and stored in a database without identifying any particular patient individually are referred to as: - CORRECT ANSWER aggregate data aggregate data - CORRECT ANSWER Any process whereby data is gathered and expressed in a summary form accession data - CORRECT ANSWER a unique number that is used to identify a patients when a case is first entered in the registry notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: - CORRECT ANSWER unstructured clinical data unstructured clinical data - CORRECT ANSWER lacks the organization and precision of structured data ex; physicians notes, standardized data - CORRECT ANSWER the process of converting data to a common format to enable users to process and analyze it. according to the Joint Commission accreditation standards, which document must be placed in the patient's health records before a surgical procedure can be performed? - CORRECT ANSWER report of history and physical examination [Show Less]
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RHIA Exam 267 Questions with Verified Answers,100% CORRECT
RHIA Exam 267 Questions with Verified Answers A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviation... [Show More] s from the prescribed plan of care is called: - CORRECT ANSWER Charting by exception 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. - CORRECT ANSWER 30 days, 24 hours, 48 hours If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? - CORRECT ANSWER Systematic sampling In a long term care setting, these are problem oriented frameworks for additional patient assessment based on problem identification items (triggered conditions) - CORRECT ANSWER Resident Assessment Protocols (RAPs) What data model is most widely used to illustrate a relational database structure? - CORRECT ANSWER Entity-relationship diagram (ERD) 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: - CORRECT ANSWER Concurrent Review 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): - CORRECT ANSWER Indicator 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? - CORRECT ANSWER Minimum Data Set Dr. Collins admitted Mr. Smith to the University Hospital, Blue Cross Insurance will pay Mr. Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Mr. Smith? - CORRECT ANSWER University Hospital In a relational database, which of the following is an example of a many to many relationship? - CORRECT ANSWER Patients to consulting physicians Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XX-XXX format for their patients. This is an example of the use of a: - CORRECT ANSWER Mask Sue is updating the data dictionary for her organization. In this dat dictionary, the data element name is considered which of the following? - CORRECT ANSWER Metadata Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information? - CORRECT ANSWER It can exist in seperate and multiple paper-based or electronic systems. According to the Joint commission accreditation standards, which document must be placed in patient's record before a surgical procedure may be performed? - CORRECT ANSWER report of history and physicial examination 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: - CORRECT ANSWER Health Record Matrix A subpoena duces tecum compels the recipient to: - CORRECT ANSWER Bring records to a legal proceeding A researcher's informed consent form stated that the patients' information would be anonymous. Later in the application form for institutional review board( (IRB) approval, the researcher described a coding system to trach respondents and nonrespondents. The IRB returned the application to the researcher with the stipulation that the informed consent must be changed. What raised the red flag? - CORRECT ANSWER The description of the use of a coding system to track respondents and nonrespondents. What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident - CORRECT ANSWER The data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA security rule. What type of network uses a private tunnel through the internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely? - CORRECT ANSWER Virtual private network An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the3 coder allowed access to the system? - CORRECT ANSWER Role-based The privacy rule generally requires documentation related to its requirements to be retained: - CORRECT ANSWER 6 Years Which legal doctrine was established by the Darling v. Charleston Community Hospital case of 1965? - CORRECT ANSWER Corporate Negligence Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy Practices" In the Notice, it is explained to her that PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she doesn't want her PHI used for those purposes. Of the options listed here, what is the best course of action? - CORRECT ANSWER The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only. St Joseph Hospital has a psychiatric service on the sixth floor. A 31 year old male came to the HIM department and requested to see a copy of his health record. he told the3 clerk he was a patient of Dr. Schmidt, as psychiatrist, and had been on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is: - CORRECT ANSWER Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient. You are a member of the hospital's health information management committee. The committee has created a HIPAA compliant authorization form. Which of the following items does the privacy rule require for the form? - CORRECT ANSWER Identification of the person or entity authorized to receive PHI What is the implication regarding the confidentiality of incident reports in legal proceedings when a staff member documents in the health record that an incident report was completed about a specific incident? - CORRECT ANSWER The incident report cannot be discovered even though it is mentioned in a discoverable document. The security rule leaves the methods for conducting the security risk analysis to discretion of the healthcare entity. The first consideration for a healthcare facility should be: - CORRECT ANSWER Its own characteristics and environment Addressable security rule implementation specifications: - CORRECT ANSWER Should be implemented unless a healthcare entity determines that the specification is not reasonable and appropriate and documents their reasoning. In order for health information exchange participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by an - CORRECT ANSWER Record Locator Service (RLS) A possible justification for building an information system in house rather than purchasing one from a vendor is that: - CORRECT ANSWER The facility has development teams they do not want to give up Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was: - CORRECT ANSWER 5% You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use? - CORRECT ANSWER Bar graph In the data warehouse, the patient's last name and first name are entered into separate fields. This is an example of what? - CORRECT ANSWER Normalization The health information services department at Medical Center Hospital identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do? - CORRECT ANSWER The manager should have each employee complete a work distribution chart. A requirements specification that lists what is needed from the vendor to support interoperability is necessary to: - CORRECT ANSWER Identify specific features and functions that must be in an information system During the influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 35 cases represent 30 percent of the nursing home's population. This rate represents the: - CORRECT ANSWER Incidence The user needs a list of the patients that were diagnosed a cerebral infarction or a cerebral hemorrhage. This is an example of a situation in which what type of search should be used? - CORRECT ANSWER Boolean search A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as: - CORRECT ANSWER Monitor Results What type of data display tool is used to display discrete categories? - CORRECT ANSWER Histogram Assume you are the manager of a 10 physician primary care practice. The physicians are interested in contracting with an application service provider to develop and manage patient records electronically. Which of the following statements is an indication that an application service provider(ASP) may be a good idea for this practice? - CORRECT ANSWER The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor. Which of the following do HIE participants use to search for health records on other healthcare organization systems using patient indexing and identification software? - CORRECT ANSWER Record locator service A physician is concerned that the data patients enter into an EHR is not as reliable as data entered by another provider. What function serves to distinguish the source of data in an EHR? - CORRECT ANSWER Data provenance A coding manager wants to display the patient types that have the most coding errors in relationship to coder years of service. The desire of the coding manager is to display how coder years of service is responsible for coding errors. The type of graph or chart best suited for this is a: - CORRECT ANSWER Pareto Chart For Medicare patients, how often must the home health agency's assessment and case plan be updated? - CORRECT ANSWER At least every 60 days or as often as the severity of the patient's condition requires A physician query may not be appropriate in which of the following instances? - CORRECT ANSWER Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors according to which of the following Code of Ethics principles? - CORRECT ANSWER Put service before self-interest Which of the following healthcare entities' mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments? - CORRECT ANSWER Recovery audit contractor (RAC) Phil White had coronary artery bypass graft surgery. Unfortunately during the surgery Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care: acute care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled? - CORRECT ANSWER One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of dix errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information what action should the coding supervisor take? - CORRECT ANSWER Take no action since not enough information is given to make a judgement Community hospital is trying to improve its compliance with Medicare quality reporting requirements and in turn its reimbursement from Medicare's hospital value based purchasing program. The hospital has added a _________ to assist in educating medical staff members on documentation needed for accurate billing. - CORRECT ANSWER Physician advisor Which of the following is not a characteristic of leadership strategy? - CORRECT ANSWER A description of specific implementation plans Which joint commission survey methodology involves an evaluation that follows the hospital experiences of current patients? - CORRECT ANSWER Tracer methodology Employees covered by the provisions of the fair labor standards act are called ____________employees. - CORRECT ANSWER Nonexpempt A technique for measuring healthcare entity performance across the four prospectives of customer, financial, internal processes, and learning and growth is called: - CORRECT ANSWER Balanced scorecard methodology The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a (n): - CORRECT ANSWER Unfavorable variance of $2,000 Which of the following best differentiates the role of strategic management and strategic thinking as compared to other management tools and approaches? - CORRECT ANSWER A component of each of the major function of management What is data granularity? - CORRECT ANSWER requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data Where can you find guidelines for the retention and destruction of healthcare information? - CORRECT ANSWER Accreditation Standards Firewalls - CORRECT ANSWER hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders. One of the four general requirements a covered entity must adhere to in order to be in compliance with HIPAA Security Rule is to ensure the confidentiality, integrity, and ___________ of ePHI - CORRECT ANSWER Availability. Think of it as people having access to that information, or that information being available to them. A visitor sign-in sheet to a computer area is an example of what type of control? - CORRECT ANSWER Facility Access Administrative safeguards - CORRECT ANSWER administrative actions such as policies and procedures and documentation retention to manage the selection, development, and maintenance of security measures to safeguard ePHI and manage the conduct of the covered entities or business associates' workforce. Order of next of kin: - CORRECT ANSWER Spouse, adult child, parent, adult sibling. Respondeat Superior - CORRECT ANSWER Latin for "let the master answer." Also referred to as vicarious lability, under the doctrine the hospital holds itself out as responsible for the actions of its employees, provided that these individuals were acting within the scope of their employment of at the hospital's direction at the time they conducted the tortious activity in question. A hospital releases information to an insurance company with proper authorization by the patient. The insurance company forwards the information to a medical data clearinghouse. This process is referred to as: - CORRECT ANSWER Redisclosure AHIMA recommends that documents of health record destruction include all of the following except: - CORRECT ANSWER Reason for destruction Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? - CORRECT ANSWER The Privacy Rule's minimum necessary requirement does not apply The confidentiality of incident reports is generally protected in cases when the report is filed in: - CORRECT ANSWER The hospital risk manager's office An original goal of HIPAA Administrative Simplification was to standardize: - CORRECT ANSWER The electronic transmission of health data The Administrative simplification portion of Title 2 of HIPAA addresses which of the following? - CORRECT ANSWER Uniform standards for transactions and code sets Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? - CORRECT ANSWER Present an authorization that at least one of them has signed Which of the following would be included in an accounting of disclosures? - Incidental to an otherwise permitted or required use of disclosure - Disclosures to the individual about whom the information pertains - Disclosures made pursuant to an authorization -Patient information faxed to the bank - CORRECT ANSWER Patient information faxed to the bank A valid subpoena duces tectum seeking health records does NOT have to: - CORRECT ANSWER Be signed by the plaintiff and the defendant Which of the following presents the greatest risk of large scale health information breaches? -Unlocked rooms - Computer monitors positioned toward high traffic areas - Unattended computer workstations - Laptop theft - CORRECT ANSWER Laptop Theft In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? - CORRECT ANSWER X12N Interrater - CORRECT ANSWER Reliability is checked by having more than one person abstract data for the same case. The results are then compared to identify any discrepancies. A clinic that is expanding its service offerings and needs an individual to help design a new database will be searching for a: - CORRECT ANSWER Data administrator A data model is used to: - CORRECT ANSWER Describe how data are used in creating information This type of chart is used to focus attention on any variation in a process and helps the team to determine whether or that variation is normal or a result of special circumstances: - CORRECT ANSWER A control chart Association learning - CORRECT ANSWER type of data mining that identifies interesting relationships between two concepts in the database. For example, it may identify that patients who are treated with drug A have a better outcome than patients who are treated with drug B. Natural language queries - CORRECT ANSWER Use common words to tell the database which data are needed. The following question was typed into the system: how many patients were discharged on November 12, 2020? This is an example of what type of query? - CORRECT ANSWER Natural Language Query How long should the master patient index be maintained? - CORRECT ANSWER Permanently In which information system would the data element "principal procedure" be found? - CORRECT ANSWER Encoder/Grouper Providing a process's policy and procedure guide to a user who has never used the information system and then asking the user to perform the process could be used in what type of testing? - CORRECT ANSWER Documentation What process must the HIM operations manager perform to ensure that all patient information is contained within the correct electronic file in the EHR? - CORRECT ANSWER Data Audit The term used to describe breaking data elements into the level of detail needed to retrieve the data is: - CORRECT ANSWER Normalization Normalization - CORRECT ANSWER breaking the data elements into the level of detail desired by the facility Consumer informatics is based on: - CORRECT ANSWER Information structures and processes The probability of making a Type 1 error based on a particular set of data is called the: - CORRECT ANSWER P-value LOINC - CORRECT ANSWER set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results. Lab data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? - CORRECT ANSWER LOINC OCR (Optical Character Recognition) - CORRECT ANSWER enhances the accuracy of indexing features on forms In which of the following processes does an analyst perform exploratory data analysis to determine trends and identify patterns in the data set? - CORRECT ANSWER Data mining DICOM (Digital Imaging and Communications in Medicine) - CORRECT ANSWER supports retrieval of information from imaging devices and equipment to diagnostic and review workstations as well as short term and long term storage systems. Protocols that support communication between applications are often referred to as: - CORRECT ANSWER Messaging standards The process of integrating healthcare facility systems requires the creation of: - CORRECT ANSWER Enterprise master patient indexes Which of the following is NOT a statistical technique used to create a model to assess the probability that current Medicare claims are fraudulent? - CORRECT ANSWER Database warehousing A quality coding review that is based on specific problems identified during an initial baseline review in a hospital is called a: - CORRECT ANSWER Focused coding review Which model for HIE stores patient records in a single database built to allow queries into the system? - CORRECT ANSWER Centralized Which of the following is an organization that develops standards related to the interoperability of health information technology? - CORRECT ANSWER Health level 7 Which of the following processes are financial counselors typically responsible for? - CORRECT ANSWER determining whether the patient is eligible for charity care The insurance verification process involves confirming the patient is a member of the insurance plan communicated to the provider. Which of the following describes the most common time when insurance verification occurs for an unscheduled patient? - CORRECT ANSWER After medical screening. Patient accounting is reporting an increase in national coverage decisions and local coverage determinations failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? - CORRECT ANSWER The HIM department Patient accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should: - CORRECT ANSWER Write off the failed charges to bad debt and bill Medicare for the clean charges What's the rule for NON PAR (NON PARTICIPATING) physicians? - CORRECT ANSWER 95%/80%. 95% of medicare fee, then 80% of that. When attempting to build patient relations and customer service in the revenue cycle related to the patient's financial obligations, providers should focus which of the following approaches? - CORRECT ANSWER Transparency approach A CDI program facilitates accurate coding and helps coders avoid: - CORRECT ANSWER Assumption coding Which of the following is NOT a reason to deliver a hospital issued notice of noncoverage to a medicare beneficiary? - CORRECT ANSWER Service was not preauthorized Reviewing claims to ensure appropriate coding for deserved payments is one method of: - CORRECT ANSWER Achieving legitimate optimization The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? - CORRECT ANSWER Conversion factor The provider staff who are involved with communicating adverse determinations to patients and their families are considered - CORRECT ANSWER Utilization management staff the accounts recievable collection cycle involves the time from: - CORRECT ANSWER Admission to deposit in the bank Which of the following terms does NOT describe the requirement for a healthcare provider to obtain permission from the health insurer to provide predefined services to the patient? - CORRECT ANSWER Preassesment In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar? - CORRECT ANSWER based on principal diagnosis In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area? - CORRECT ANSWER Claims reconciliation and collections The purpose of this program is to reduce improper Medicare payments and prevent future improper payments made on claims of healthcare services: - CORRECT ANSWER Recovery audit contractors A payer has advised your hospital that it is auditing records from last year due to a suspected payment error. Your hospital's first action should be to: - CORRECT ANSWER Review the contract to determine whether this is a violation of the look back period clause Exploding charges - CORRECT ANSWER items that must be reported seperately but are used together, such as interventional radiology imaging and injection procedures. There has been a recent increase in errors regarding the posting of the admitting diagnosis. Correction of this error falls to the coding staff. With which department will HIM have to partner in order to identify and eliminate this recurring error? - CORRECT ANSWER Patient access With what agency may patients file a complaint if they suspect medical identity theft violations? - CORRECT ANSWER Federal Trade Commission In the APC system, a high-cost outlier payment is paid when which of the following occurs? - CORRECT ANSWER The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount. The facility's Medicare CMI has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? - CORRECT ANSWER Focused Audit Which of the following is the principal goal of internal auditing programs for billing and coding? - CORRECT ANSWER Protect providers from sanctions or fines Which of the following requires financial institutions to develop written medical identity theft programs? - CORRECT ANSWER Fair and Accurate Credit Transactions Act A patient is admitted to the hospital with SOB and CHF. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? - CORRECT ANSWER Query the attending physician as to the reason for the intubation and mechanical ventilation to add a secondary diagnosis The joint commission has published a list of abbreviations classified as "DO NOT USE" for the purpose of: - CORRECT ANSWER Preventing potential medication errors due to misinterpretation Which of the following is an example of a budget used as a controlling tool? - CORRECT ANSWER Responding to a monthly budget variance report The time required to recoup the cost of an investment is called the: - CORRECT ANSWER Payback period Which of the following is true about contracts? a. they must be in writing b. they must be expressed. c. they must contain an offer and acceptance. d. they must contain a request for approval. - CORRECT ANSWER They must contain an offer and acceptance. One of the most common issues that healthcare organizations fail to do well in the strategic process is: - CORRECT ANSWER Execute the implementation plan The percent of antibiotics administered immediately prior to open reduction and internal fixation surgeries or the percent of deliveries accomplished by cesarean section are examples of what type of performance measure? - CORRECT ANSWER Process measure All of the following are risks that must be considered when entering into an outsourcing contract EXCEPT: - CORRECT ANSWER Efficient productivity At the beginning of a recent accreditation visit, the surveyors met with key leaders of the organization. During the meeting an outline of the schedule was discussed and key interviewees were identified. What is the term for this important accreditation meeting? - CORRECT ANSWER Opening conference The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area is called - CORRECT ANSWER Licensure Which tool is used to determine the most critical areas for training and education for a group of employees? - CORRECT ANSWER Needs analysis Which of the following is a statement made by one party to induce another party to enter a contract? - CORRECT ANSWER Warranty A strategy map can be a useful tool because it: - CORRECT ANSWER Provides a visual framework for integrating strategies Sarah is not clear about why she needs to collect so much data as she performs her HIM job. Sarah's manager explains that the basic premise behind collecting job analysis data is to determine the job requirements and delineate appropriate _____________and ___________________. - CORRECT ANSWER Position classification; grade level assignments [Show Less]
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RHIA Exam Terms and Definitions 243 Questions with Verified Answers,100% CORRECT
RHIA Exam Terms and Definitions 243 Questions with Verified Answers Joint Commission - CORRECT ANSWER This is a private, non-for-profit organization tha... [Show More] t evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards. Health record review - CORRECT ANSWER This is a concurrent or ongoing review of health record content performed by caregivers or HIM professionals while the patient is still receiving inpatient services to ensure the quality of the services being provided and the completeness of the documentation being maintained, this is also known as health record analysis: Obliterate errors - CORRECT ANSWER This is the act of altering the original entry by blacking out with marker, using white out, writing over an entry, etc: Abstracting - CORRECT ANSWER This is the process of extracting information from a document or create a brief summary of a patient's illness, treatment and outcome. This is also the process of extracting elements of data from a source document or database and entering them into an automated system: Derived data - CORRECT ANSWER This data consist of factual details aggregated or summarized from a group of health records that provide no means to identify specific patients: Accession number: - CORRECT ANSWER This is a number assigned to each case as it is entered in a cancer registry or for an imaging test: Access control - CORRECT ANSWER This is a computer software program designed to prevent unauthorized use of an information resource/system. This is also a process for designing, implementing, and monitoring a system for guaranteeing that only individuals who have legitimate need are allowed to view or amend specific data: Accession registry - CORRECT ANSWER This is a list of cases in a cancer registry in order in which they were entered: Accounts payable (A/P) - CORRECT ANSWER These are records of payments owed by an organization to other entities: Accounts receivable (A/R) - CORRECT ANSWER These are records of the payments owed to the organization by outside entities such as third-party payers and patients: Accreditation - CORRECT ANSWER This is a voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against pre-established written criteria: Acute care prospective payment system (PPS) - CORRECT ANSWER This is a reimbursement system for inpatient hospital services provided to Medicare and Medicate beneficiaries that is based on the use of diagnosis-related groups as a classified tool: Administrative information - CORRECT ANSWER This is information used for administrative and healthcare operations purposes such as billing and quality oversight: Administrative information systems - CORRECT ANSWER This is a category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions: Advance Beneficiary Notice (ABN) - CORRECT ANSWER This is a statement signed by the patient when s/he is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that s/he will be responsible for any charges: Advance directive - CORRECT ANSWER This is a legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences: Aggregate data - CORRECT ANSWER This is data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed: Ambulatory patient classification (APC system) - CORRECT ANSWER Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided and are based on HCPCS/CPT codes: Global payment - CORRECT ANSWER This is a form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lap sums to be distributed between the physician and the healthcare facility: Global surgery payment - CORRECT ANSWER This is whey a payment is made for surgical procedures that includes the provision of all healthcare services, form the treatment decision through postoperative patient care: Medicare severity diagnosis-related groups (MS-DRGs) - CORRECT ANSWER This is a system of classifying a Medicare patient's hospital stay into various groups in order to facilitate payment of services: Major diagnosis categories (MDCs) - CORRECT ANSWER To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into one of these 25 categories and most are based on body systems and include disease and disorders relating to a particular system: Complication - CORRECT ANSWER This is a secondary condition that arises during hospitalization: Comorbidity (CC) - CORRECT ANSWER This is a condition that existed at admission: Clinical documentation improvement (CDI) program - CORRECT ANSWER This is a process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes: Alternative hypothesis - CORRECT ANSWER This hypothesis states that there is an association between the independent or dependent variables: Ancillary systems - CORRECT ANSWER These are electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, etc: Application service provider (ASP) - CORRECT ANSWER A third party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage or transaction-based pricing: Audit controls - CORRECT ANSWER These are mechanisms that record and examine activity in information systems: Audit log - CORRECT ANSWER This is a chronological record of electronic system(s) activities that enables the reconstruction, review, and examination of the sequence of events surrounding or leading to each event and/or transaction from its beginning to end: Audit trail - CORRECT ANSWER This is a chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations: Auditing - CORRECT ANSWER This is the performance of internal and/or external reviews to identify variations from established baselines: Authentication - CORRECT ANSWER This is the process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature. This is the proof of authorship that ensures that log-ins and messages from a user originate from an authorized source: Authorization - CORRECT ANSWER This is the granting of permission to disclose confidential information as defined by HIPAA privacy rule, an individual's formal, written permission to use of disclose his or her personally identifiable health information for purposes other than treatment, payment or healthcare operations: Autoauthentication - CORRECT ANSWER This is a procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit: Balance billing - CORRECT ANSWER This is a reimbursement method that allows providers to bill patients for charges in excess of the amount paid b the patient's health plan or other third-party payer (not allowed under Medicare or Medicaid): Balance sheet - CORRECT ANSWER This is a report that shows the total dollar amounts in accounts, expressed in accounting equation format at a specific point in time: Balanced scorecard methodology - CORRECT ANSWER This is a strategic planning tool that identifies performance measures related to strategic goals: Bar chart - CORRECT ANSWER This is a graphic technique used to display frequency distributions of nominal or original data that fall into categories: Bar-coding technology - CORRECT ANSWER This is a method of encoding data that consists of parallel arrangements of dark elements, referred to as bars, and light elements, referred to as spaces, and interpreting the data for automatic identification and data collection purposes: Benchmarking - CORRECT ANSWER This is an analysis based on comparison: Best of breed - CORRECT ANSWER This is a vendor strategy used when purchasing an EHR that refers to system application that are considered the best in their class: Best of fit - CORRECT ANSWER This is a vendor strategy used when purchasing an EHR in which all the systems required by healthcare facility area available from one vendor: Bill hold period - CORRECT ANSWER This is the span of time during which a bill is suspended in the billing system awaiting late charges, diagnosis and procedure codes, insurance verification, or other required information: Boxplot - CORRECT ANSWER This is a tool in the form of a graph that displays five-number data summary: Bundled payments - CORRECT ANSWER This is a period of relatively continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation: Case mix - CORRECT ANSWER This is a description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received and resources used: Case-mix groups - CORRECT ANSWER This is the average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system (calculated by dividing the sum of the weights of diagnosis-related groups for patient discharged during a given period divided by the total number of patient discharged): Certification - CORRECT ANSWER This is the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting pre-determined requirements: Champion - CORRECT ANSWER This is someone in the organization who believes in the idea, acknowledges the practical problems and assists in overcoming barriers: Charge capture - CORRECT ANSWER This is the process of collecting all services, procedures and supplies provided during patient care: Chargemaster - CORRECT ANSWER This is a financial management form that contains information about the organization's charges for the healthcare services if provides to patients: Check Sheet - CORRECT ANSWER This is a tool that permits the systematic recording of observations of a particular phenomenon so that trends or patterns can be identified: Claim - CORRECT ANSWER This is an itemized statement of healthcare services and their costs provided by a hospital, physician office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan either by the insured party or the provider: Claims processing - CORRECT ANSWER This is the process of accumulating claims for services, submitting claims for reimbursement, and ensuring that claims are satisfied: Claims scrubber software - CORRECT ANSWER This is a type of computer program at a healthcare facility that checks for the claim elements of accuracy and agreement before the claims are submitted: Client/Server architecture - CORRECT ANSWER This is a computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data: Care plans - CORRECT ANSWER These are care guidelines created by healthcare providers for individual patients for a specified period of time: Clinical practice guidelines - CORRECT ANSWER This is a detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency: Clinical decision support (CDS) system - CORRECT ANSWER This is a special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions: Clinical/physician web portals - CORRECT ANSWER This is a media for providing clinical/physician access to the provider organization's multiple sources of data from any network-connected device: Cluster sampling - CORRECT ANSWER This is a process of selecting subjects for a sample from each cluster within a population: Coded data - CORRECT ANSWER This is data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed and compared: Coding - CORRECT ANSWER This is the process of assigning numeric representations to clinical documentation: Comorbidity - CORRECT ANSWER This is a medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay: Conditions of Participation - CORRECT ANSWER This is the administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs: Data dictionary - CORRECT ANSWER This a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology: Data element - CORRECT ANSWER This is an individual fact or measurement that is the smallest unique subset of a database: Data Elements for Emergency Department Systems (DEEDS) - CORRECT ANSWER This is a data set designed to support the uniform of information in hospital-based emergency departments: Data mining - CORRECT ANSWER This is the process of extracting information from a database and then quantifying and filtering discrete, structured data: Data set - CORRECT ANSWER This is a list of recommended data elements with uniform definitions that are relevant for a particular use: Data warehouse - CORRECT ANSWER This is a database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface: Database - CORRECT ANSWER This is an organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple systems: Deemed status - CORRECT ANSWER This is an official designation indicating that a healthcare facility is in compliance with Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by the Joint Commission or the American Osteopathic Association: Denial - CORRECT ANSWER This is when a bill has been returned unpaid for any of several reasons: Descriptive statistics - CORRECT ANSWER This is a set of statistical techniques used to describe data such as means, frequency distributions, and standard deviations; statistical information that describes the characteristics of a specific group or a population: Diagnosis-related group (DRG) - CORRECT ANSWER This is unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost: Disease index - CORRECT ANSWER This is a list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use: DRG grouper - CORRECT ANSWER This is a computer program that assigns inpatient cases to diagnosis-related groups and determines the medicare reimbursement: Encoder - CORRECT ANSWER This is speciality software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system: Episode-of-care (EOC) reimbursement - CORRECT ANSWER This is a category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers: Fee schedule - CORRECT ANSWER This is a list of healthcare services and procedures (usually CPT/HCPCS) codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan: Fishbone diagram - CORRECT ANSWER This is a performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically: Foreign key - CORRECT ANSWER This is a key attribute used to link one entity or table to another: Free-text data - CORRECT ANSWER This is data that are narrative in nature: Professional component - CORRECT ANSWER This is a portion of a healthcare procedure performed by a physician. Its generally used in reference to the elements of radiological procedures performed by a physician: Group health insurance - CORRECT ANSWER This is a prepaid medical plan that covers the healthcare expenses of an organization's full-time employees: Grouper - CORRECT ANSWER This is a computer software program that automatically assigns prospective payment groups on the basis of clinical codes: Hard-coding - CORRECT ANSWER This is the process of attaching a CPT/HCPCS code to a procedure located on the facility's charge maser so that the code will automatically be included on the patient's bill: Healthcare data analytics - CORRECT ANSWER This is the practice of using data to make business decisions in healthcare: Histogram - CORRECT ANSWER This is a graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percentages in a series of bars: Home health prospective payment system (HH PPS) - CORRECT ANSWER This is the reimbursement system developed by CMS to cover home health services provided to Medicare beneficiaries: Hypothesis - CORRECT ANSWER This is the statement that describes a research question in measurable terms: Hypothesis test - CORRECT ANSWER This allows the analyst to determine the likelihood that a hypothesis is true given the data present in the sample with a predetermined acceptable level of making an error: Identity management - CORRECT ANSWER In the master patient index, these are policies and procedures that manage patient identity, such as prohibiting the same record number for duplicate patients or duplicate records for one patient: Income statement - CORRECT ANSWER This is a statement that summarizes an organization's revenue and expense accounts using totals accumulated during the fiscal year: Informed consent - CORRECT ANSWER This is a type of consent in which the patient should have a basic understanding of which medical procedures or test may be performed as well as risks, benefits and alternatives for those tests or procedures: Integrated health record - CORRECT ANSWER This is a system of health record organization in which all of the paper forms are arranged in strict chronological order and mixed with forms created by different departments: Key attributes - CORRECT ANSWER These are common fields within a relationship database that are used to link tables to one another: Legal health record - CORRECT ANSWER This is a subset of all patient-specific data created or accumulated by a healthcare provider that may be related to third parties in response to legally permissible requests: Licensure - CORRECT ANSWER This is legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission: Line graph - CORRECT ANSWER This is a graphic technique used to illustrate the relationship between continuous measurements: Linkage analysis - CORRECT ANSWER This is a technique used to explore and examine relationship among a large number of variables of different types: Longitudinal health record - CORRECT ANSWER This is a permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death: Many-to-may relationship (M:M) - CORRECT ANSWER This is the concept that multiple instances of any entity may be associated with multiple instances of another entity: Mean - CORRECT ANSWER This is the measure of calculating the average of observations in a frequency distribution: Median - CORRECT ANSWER This is the central tendency that shows the midpoint of a frequency distribution when observations been arranged in order from lowest to highest: Medical necessity - CORRECT ANSWER This is a concept that procedures are only eligible for reimbursement as a covered benefit when they are performed for a specific diagnosis or specified frequency: Minimum data set - CORRECT ANSWER This is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF (skilled nursing facility): Medicare Summary Notice (MSN) - CORRECT ANSWER This is a summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided: Medicare Provider Analysis and Review (MEDPAR) - CORRECT ANSWER This is a database containing information and files submitted by fiscal intermediaries that is used by the Office of the Inspector General to identify suspicious billing and charge practices: Metadata - CORRECT ANSWER This is descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date: Mode - CORRECT ANSWER A measure of central tendency that consists of the most frequent observation in a frequency distribution: Minimum Data Set for Long-Term Care - CORRECT ANSWER This is a federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements: National Coverage Determination (NCD) - CORRECT ANSWER This sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Nominal-level data - CORRECT ANSWER This is data that fall into groups or categories that are mutually exclusive and with no specific order (for example, patient demographics such as third-party payer, race, and sex); Also called categorical data: Nonparticpating provider (nonPAR) - CORRECT ANSWER Physicians who treat Medicare beneficiaries but do not have a legal agreement with the program to accept assignment on all Medicare services and who, therefore, may bill beneficiaries more than the Medicare reasonable charge on a service-by-service basis Notable disease - CORRECT ANSWER This is a disease that must be reported to a government agency so that regular, frequent, and timely information on individual cases can be used to prevent and control future cases of the disease such as HIV: Normalization - CORRECT ANSWER This is a formal process applied to relational database design to determine which variables should be grouped in a table in order to reduce data redundancy: Nonrandom sampling - CORRECT ANSWER This is a type of convenience or purposive sampling in which all members of the target population do not have an equal or independent chance of being selected for a research study: Null hypothesis - CORRECT ANSWER This is a hypothesis that states there is no association between the independent and dependent variables in a research study: One-to-one relationship - CORRECT ANSWER This is a relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa: One-to-many relationship - CORRECT ANSWER This is a relationship that exists when one instance of an entity is associated with multiple instances of another entity One-sample t-test - CORRECT ANSWER This is a test used to compare a population to a standard value: Online/real-time transaction processing (OLTP) - CORRECT ANSWER This is real-time processing of day-to-day business transactions from a database; See online analytical processing: Online analytical processing (OLAP) - CORRECT ANSWER This is a data access architecture that allows the user to retrieve specific information from a large volume of data: Open-record review - CORRECT ANSWER This is a review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process: Closed-record review - CORRECT ANSWER This is a review of records after a patient has been discharged from the organization or treatment has been terminated: Optical character recognition (OCR) technology - CORRECT ANSWER This is a method of encoding text from analog paper into bitmapped images and translating the images into a form that is computer readable: Ordinal data - CORRECT ANSWER This is a type of data that represents values or observations that can be ranked or ordered: ORYX initiative - CORRECT ANSWER The Joint Commission's initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process: Outcome measures - CORRECT ANSWER This is a measure that indicates the result of the performance: Outpatient prospective payment system (OPPS) - CORRECT ANSWER This is a Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications: Pareto chart - CORRECT ANSWER This is a bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions: Performance measure - CORRECT ANSWER This is a gauge used to assess the performance of a process or function of any organization Per patient per month (PPPM) - CORRECT ANSWER This is a type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time Pie chart - CORRECT ANSWER This is a graphic technique in which the proportions of a category are displayed as portions of a circle (like pieces of a pie); used to show the relationship of individual parts to the whole: Primary key - CORRECT ANSWER This is an explanatory notation that uniquely identifies each row in a database table: Principal diagnosis - CORRECT ANSWER This is a disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care: Principal procedure - CORRECT ANSWER This is performed for definitive treatment rather than for diagnostic or exploratory purpose, or necessary to take care of a complication: Problem-oriented medical or health record - CORRECT ANSWER This is a way organizing information in a health record in which clinical problems are defined and documented individually: Quality improvement organization - CORRECT ANSWER This is an organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room: Range - CORRECT ANSWER This is a measure of variability between the smallest and largest observations in a frequency distribution: Resident Assessment Instrument (RAI) - CORRECT ANSWER This is a uniform assessment instrument developed by CMS to standardize the collection of skilled nursing facility patient data; this includes the minimum data set: Recovery audit contractor (RAC) - CORRECT ANSWER This is a governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments: Resident assessment protocols (RAPs) - CORRECT ANSWER This is a summary of a long-term care resident's medical condition and care requirements, used in conjunction with the MDS to create a clear picture of the patient's status and care plan: Resource-based relative value scale (RBRVS) - CORRECT ANSWER This is a scale of national uniform relative values for all physicians' services. The relative value of each service must be the sum of relative value units representing the physicians' work, practice expenses net of malpractice insurance expenses, and the cost of professional liability insurance: Scatter plot - CORRECT ANSWER This is a graph that visually displays the linear relationships among factors: Simple random sampling - CORRECT ANSWER This is a process of selecting units from a population so that each one has exactly the same chance of being included in the sample: Source-oriented health record - CORRECT ANSWER This is a system of health record organization in which information is arranged according to the patient care department that provided the care: Standard deviation - CORRECT ANSWER This is a measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement: Stratified random sampling - CORRECT ANSWER This is a process of selecting the same percentages of subjects for a study sample as they exist in the subgroups (strata) of the population: Strategic IS planning - CORRECT ANSWER There is a process for setting IS priorities within an organization; the process of identifying and prioritizing IS needs based on the organization's strategic goals with the intent of ensuring that all IS technology initiatives are integrated and aligned with the organization's overall strategic plan: Systematic sampling - CORRECT ANSWER This is a process of selecting a sample of subjects for a study by drawing every nth unit on a list Systems development life cycle (SDLC) - CORRECT ANSWER This is a model used to represent the ongoing process of developing (or purchasing) information systems: Technical component (TC) - CORRECT ANSWER The portion of radiological and other procedures that is facility based or nonphysician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on): Terminal-digit filing system - CORRECT ANSWER This is a system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement: Tracer methodology - CORRECT ANSWER This is a process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; an evaluation that follows (traces) the hospital experiences of specific patients to assess the quality of patient care: Traditional fee-for-service (FFS) reimbursement - CORRECT ANSWER This is a reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers: Uniform Bill-04 (UB-04) form - CORRECT ANSWER This is a single standardized Medicare form for standardized uniform billing, implemented in 2007 for hospital inpatients and outpatients; this form will also be used by the major third-party payers and most hospitals: Unbundling - CORRECT ANSWER This is a practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure: Uniform Ambulatory Care Data Set (UACDS) - CORRECT ANSWER This is a data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient- or client-specific data elements to be collected in ambulatory care settings: Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER This is a core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems: Universal chart order - CORRECT ANSWER This is a system in which the health record is maintained in the same format while the patient is in the facility and after discharge: Upcoding - CORRECT ANSWER This is a practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients: Use case - CORRECT ANSWER This is a technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements: Utilization management (UM) - CORRECT ANSWER This is a collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs and is a program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner: Utilization review (UR) - CORRECT ANSWER This is a process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan: Vocabulary standard - CORRECT ANSWER This is a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field: Critical path - CORRECT ANSWER This is the path with the great total duration in time and represents the longest duration in time to complete a total project: Project Assumptions - CORRECT ANSWER These are scope-limiting parameters. They provide constraints on what is and is not included in the project: Sponsor - CORRECT ANSWER This is a person who supports, protects and promotes an idea within the organization: Implied consent - CORRECT ANSWER This consent which is not expressly granted by a person, but rather implicitly granted by a person's actions and the facts and circumstances of a particular situation (or in some cases, by a person's silence or inaction): Express consent - CORRECT ANSWER This consent is communicated through words, regardless of whether those words are written or spoken: Interval history - CORRECT ANSWER If the history and physical have been completed within the 30 days prior to admission, there must be an updated entry in the medical record that documents an examination of any changes in the patient's condition since the original history and physical examination and this entry must be included in the record within the first 24 hours of admission, this is called obtaining an: Face sheet - CORRECT ANSWER This is usually the first page of the health record, which contains patient identification, demographics, date of admission, insurance coverage or payment source, referral information, hospital stay dates, physician information, and discharge information, as well as the name of the responsible party, emergency and additional contacts, and the resident's diagnoses: Format - CORRECT ANSWER This refers to the organization of information in the health record: Source-oriented health record - CORRECT ANSWER This is the conventional or traditional method of maintaining paper-based health records. In this method, health records are organized according to the source, or originating, department that rendered the service (for example lab reports are filed together, all radiological reports are filed together): Problem-oriented health record (POMR) - CORRECT ANSWER This is comprised of the problem list, history and physical examination, lab findings, the initial plan and progress notes organized so that every member of the healthcare team can easily follow the course of the patient treatment: SOAP format - CORRECT ANSWER This is the most recognizable component of the problem-oriented health record and it helps providers remember the specific and systematic decision-making process being documented: Integrated health records - CORRECT ANSWER This is arranged in strict chronological order. The order of the record is determined by date the information was entered, the date of service, or the date the report was received, rather by then source department: the record gives the sequence of the patient's care delivered: Quantitative analysis - CORRECT ANSWER This is a review of the health record to determine its completeness and accuracy. This is generally done retrospectively, but may be done while the patient is in the facility, in which it is referred to concurrent review or concurrent analysis: Universal chart order - CORRECT ANSWER When facilities leave the health record in the same format as it was maintained while the patient was in the facility rather than spend the time rearranging the forms this is called: Qualitative analysis - CORRECT ANSWER This is a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care. When done when the patient is in the facility it is called open-record review or ongoing review: Serial-unit numbering system - CORRECT ANSWER This is when each patient receives a new number at each visit, and numbers are assigned in straight numerical sequence to consecutive patients in the order in which they arrive for treatment: Unit-numbering system - CORRECT ANSWER This is when each patient is assigned a number during the first encounter for care and keeps it for all subsequent encounters: Terminal-digit filing system - CORRECT ANSWER This is when records are filed according to a three-part number made of up of two digits. Ex 01-02-03, the first part of digits on the right (03) is called the primary number of the terminal-digit, the second pair of digits (02) is called the secondary number and the third pair of digits (01) is called the tertiary or final number: Master patient index (MPI) or enterprise master patient index (EMPI) - CORRECT ANSWER This is a permanent database including every patient ever admitted to or treated by the facility: Overlap - CORRECT ANSWER This occurs when a patient has more than one medical record number assigned across more than one database: Overlay - CORRECT ANSWER This occurs when one patient record is overwritten with dat from another patient's record: Outcomes and Assessment Information Set (OASIS) - CORRECT ANSWER This is a standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs: Healthcare Effectiveness Data and Information Set (HEDIS) - CORRECT ANSWER This is a set of standardized performance measures designed to provide healthcare purchasers and consumers with information they need to compare the performance of managed healthcare plans: Divison - CORRECT ANSWER Under ICD-10-PCS, this is a root procedure that involves cutting into a body part without draining fluids or gases from the body part in order to separate or transect the body part, ex: osteotomy: Alteration - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves modifying the natural anatomic structure of a body part without affecting the function of the body part, ex: facelift: Bypass - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves altering the route of passage of the contents of a tubular body part, ex: coronary artery bypass: Change - CORRECT ANSWER Under ICD-10-PCS, this a root procedure that involves taking out or off a device from a body part and putting back an identical or similar devices in or on the same body part without cutting or puncturing the skin or a mucous membrane: Control - CORRECT ANSWER Under ICD-10-PCS, a root operation that involves stopping, or attempting to stop, postprocedural bleeding: Creation - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves making a new genital structure that does not physically take the place of a body part, ex gender change Destruction - CORRECT ANSWER Under ICD-10-PCS, this a root operation that involves physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent, ex: skin lesion: Detachment - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves cutting off all or part of the upper or lower extremities: Dilation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves expanding an orifice or the lumen of a tubular body part: Excision - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves cutting out or off, without replacement, a portion of a body part: Extirpation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves taking or cutting out solid matter from a body part: Extraction - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves pulling or stripping out or off all or a portion of a body part by the use of force: Fragmentation - CORRECT ANSWER Under ICD-10-PCS, this is a root operation that involves breaking solid matter in a body part into pieces: Fusion - CORRECT ANSWER Under ICD-10-PCS, this is a root procedure that involves joining together portions of an articular body part rendering the articular body part immobile: Central model - CORRECT ANSWER This stores patient records in a single database built to allow queries into the system. This model tends to return results quicker than the other models: Decentralized or Federated model - CORRECT ANSWER This maintains the database at each participant's facility. This allows for easy updates to the record: Hybrid model - CORRECT ANSWER This is a cross between the centralized and federal models. This usually entails shared patient consent databases and perhaps the development of shared directories for providers and healthcare facilities for use by all participating organizations: Regional health information organizations (RHIOs) - CORRECT ANSWER These are collaboratives of healthcare providers, payers and patients that regionally exchange healthcare information: Business process reengineering (BRP) - CORRECT ANSWER This is the redesign of the organization and its business processes in order to reduce costs, streamline operations, and improve quality of service: Payback period - CORRECT ANSWER This is the time required to recoup the cost of an investment: Net income - CORRECT ANSWER This is the arithmetic difference between total revenue and total expenses: Accounting rate of return - CORRECT ANSWER This method compares the projected annual cash inflows, minus any applicable annual depreciation, divided by the initial investment: Budget cycle - CORRECT ANSWER This is a complete process of financial planning, operations, and control for a fiscal year; overlaps multiple fiscal years; Also called budget calendar: Depreciation - CORRECT ANSWER This is the allocation of the dollar cost of a capital asset over its expected life: Process measure - CORRECT ANSWER There are measures that focus on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome: Flow chart - CORRECT ANSWER This is a graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process: Force-field analysis - CORRECT ANSWER This is a performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced: Predefined process icon - CORRECT ANSWER In flowcharting, this symbol represents formal procedures that participants are expected to carry out the same way every time: Manual input icon - CORRECT ANSWER In flowcharting, this symbol represents a point in the process at which the participants must record data in paper-based or computer based formats: Strategic plan - CORRECT ANSWER This is a document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity: Tactical plans - CORRECT ANSWER This is a strategic plan at the level of divisions and departments: Operational plans - CORRECT ANSWER This is a strategic plan at the lower departmental levels and are implemented as daily activities: Liquidity - CORRECT ANSWER This is the degree to which assets can be quickly and efficiently turned into cash, for example, marketable securities are generally liquid, the assumption being that they can be sold for their full value in a matter of days, whereas buildings are not liquid, because they cannot usually be sold quickly Statement of cash flows - CORRECT ANSWER This details the reasons that cash changed from one balance sheet period to another. It shows the analyst whether cash was used to purchase equipment or to pay down debt and whether any unusually large transactions took place: Statement of retained earnings - CORRECT ANSWER This expresses the change in retained earnings from the beginning of the balance sheet period to the end: Cost-benefit feasibility study - CORRECT ANSWER This is a process that uses quantitative techniques to evaluate and measure the benefit of providing products or services compared to the cost of providing them: Strategy map - CORRECT ANSWER This is a visual representation of the cause-and-effect relationships among the components of an organization's strategy: Work sampling - CORRECT ANSWER This is a work measurement technique that uses random sampling measurements to characterize the performance of the whole: Work distribution analysis - CORRECT ANSWER This is an analysis used to determine whether a department's current work assignments and job content are appropriate: Liability - CORRECT ANSWER This is a legal obligation or responsibility that may have financial repercussions if not fulfilled or an amount owed by an individual or organization to another individual or organization: Needs Assessment - CORRECT ANSWER This is a procedure performed to determine what is required, lacking, or desired by an employee, a group, or an organization: Strategic thinker - CORRECT ANSWER This type of successful leader understand that three competencies can and must be developed such as visioning, strategy development and change management: Serial work division - CORRECT ANSWER This is consecutive handling of tasks or products by individuals or perform a specific function in sequence: Parallel work division - CORRECT ANSWER This is the concurrent handling of tasks or when multiple employees do identical types of tasks: Unit work division - CORRECT ANSWER This is the simultaneous assembly in which everyone performs a different specialized has at the same time: Object-oriented database - CORRECT ANSWER This is considered a basic component of itself and contains data and their relationships in a single structure: Sherman Anti-Trust Act - CORRECT ANSWER Deficit Reduction Act - CORRECT ANSWER False Claims Act - CORRECT ANSWER Data integrity - CORRECT ANSWER Data granularity - CORRECT ANSWER [Show Less]
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RHIA EXAM PREP 77 Questions with Verified Answers,100% CORRECT
RHIA EXAM PREP 77 Questions with Verified Answers The director of the health information department wanted to determine the level of physicians' satis... [Show More] faction with the department's services. The director surveyed the physicians who came to the department. What type of sample is this? Non-probability or opportunity sample, sample drawn without any underlying probability-based selection method. - CORRECT ANSWER Convenience As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed that more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the committee's first action? - CORRECT ANSWER Establish a data dictionary policy with associated standards Systems linked by ________ allow HIE participants to search for health records on each of the other systems using patient indexing and identification software. - CORRECT ANSWER RLSs - Record Locator Service Community Hospital is reviewing its job descriptions and notices that some job descriptions for clinical positions include a reference to the potential risks of exposure to blood-borne pathogens while others do not. The human resource manager insists that all job descriptions should include this language. Why is this important to include? - CORRECT ANSWER Community Hospital needs to define the level of risk for infection from blood-borne pathogens for its employees. The patient is a 47-year-old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia? - CORRECT ANSWER 49507, Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated A hospital is undergoing a major reconstruction project and a new director of nursing has been hired. At the same time, the nursing documentation component of the EHR has been implemented. The fact that nursing staff satisfaction scores have risen is: - CORRECT ANSWER Uncertain due to existence of confounding variables As part of his role at the local hospital, Jake is reviewing Joint Commission standards to ensure that the organization is meeting the accreditation requirements. As part of the review, Jake is looking at a specific set of standards that are primarily focused on documentation. Some of the standard requirements include care provided, procedures that were done on the patient, and the progress of the patient. Based on this scenario, which set of Joint Commission standards is Jake reviewing? - CORRECT ANSWER Record of Care Standards Following a motor vehicle accident, a patient presents to the emergency department (ED) with obvious head trauma and lower abdominal pain. The patient also notes recent hematuria prior to the accident and has a slight fever. A CT brain scan reveals the presence of a skull fracture with a hematoma, and the patient is admitted. During the hospital stay, the patient is treated for a urinary tract infection. The coder assigns the skull fracture and hematoma as present on admission, and the urinary tract infection as not present on admission. The coding manager reviews this case and identifies the following error: - CORRECT ANSWER The urinary tract infection was present on admission because fever and hematuria were documented in the ED, so the coder was incorrect by not identifying it as present on admission. If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: - CORRECT ANSWER Comply with the patient's request and keep the information private Between which two health information system applications is there the least interoperability at the present time? - CORRECT ANSWER EHR in a physician office and revenue cycle management An employee forgot his user ID badge at home and uses another employee's badge to access the computer system. What controls should have been in place to minimize this security breach? - CORRECT ANSWER Workforce security awareness training What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals? - CORRECT ANSWER State licensure agencies The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called: - CORRECT ANSWER Environmental assessment Which of the following would be used to determine what the users need in an information system? - CORRECT ANSWER Questionnaire For a contract to be valid, it must include three elements. Which of the following is one of those elements? A valid offer, acceptance and ... - CORRECT ANSWER Consideration The process of releasing health record documentation originally created by a different provider is called: - CORRECT ANSWER Redisclosure If a data breach caused by willful neglect is corrected within 30 days from the date of the covered entity or business associate becoming aware of it, what level of violation of the HIPAA Omnibus Rule is this breach? - CORRECT ANSWER Tier 3 The nurse manager on the internal medicine unit of the hospital noticed that Dr. Smith in the ED admits many patients to the internal medicine unit. She is wondering if he admits patients to the hospital from the ED more often than other physicians. What type of analysis should be done to answer her question? - CORRECT ANSWER Data mining - the analyst determines any trends and identifies patterns in the data A patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond? - CORRECT ANSWER The hospital must accept the request but does not have to agree to it. Dr. Smith, a surgeon at Community Hospital, is trying to understand how she can help the hospital improve reimbursement from Medicare. The HIM manager explains to Dr. Smith that reducing catheter-associated UTIs and surgical site infections would improve the hospital's scores in which of the following domains of the Medicare Value-Based Purchasing program? - CORRECT ANSWER Safety Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: - CORRECT ANSWER Vocabulary Standards A visitor walks through the work area and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? - CORRECT ANSWER Facility Access Controls Today, Janet Kim had her first appointment with a new dentist. She was not presented with a Notice of Privacy Practices. Is this acceptable? - CORRECT ANSWER No, it is a violation of the HIPAA Privacy Rule. The medical staff at Regency Health is nationally renowned for its skill in performing cardiac procedures. The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: - CORRECT ANSWER Physician Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER Date the claim drops What relationships is the following entity relationship diagram showing? - CORRECT ANSWER Each division has one hospital, but each hospital has many divisions. When adopting value-based care, what technology helps healthcare professionals appropriately use financial information that may impact their choice of drugs, referrals, need for care coordination, and other factors for their patients? - CORRECT ANSWER Integration of EHR and RCM An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard? 114 / 0.60 = 190; 190 - 114 = - CORRECT ANSWER 76 pages In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? - CORRECT ANSWER Nursing staff What term is used to represent a difference between the budgeted amount and the actual amount of a line item that is not expected to reverse itself during a subsequent period? - CORRECT ANSWER Permanent Variance Which of the following would a data analyst use to locate, retrieve, and use data? By describing data, ___________ makes it easier to locate, retrieve, use, and manage. - CORRECT ANSWER Metadata Identifying future health information needs for a healthcare entity and projecting specific initiatives required to meet those needs is part of: - CORRECT ANSWER Strategic Planning City Hospital's HIPAA committee is considering a change in policy to allow hospital employees who are also hospital patients to access their own patient information in the hospital's EHR system. A committee member notes that HIPAA provides rights to patients to view their own health information. However, another member wonders if this action might present other problems. In this situation, what suggestion should the HIM director provide? - CORRECT ANSWER Allowing employees to access their own records using their job-based access rights appears to violate HIPAA's minimum necessary requirement; therefore, allow employees to access their records through normal procedures. What architectural model of health information exchange allows participants to access data in point-to-point exchange? - CORRECT ANSWER Federated—inconsistent databases A performance improvement (PI) team has been established within a local hospital. Becky, the privacy officer for the hospital, is contacted by the PI team leader, Mike, who is aware that there may be instances in which he needs to consult Becky but is unsure under what circumstances this contact would need to be made. Becky is tasked with responding to the PI team leader. Under which of the following circumstances should Becky inform Mike that the team would need to contact her for consultation? - CORRECT ANSWER To ensure that PHI is used, stored, and disclosed properly. 83. In the Hospital Value-Based Purchasing Program, a facility's total performance score (TPS) is used to determine the amount of holdback dollars the facility has earned. In regard to the TPS, which is better? - CORRECT ANSWER A higher TPS is better. The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term? - CORRECT ANSWER Focus reviews on lower-weighted MS-DRGs from triples and pairs A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? - CORRECT ANSWER Counsel the coder to stop the practice immediately Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? - CORRECT ANSWER Constructive confrontation What is the benefit of comparing the coding assigned by coders to the coding that appears on the claim? - CORRECT ANSWER May find claim generation issues that cannot be found in other ways Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking? - CORRECT ANSWER Reliability Which data collection program is the basis for the CMS value-based purchasing program? - CORRECT ANSWER Hospital compare Healthright Clinic, a large IDS, is evaluating the processes of patient care and patient outcomes in pediatrics. It is using software to help solve problems and check if the care given meets established guidelines. What method or tool is in the software that helps in this process? - CORRECT ANSWER Algorithms Johnny is 12 years old and his parents are divorced. In order for Johnny to receive medical treatment, generally: - CORRECT ANSWER One parent must consent A potential employee was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. This employee's medical information is: - CORRECT ANSWER Not protected by the Privacy Rule because it is part of a personnel record Aging of accounts is the practice of counting the days, generally in increments, from the time a bill has been sent to the payer to the current day. What is the standard increment, in days, that most healthcare entities use for the aging of accounts? - CORRECT ANSWER 30-day increment This analytic technique is being used by CMS to assist in prepayment audits? - CORRECT ANSWER Predictive modeling An encrypted laptop was stolen from your organization. Based on the Breach Notification Rule, how should you respond? - CORRECT ANSWER Do nothing, as a breach did not occur Based on the financial data listed, what was Triad's total net assets before posting net income for the year? Assets - Liabilities = Net assets (equity) assets (cash $500,000 + A/R $250,000 + building $1,000,000 + land $700,000 = $2,450,000) and then subtract the liabilities (A/P $350,000 + mortgage $600,000 = $950,000) or $2,450,000 - $950,000 = - CORRECT ANSWER $1,500,000 A comprehensive retrospective review should be conducted at least once a year of what aspect of the CDI program? - CORRECT ANSWER All query opportunities In data quality management, the process of translating data into information to be utilized by an application is called: - CORRECT ANSWER Analysis The patient accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills? - CORRECT ANSWER Discharged, not final billed The Hay method is used to measure the three levels of major compensable factors: the know-how, problem-solving, and accountability requirements of each position. This system is used for: - CORRECT ANSWER Job evaluation Shirley Denton has written to request an amendment of her PHI from Bon Voyage Hospital, stating that incorrect information is present on the document in question. The document is an incident report from Bon Voyage Hospital that was erroneously placed in Ms. Denton's health record. The covered entity declines to grant her request based on which Privacy Rule provision? - CORRECT ANSWER It is not part of the designated record set. Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed. - CORRECT ANSWER K21.9, 0DB58ZX In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation? Numerical data - CORRECT ANSWER Precision Burning, shredding, pulping, and pulverizing are all acceptable methods in which process? - CORRECT ANSWER Destruction of paper-based health records The computer-based process of extracting, quantifying, and filtering data that reside in a database is called: - CORRECT ANSWER Data mining In establishing roles and responsibilities within a data governance program, which of the following would normally be embedded within an organization's business unit and be responsible for monitoring the data quality of the unit? - CORRECT ANSWER Data steward How do providers benefit from the health insurance exchanges created under the Affordable Care Act? - CORRECT ANSWER Providers should see an increase in reimbursement both from newly insured patients and from patients who are now eligible for Medicaid under the expanded programs. This type of data display tool is a plotted chart of data that shows the progress of a process over time. - CORRECT ANSWER line graph or plot Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? - CORRECT ANSWER Use of Mary's individually identifiable information related to her asthma treatments Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: - CORRECT ANSWER Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment Which of the following statements provide the most appropriate reflection about national and local coverage determinations (NCDs and LCDs)? - CORRECT ANSWER They define the specific diagnosis that supports medical necessity. At a recent medical staff committee meeting, a committee member asked what the state laws are for breach notification and how these laws will impact facility policy. The HIM director explained to the committee member that the state laws for breach notification are ________ and therefore may not guide facility policies related to breach notification for medical information. - CORRECT ANSWER Generally not tailored to medical information Physicians use the ________ to access multiple sources of patient information within the healthcare organization's network. - CORRECT ANSWER Clinical web portal Community Hospital is discussing restricting the access that physicians have to electronic clinical records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available; whereas, others maintain that HIPAA restricts access. The HIM director is part of the committee. Which of the following statements should the director advise to the committee? - CORRECT ANSWER The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the healthcare entity must define what physicians need as part of their treatment role. What information can be determined from the data in the following graph? - CORRECT ANSWER Doctor X uses code 99215 less frequently than his peers. General Hospital is performing peer reviews of its medical providers for quality outcomes of care. The hospital has over 500 providers on its medical staff. The process to review even 10 cases for each provider is quite extensive. The quality department has concluded that, to accomplish this review process, it will review 20 percent of each provider's inpatient admissions to the hospital on an every-other-year rotation. In this situation, the quality department has applied which of the following techniques to its review process? - CORRECT ANSWER sampling When a payer rejects a claim for payment, organization staff must determine the reason for denial. If the denial was deemed due to eligibility determination, what process in the revenue cycle failed to operate as intended? - CORRECT ANSWER Front-end process The use of simulation as a training technique is best suited for which of the following scenarios? - CORRECT ANSWER Disaster preparedness exercises Under what access security mechanism would an individual be allowed access to ePHI if he or she has a proper login and password, belongs to a specified group, and his or her workstation is located in a specific place within the facility? It takes into account the person attempting to access the data, the type of data being accessed, and the _________ of the transaction in which the access attempt is made. - CORRECT ANSWER Context-based What is the most common type of security threat to a health information system? - CORRECT ANSWER Internal to the healthcare entity A distance learning method in which groups of employees in multiple classroom locations may listen to and see the material presented at the same time via satellite or telephone is called: - CORRECT ANSWER videoconferencing You want to graph the number of deaths due to prostate cancer from 2010 through 2017. Which graphic tool would you use? - CORRECT ANSWER Line graph or plot Which type of identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits? - CORRECT ANSWER Medical Which of the following is an operational element that should be included in a migration path for a hospital with an existing EHR and wishing to improve its population health data for value-based care reimbursement? - CORRECT ANSWER Coordinating the collection and use of social determinants of health [Show Less]
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RHIA Exam Prep 116 Questions with Verified Answers,100% CORRECT
RHIA Exam Prep 116 Questions with Verified Answers Data Set - CORRECT ANSWER A group of data items or elements and their definitions. Each element can... [Show More] have its own defined value. Clinical or Medical Vocabulary - CORRECT ANSWER A formally-recognized list of preferred medical terms and their corresponding definitions. They assist in standardizing the language within the health record. Clinical Terminology - CORRECT ANSWER A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement Nomenclature - CORRECT ANSWER A system of naming, especially in the arts or sciences Data Mapping - CORRECT ANSWER The process of identifying relationships between two distinct data models. MS-DRG - CORRECT ANSWER Medicare-severity diagnosis-related group. Medicare restructuring of reimbursement of inpatient hospital admissions. UHDDS - CORRECT ANSWER Uniform Hospital Discharge Data Set. Used by federal and state agencies to collect data on inpatients. NCVHS - CORRECT ANSWER National Committee on Vital and Health Statistics An advisory body to HHS that deals with health data, statistics and national health information policy. UACDS - CORRECT ANSWER Uniform Ambulatory Care Data Set. Collects data about ambulatory care patients HIPAA - CORRECT ANSWER Health Insurance Portability and Accountability Act. Legislation in 1996 enacted to focus on health insurance and health information privacy and security ANSI - CORRECT ANSWER American National Standards Institute. Oversees and accredits private standards development for organizations in the US. DEEDS - CORRECT ANSWER Data Elements for Emergency Department Systems. Uniform specifications for data entered in ED patient records. MDS - CORRECT ANSWER Minimum Data Set (Look up further - is this for long term care?) OASIS - CORRECT ANSWER Outcome and Assessment Information Set. Standardized reproducible assessment instrument used to monitor home health care. CDC - CORRECT ANSWER Centers for Disease Control. Concerned with communicable diseases and environmental health. DHHS (HHS) - CORRECT ANSWER Department of Health and Human Services. Branch of the federal government responsible for regulatory programs affecting the healthcare industry. TJC (JCAHO) - CORRECT ANSWER The Joint Commission. Private accrediting organization whose goal is to improve the quality of patient care through the development and assessment of standards of performance by healthcare organizations. NCQA - CORRECT ANSWER National Committee for Quality Assurance. Accrediting agency for managed care organizations (MCOs). HEDIS - CORRECT ANSWER Healthcare Effectiveness Data and Information Set. Standardized set of performance measures designed to allow consumers of managed care plans to compare performance. NEDSS - CORRECT ANSWER National Electronic Disease Surveillance System. Web-based strategy intended to monitor and assess disease trends, guide prevention and intervention programs, inform public health makers, and identify issues of concern. ASTM - CORRECT ANSWER American Society for Testing and Materials. National standards development body. AMIA - CORRECT ANSWER American Medical Informatics Association. Provides leadership in the development/implementation of information systems to improve patient care. HIMSS - CORRECT ANSWER Healthcare Information and Management Systems Society. Focuses on optimal use of healthcare information technology and management systems for the betterment of human health. AAMT - CORRECT ANSWER American Association for Medical Transcription. Committed to the creation of quality health record reports from dictation by healthcare providers. AHRQ - CORRECT ANSWER Agency for Healthcare Research and Quality. Focuses on production and dissemination of information which improves quality, reduces cost, and enhances the effectiveness of healthcare. Interviews, Surveys, and Questionnaires - CORRECT ANSWER Data collection tools. CLIA - CORRECT ANSWER Clinical Laboratory Improvement Amendments. Legislature mandating certification of clinical laboratories prior to obtaining billing privileges for tests conducted. LOINC - CORRECT ANSWER Logical Observation Identifiers Names and Codes. Database designed to perform the exchange and aggregation of laboratory tests. Flowchart - CORRECT ANSWER Provides a graphical depiction of the sequencing of the steps in a process. Organizational Chart - CORRECT ANSWER Illustrates hierarchical relationships between entities. Timelines - CORRECT ANSWER Presents projected indications for achievements of deadlines. PERT Chart - CORRECT ANSWER Used to provide likely completion times for projects, using smaller projects to accomplish larger goals. Gantt Chart - CORRECT ANSWER Project scheduling tool used to emphasize the work time needed to meet an identified goal. Work Simplification - CORRECT ANSWER A method used to find a better and easier way of performing a function. Its focus is on eliminating wasted time, energy, materials, and cost without compromising safety, while enhancing quality. Accuracy and Integrity - CORRECT ANSWER Two characteristics of data quality. Education, Training, Communication, and Timeliness - CORRECT ANSWER Four components that help ensure data accuracy. Quantitative Health Record Analysis - CORRECT ANSWER All tests ordered by the physician are present and authenticated by comparing the test result reports with the physician orders. Qualitative Health Record Analysis - CORRECT ANSWER A review for documentation inconsistencies related to the diagnosis on various forms and comparison of the medical administration record (MAR) with the patient's pharmacy profile. Legal Health Record Analysis - CORRECT ANSWER Errors in documentation are corrected in a legal manner. Statistical Health Record Analysis - CORRECT ANSWER The abstracting of select data items from the patient record to both clinical and administrative decisions. Metadata - CORRECT ANSWER Data about data. Descriptive, Structural, and Administrative - CORRECT ANSWER Three types of metadata. Classification System - CORRECT ANSWER A method of grouping similar items in a logical way based on common characteristics. ICD-10-CM - CORRECT ANSWER Diagnosis Codes ICD-10-PCM - CORRECT ANSWER Procedure codes Encoders - CORRECT ANSWER Computer programs that assist coding professionals in assigning the appropriate codes to natural language words and phrases contained in the health record. Logic-based and Automated Code Books - CORRECT ANSWER Two types of encoders. Logic-based Encoders - CORRECT ANSWER Allow the coding professional to enter partial words and providing options to choose from, while building and arriving at a code. Automated Code Books - CORRECT ANSWER Requires the coding professional to apply coding guidelines exactly in the same manner as if they were using the coding manual. Groupers - CORRECT ANSWER Software tools that apply logic to assign a particular payment group. MUE - CORRECT ANSWER Medical Unlikely Edits. US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day OCE - CORRECT ANSWER Outpatient Code Editor Software that combines editing logic with the new Ambulatory Payment Classification (APC) assignment program designed to meet the mandated OPPS implementation. APC - CORRECT ANSWER Ambulatory Payment Classification. Government's method of paying for facility outpatient services for the Medicare program OPPS - CORRECT ANSWER Outpatient Prospective Payment System The system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. PDX - CORRECT ANSWER Principal Diagnosis Code of Ethics - CORRECT ANSWER A tool that guides individuals of a specific profession by defining what acceptable behavior is by setting values and principles those professionals abide by. 3M - CORRECT ANSWER A logic-based encoder that allows the coding professional to enter the diagnosis as documented into the chart to locate the correct code. Database - CORRECT ANSWER A collection of interrelated data stored together in one or more computerized files. SDLC - CORRECT ANSWER System Development Life Cycle DBLC - CORRECT ANSWER Database Life Cycle Database Life Cycle Phases - CORRECT ANSWER 1. Database initial study 2. Database Design 3. Database implementation 4. Testing and Evaluation 5. Database operation 5. Database maintenance and evolution Database Initial Study - CORRECT ANSWER First phase in the database life cycle. Key users are consulted regarding their needs and technical requirements. Database Design - CORRECT ANSWER Second phase in the database life cycle. The developer determines the type of database, and data models that are developed. A user interface is created. The user continues to be consulted as to the requirements of the completed database. Database Implementation - CORRECT ANSWER Third phase in the database life cycle. The database is loaded onto the network or workstation where it will be housed. Testing and Evaluation - CORRECT ANSWER Fourth phase in the database life cycle. Users test the database in its current state and evaluate the results of their testing. Problems are identified and resolved and any needed modifications to the initial design are made. Database Operation - CORRECT ANSWER Fifth phase in the database life cycle. The database is moved from the test phase to the live environment. Database Maintenance and Evolution - CORRECT ANSWER Sixth and last phase in the database life cycle. Ongoing maintenance is performed. The database is continually evaluated for its usefulness. Updates and enhancements are added. As the need for changes in the database are identified, the life cycle begins to repeat. Relational Database - CORRECT ANSWER Consist of a collection of tables (relations) with rows and columns. Each row represents a record and each column (attribute) represents a data field that corresponds to the row. DML - CORRECT ANSWER Data Manipulation Language SQL - CORRECT ANSWER Structured Query Language (the most popular data manipulation language or DML) Object-Oriented Database - CORRECT ANSWER Composed of objects where each object is a separate entity, application, or program with a specific task to perform. These databases can process complex data types such as video, graphics, and sound. Data Model - CORRECT ANSWER A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database. Components of a Data Model - CORRECT ANSWER 1. Data Model Diagram 2. Data Dictionary 3. Narratives explaining what the diagrams and dictionary mean Data Model Diagram - CORRECT ANSWER A pictorial representation of the proposed database. It is most often a flowchart of the data flow, symbols of the relationships to be developed among the database entities, and drawings of tables representing the records and attributes in a relational database. Data Flow Diagram - CORRECT ANSWER A data flow diagram is used to visually demonstrate the relationship between the inputs to the database and the outputs from the database. There is a separate data flow diagram for each process represented in the database. Types of Data Models - CORRECT ANSWER 1. Conceptual 2. Logical 3. Physical Conceptual Data Model - CORRECT ANSWER The highest level of data model, representing the highest level of abstraction, independent of hardware and software. Logical Data Model - CORRECT ANSWER Shows the organization of data without indicating how it is stored, created, or manipulated. Physical Data Model - CORRECT ANSWER Shows how the data will actually be stored in databases or files. Data Dictionary - CORRECT ANSWER A descriptive list of names, definitions, and attributes of data elements to be collected in an information system database whose purpose is to standardize definitions and ensure consistent use. Types of Data Dictionaries - CORRECT ANSWER 1. Database Management System (DBMS) 2. Organization-Wide DBMS DD - CORRECT ANSWER Database Management System Data Dictionary. A type of data dictionary that contains all of the information about the database and its related elements. Organization-Wide Data Dictionary - CORRECT ANSWER Applies the concept of the DBMS data dictionary and applies it at the organizational level to assure all definitions across the organization are consistent. Database Administrator (DBA) - CORRECT ANSWER Responsible for overseeing all technical aspects of database management. Data Administrator - CORRECT ANSWER Oversees the managerial functions of database management, including planning for the database, training users, developing and implementing policies and procedures, and managing the organization-wide data dictionary. Data Resource Manager (DRM) - CORRECT ANSWER Responsible for retrieving data from an organization's information systems to ensure that the end users' needs are met and guarantee that the organization's data resources are secure, accessible, accurate, and reliable. Data Analyst - CORRECT ANSWER Responsible for collecting and analyzing data from the database. Data Mining - CORRECT ANSWER The process of abstracting data from a database to identify hidden trends that are then used for decision-making. Data Integrity - CORRECT ANSWER Controlling the consistency and correctness of data throughout a database. Data Integrity Constraints - CORRECT ANSWER Rules that must be followed when entering and/or changing data in a database (restrict values that may be entered). Data Security - CORRECT ANSWER Ensuring that the confidentiality, integrity, and availability of the data are in place. Data Migration - CORRECT ANSWER The process of moving data from one computer or information system to another. Data Translation Tables - CORRECT ANSWER Include specific information about files that are being migrated to a new system. Steps for Data Migration - CORRECT ANSWER 1. Data Extraction 2. Data Loading 3. Data Verification LHR - CORRECT ANSWER Legal Health Record. This is the business record generated at or for a healthcare organization that would be released upon receipt of a request. It is the officially-declared record of healthcare services provided to an individual delivered by a provider. Designated Record Set - CORRECT ANSWER A group of records maintained by or for a covered entity that is the medical and billing records about individuals; enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; information used in whole or in part by or for the HIPAA covered entity to make decisions about individuals. AAAASF - CORRECT ANSWER American Association for Accreditation of Ambulatory Surgery Facilities AAAHC - CORRECT ANSWER Accreditation Association for Ambulatory Health Care AAHP - CORRECT ANSWER American Association of Health Plans AAMC - CORRECT ANSWER Association of American Medical Colleges AAMRL - CORRECT ANSWER American Association of Medical Record Librarians AAPC - CORRECT ANSWER American Academy of Professional Coders AAPPO - CORRECT ANSWER American Association of Preferred Provider Organizations Abbreviated Injury Scale (AIS) - CORRECT ANSWER An anatomically-based, consensus-derived global severity scoring system that classifies each injury by region according to its relative importance on a 6-point ordinal scale (1=minor and 6=maximal). ABC - CORRECT ANSWER Activity-based costing ABC Codes - CORRECT ANSWER Codes that consist of five-character, alphabetic strings that identify services, remedies, or supplies. Codes are followed by a two-character code modifier, which identifies the practitioner type who delivered the care. Aberrancy - CORRECT ANSWER Services in medicine that deviate from what is typical in comparison to the national norm ABN - CORRECT ANSWER Advance beneficiary notice Abnormal Involuntary Movement Scale (AIMS) - CORRECT ANSWER A standardized form that can be used in facilities to document involuntary movements Absolute Frequency - CORRECT ANSWER The number of times that a score of value occurs in a data set Abstract - CORRECT ANSWER A brief summary of the major parts of a research study Abstracting - CORRECT ANSWER 1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment and outcome; 2. The process of extracting elements of data from a source document or database and entering them into an automated system. Abuse - CORRECT ANSWER Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. This includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced. Accept Assignment - CORRECT ANSWER A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided Acceptance Theory of Authority - CORRECT ANSWER A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions. Accession Number - CORRECT ANSWER A number assigned to each case as it is entered in a cancer registry [Show Less]
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RHIA Exam 2: 104 Questions with Verified Answers,100% CORRECT
RHIA Exam 2: 104 Questions with Verified Answers Data elements for emergency department systems - CORRECT ANSWER DEEDS Minimum data set - CORRECT ANS... [Show More] WER MDS Outcome and assessment information set - CORRECT ANSWER OASIS Uniform ambulatory care data set - CORRECT ANSWER UACDS Facility - CORRECT ANSWER Owner of the health record of patients treated in a healthcare facility. Precision - CORRECT ANSWER This dimension of data quality that often relates to numerical data. It donates how close to an actual size, weight, or other standard a particular measurement is. Statutes of limitation - CORRECT ANSWER The time period in which a lawsuit may be filed, must be considered in establishing a retention schedule Longitudinal health record - CORRECT ANSWER Maintains information throughout the lifespan of the patient, ideally from birth to death Problem oriented health record - CORRECT ANSWER Type of health record. A method of recording data about the health status of a patient in a problem solving system. It preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plans by all members of the health care team. Principal procedure - CORRECT ANSWER The procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition. Attending physician - CORRECT ANSWER The physician principally responsible for the patient's hospital care generally dictates the discharge summary. Comorbidity - CORRECT ANSWER The simultaneous presence of two chronic diseases or conditions in a patient. Vocabulary standard - CORRECT ANSWER A common definition for medical terms to encourage consistent descriptions of an individual's condition in the health record Migration plan - CORRECT ANSWER To meet meaningful use standards, Anywhere Hospital is implementing a document imaging system and electronic document management system. This is an interim step before full implementation of computerized provider order entry and point of care documentation. This step by step process is part of the hospital's... Accession number - CORRECT ANSWER This number consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year. H&P - CORRECT ANSWER According to accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed? Excludes 1 - CORRECT ANSWER In ICD 10 CM this note means "not coded here" Peer review - CORRECT ANSWER A review in which a member of a profession assesses the work of colleges within that same profession. This review has traditionally been at the center of quality assessment and assurance efforts. The medical profession's ______ ________ efforts have emphasized the scientific aspects of quality. Appropriate use of pharmaceuticals, postoperative infection rates, and accuracy of diagnosis are among the measures of quality that have been used. It is a requirement of both CMS and the JC. Utilization review - CORRECT ANSWER The critical examination (as by a physician or nurse) of health care services provided to patients especially for the purpose of controlling costs (as by identifying unnecessary medical procedures) and monitoring the quality of care. Retention policies - CORRECT ANSWER This type of health record policies dictate how long individual health records must remain available for authorized use. Structured data - CORRECT ANSWER This type of data has many benefits including completeness, quality, and accessibility of the data for a variety of purposes. This data is often entirely appropriate and highly recommended for data entry when the options are limited or are required to conform to a specific standard. Aggregate data - CORRECT ANSWER Data combined from several measurements. For this type of data, groups of observations are replaced with summary statistics based on those observations. It dramatically reduces the time to query large sets of data. Unstructured data - CORRECT ANSWER Information that either does not have a pre-defined manner. It is typically text-heavy, but may contain data such as dates, numbers, and facts as well. Database - CORRECT ANSWER Term used to refer to an organized collection of data that have been stored electronically to facilitate easy access. Telemedicine - CORRECT ANSWER The remote diagnosis and treatment of patients by means of telecommunications technology Centralized - CORRECT ANSWER EHR database model in which all of the healthcare entity's patient health information stored in one system. Distributed - CORRECT ANSWER EHR database model in which the healthcare entity's patient health information is stored in multiple systems. American society for testing and materials - CORRECT ANSWER ASTM Continuity of care record - CORRECT ANSWER A core data set developed by the ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another. Abstracting - CORRECT ANSWER The process of reviewing the patient's health records and entering the required data elements into the database. Data migration - CORRECT ANSWER The process of transferring data from one system to another while changing the storage, database or application. Usually occurs during a system upgrade Occlusion - CORRECT ANSWER A procedure that attempts to obstruct the blood flow to a malignant tumor would be coded to what ICD-10 root operation. Healthcare effectiveness data and information set - CORRECT ANSWER HEDIS HEDIS - CORRECT ANSWER A set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need for comparing the performance of managed healthcare plans. ORYX - CORRECT ANSWER A joint commission initiative that incorporates the reporting on performance measure data into its accreditation and certification processes, and is intended to support JC accredited and certified organizations in their quality improvement efforts. Application, collection, warehousing, Analysis - CORRECT ANSWER Data quality functions involve continuous improvement for data quality throughout an organization and include four key processes. These processes are... Analysis - CORRECT ANSWER The process of translating data into information utilized for an application. Treatment - CORRECT ANSWER Only when copies of the personal health record are used for ___________ can b they be considered part of the facilities' legal health record; however, the PHR does not replace the legal health record. Risk analysis - CORRECT ANSWER A systemic process of identifying security measures to afford protections given an organization's specific environment, including where the measures are located, what level of automation they have, how sensitive the information ours that needs protection, what remediation will cost, and many other factors. Gap analysis - CORRECT ANSWER A method of addressing the differences in performance between a business' information systems or software applications to determine whether business requirements are being met and, if not, what steps should be taken to ensure they are met successfully. Operational review - CORRECT ANSWER An in-depth look at the big picture, addressing communication issues, operating procedures, profitability issues, and other factors that affect a business, making it unstable. Internal - CORRECT ANSWER What is the most common type of security threat to a health information system. Risks - CORRECT ANSWER Mary is contemplating triple bypass surgery. Informed consent by her surgeon would typically contain what? Entity authentication - CORRECT ANSWER The verification of a user's identity. Simply put, this standard seeks to ensure that organizations put methods in place to verify that users are who they claim they are. Firewalls - CORRECT ANSWER Hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders. However, they also can be used to protect entities within a single network, for ex. To block lap techs from getting into payroll records. Vulnerability - CORRECT ANSWER An inherent weakness or absence of a safeguard that could be exploited by a threat. They are grouped into either technical or non technical categories. Non technical vulnerability - CORRECT ANSWER Vulnerabilities that are demonstrated by such things as policy and procedure weaknesses Technical vulnerability - CORRECT ANSWER Vulnerabilities that reflect inappropriate information systems protective methods. Trigger - CORRECT ANSWER Something within the security audit process that identifies the need for a insurrection. Not all __________ are a breach. Psychotherapy - CORRECT ANSWER Under the HIPAA privacy standard, what type of PHI must be specifically identified in an authorization. Personal identifiable information - CORRECT ANSWER Per the HIPAA Privacy Rule, what type of information requires authorization for research purposes. Patient self determination act - CORRECT ANSWER This Act, which is part of the omnibus budget reconciliation act of 1990, requires healthcare providers to inform patients of their right to create advance directives, document the presence of absence of an advance directive in a patient's health record, and ensure compliance with state law respecting advance directives. Information access management standard - CORRECT ANSWER This standard is focused on policies and procedures that, based upon the entity's access authorization policies, establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process. Redisclosure - CORRECT ANSWER The process of releasing health record documentation originally created by a different provider. Federal and state regulations provide specific ___________ guidelines. Custodian of health records - CORRECT ANSWER The individual who had been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records for such persons or institutions that prepare and maintain records of healthcare. Physician - CORRECT ANSWER The individual responsible for obtaining informed consent from the patient is the... 30 days/60 days - CORRECT ANSWER Protected health information that is maintained in a designated record set can be accessed by the patient or other authorized pay upon request. Covered entities must respond to requests within ______ or file an extension to have _________. Comply - CORRECT ANSWER If a patient has health insurance but paid in full themselves and asks that the information is kept private, the provider must ________. Operations - CORRECT ANSWER A committee is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of the patient's health record is considered healthcare... Data mining - CORRECT ANSWER The computer based process in which an analyst extracts, quantifies, and filters data that reside in a database. Healthcare entity's strategic plan - CORRECT ANSWER It is critical that the organization information system plans be well aligned and integrated to the _____ ______ ______ ______. To develop a tactical plan for IS technology, the healthcare organization should engage in strategic IS planning. Line graph - CORRECT ANSWER Graph used to display time trends. The x axis shows the unit of time from left to right, and the y axis measures the number of instances. MPI - CORRECT ANSWER This index contains the patient's date of birth, gender, and health record number Due diligence - CORRECT ANSWER In purchasing an EHR system from a vendor the healthcare entity performs research in the fourth off site visits, corporate visits, reference checks, credit checks on owners of the vendor company, and other steps needing to be performed before a final contract is negotiated to ensure that the organization is getting the product it wants. Basic, functional, semantic - CORRECT ANSWER Correct sequence of levels of interoperability Claim - CORRECT ANSWER If an analyst wishes to determine the root cause of claim denials during June via a random sample. What is the sampling unit? Analysis - CORRECT ANSWER This it's generally the first step in the development life cycle after the decision to implement the system has been made. Our helps determine the need for data, storage, reporting, and functionality. Outlier - CORRECT ANSWER What is the biggest problem with using mean length of stay as a facility statistic? External and internal - CORRECT ANSWER As a preliminary step in designing an IS strategy, it is important for the steering committee to conduct scans of the ______ and ______ environments. Questionnaire - CORRECT ANSWER What tool would be used to determine what the users need in an information system? Automatic recognition technology - CORRECT ANSWER Barcoding technology is an of... Hospital care - CORRECT ANSWER Data collection program is the basis for the CMS value-based purchasing program Bar charts - CORRECT ANSWER Charts used to display data from one or more variables. It can be drawn horizontally or vertically. Used for ordinal or nominal data. Predictive modeling - CORRECT ANSWER Analytic technique that applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are supplied to historical data to learn the patterns in the data. These patterns dare used to create Morris of what it's most likely to occur. Contingency table - CORRECT ANSWER Table used to display the relationship between two categorical variables. They are often referred to by the number of rows and columns. Hard coding - CORRECT ANSWER During order entry a unique identifier for each service is entered. This unique identifier triggers a charge from the chargemaster to be posted on the patient's account. This process is known as... Nursing staff - CORRECT ANSWER In developing a coding compliance program, which of the following would not be ordinarily be included as participants in coding education. 30 days - CORRECT ANSWER Adding of accounts is the practice of counting the days, generally in increments, from the time a bill had been sent to the payor to the current day. What is the standard increment in days, that most healthcare entities use for the aging of accounts Medicare audit contractor - CORRECT ANSWER MAC Medicare recovery audit contractor - CORRECT ANSWER RAC Quality improvement organization - CORRECT ANSWER QIO MAC - CORRECT ANSWER Medicare audit that reviews prepayment and postpayment, automated and complex types of reviews to prevent future improper payment RAC - CORRECT ANSWER Medicare audit that reviews postpayment, automated and complex review to detect and correct past improper payments. QIO - CORRECT ANSWER Audit that reviews inpatient hotspots claims to prevent improper payment through DRG upcoming. MAC, RAC, QIO - CORRECT ANSWER Which entities have a role in the various Medicare Improper Payment Review processes. Revenue Cycle Management - CORRECT ANSWER The supervision off all administrative and clinical functions that contribute to bff the capture, management, and collecting of patient service revenue. Contingent accreditation - CORRECT ANSWER One of the JC's 5 accreditation decision categories. It is when an organization fails to resolve the requirements of an Accreditation with a follow up survey. Although organization that receive this accreditation may also, they must also remedy the noncompliance to b the satisfaction of the Commission and, inn most cases, are subject to a follow up survey in 30 days. Claim from - CORRECT ANSWER Most facilities begin counting data in accounts receivable at what time? Focus audit - CORRECT ANSWER This type of audit is necessary for deeper understanding of patterns of errors or change in high risk areas or other areas of specific concern. Claim - CORRECT ANSWER The physician's office sent a request for payment to Able insurance company. The term used in the healthcare industry for request for payment is... Environmental assessment - CORRECT ANSWER The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called... Permanent variance - CORRECT ANSWER Financial term that refers to the difference between the budgeted amount and other the actual amount of a line item that is not expected to reverse itself during a subsequent period Fixed cost - CORRECT ANSWER Financial term that refers to business costs, such as rent, that is are constant whatever the quantity of goods or services produced. Flexible cost - CORRECT ANSWER Personal finance term that refers to costs that are easily changed, reduced or eliminated. Ex. Money spent on entertainment or clothing. Temporary variance - CORRECT ANSWER Allows employers short term relief from a standard when v they can't comply with belt b published OSHA requirements by the prescribed effective date. Ground rules - CORRECT ANSWER In order to expedite basic performance improvement tank functioning, the team should... Strategic plan - CORRECT ANSWER A formalized road mask the reactors hire the company edited the chosen strategy. It does or where an organization is going over the next 3-5 years and how to its going to get there. HIM professionals can use strategy to shape and influence change in their department and organization. employee assistance programs - CORRECT ANSWER Outpatient programs designed to provide employees with immediate access to psychological counseling on a limited basis that may be provided on site or through local providers. Ergonomics - CORRECT ANSWER A discipline that had helped redefine the employee workspace with consideration for comfort and safety. Work distribution chart - CORRECT ANSWER The health information services department at anywhere hospital had identified problems with its work processes. To much time outs spent on unimportant tasks, there it's duplication of effort, and task assignment is uneven in quality and volume employees. The manager has each employee complete a form identifying the amount of time spent each day on various tasks. This tool is called.. Scope crop - CORRECT ANSWER In project management, this refers to changes ,continuous of uncontrolled growth in a project's score, at any point after the project behind. This occurs when the project's snow isn't clearly defined, documented, it's controlled. It is generally considered harmful. Video conferencing - CORRECT ANSWER A distance learning method in which groups of employees in multiple classroom locations may listen to and see the material presented at the same time via satellite or telephone it's called... Public health - CORRECT ANSWER Releasing accurate information about patient's with communicable diseases, such as AIDS or a venereal disease, and assisting in the complexities of information management in the context of bioterrorism and the threat or reality of global diseases, such as small pox or avian flu, are ethical responsibilities of the HIM professional in the interest of _____ _____. Emotional intelligence - CORRECT ANSWER Research on ______ ______ shows that a combination of feelings and rationality make managers more successful. [Show Less]
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RHIA Practice Exam Questions Domain 1 with Verified Answers,100% CORRECT
RHIA Practice Exam Questions Domain 1 with Verified Answers A method of documenting nurses' progress notes by recording only abnormal or unusual finding... [Show More] s or deviations from the prescribed plan of care is called: a. Problem-oriented progress notes b. Charting by exception c. Consultative notations d. Open charting - CORRECT ANSWER Charting by exception 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? a. Data accuracy b. Data consistency c. Data accessibility d. Data comprehensiveness - CORRECT ANSWER Data consistency Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data: a. Research b. Reference c. Coded d. Demographic - CORRECT ANSWER Coded Which of the following is an acceptable means of authenticating a record entry: a. The physician's assistant signs for the physician b. The HIM clerk stamps entries with the physician's signature stamp c. The charge nurse signs the physician name d. The physician personally signs the entry - CORRECT ANSWER The physician personally signs the entry All documentation entered in the health record relating to the patients diagnosis and treatment are considered this type of data: a. Clinical b. Financial c. Identification d. Secondary - CORRECT ANSWER Clinical In a long term care setting, these are problem-oriented frameworks for additional patient based on problem identification items (triggered conditions): a. Resident Assessment Protocols (RAPs) b. Resident Assessment Instrument (RAI) c. Utilization Guidelines (UG) d. Minimum Data Set (MDS) - CORRECT ANSWER Resident Assessment Protocols (RAPs) Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a: a. Case-mix index b. Master patient index c. Health record matrix d. Retention program - CORRECT ANSWER retention program What is the principal function of health records? a. Determine the appropriate function of health records b. Serve as the repository of clinical documentation relevant to the care of individual patients c. Provide information for performance improvement activities d. Support billing and reimbursement processes - CORRECT ANSWER Serve as the repository of clinical documentation relevant to the care of individual patients What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records? a. Administrative information b. Demographic information c. Progress notes d. Uniform data sets - CORRECT ANSWER Uniform data sets 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: a. Case-mix index b Master patient index c. Health record matrix d. Retention schedule - CORRECT ANSWER Health record matrix Which of the following materials are required elements in an emergency care record? a. Patient's instructions at discharge & a complete medical history b. Time & means of the patient's arrival, treatment rendered, and instructions at discharge c. Time & means of the patient's arrival, patients complete medical history, and instructions at discharge. d. Treatment rendered, instructions at discharge, and the patient's complete medical history - CORRECT ANSWER Time & mean of the patient's arrival, treatment rendered, and instructions at discharge Charting by exception - CORRECT ANSWER a method of documenting only abnormal or unusual findings or deviations from the prescribed plan of care. *Purpose of charting by exception is to reduce repetitive recordkeeping and documentation of normal events. What is coded data? - CORRECT ANSWER data that is translated into standard nomenclature(the devising or choosing of names for things, especially in a science or other discipline) of classification so that it may be aggregated, analyzed and compared. What is a resident assessment protocols (RAPs)? - CORRECT ANSWER forms a critical link to decisions about care planning and provide guidance on how to synthesize assessment info w/in a comprehensive assessment. *RAPs guidelines help facility staff evaluate triggered conditions. *Triggers target conditions for additional assessment and review, as warranted by Minimum Data Set(MDS) item responses. Once a legal health record(LHR) is defined, its best practice is to create a: - CORRECT ANSWER health record matrix because it identifies and tracks the physical location of each paper document and the source of each electronic document that consists in the LHR. In a relational data base, which of the following is an example of many to many relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to hospital records d. Primary care physician to patients - CORRECT ANSWER Patients to consulting physicians What is a relational database? - CORRECT ANSWER A group of database tables that is connected or linked by a defined relationship that ties the information together. In ICD-10-PCS, what value is used if there is a character that does not apply to a given code? a. X b. - c. 0 d. Z - CORRECT ANSWER Z Which is considered a unique identifier in the relational database patient table? a. Patient last name b. Patient last name & first name c. Patient date of birth d. Patient number - CORRECT ANSWER Patient number Which of the following is used by a long term facility to GATHER info about SPECIFIC health status factors and includes info about specific risk factors in the resident's care? a. Case management b. Minimum Data Set c. Outcomes and assessment information set d. Core measure abstracting - CORRECT ANSWER Minimum Data Set minimum data set - CORRECT ANSWER a standard established by health care institutions that specifies the information that must be collected from every patient Dr. Collins admitted Ms.Smith to University Hospital. Blue cross insurance will pay Ms.Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Ms.Smith? a. Ms.Smith b. Blue cross c. University Hospital d. Dr. Collins - CORRECT ANSWER University Hospital Documenting the full depth and breadth of data use in a healthcare entity requires: a. Identifying all of the data consumers b. Identifying the needs of data consumers c. Understanding all of the functionality requirements d. Performing a gap analysis - CORRECT ANSWER Identifying the needs of data consumers The most recognizable component of the problem-oriented health record is: a. The problem list as an index b. The initial plan c. The SOAP form of progress notes d. The database - CORRECT ANSWER The SOAP form of progress notes A 45 year old women is admitted for blood loss anemia due to dysfunctional uterine bleeding. How would you code? D25.9 Leiomyoma of uterus, unspecified D50.0 Iron deficiency anemia secondary to blood loss (chronic) D62 Acute posthemorrhagic anemia N93.8 Other specified abnormal uterine and vaginal bleeding a. D50.0, N93.8 b. D62, N93.8 c. N93.8, D50.0 d. D50.0, D25.9 - CORRECT ANSWER N93.8, D50.0 (always code due to/secondary condition AFTER the primary) The insured party's member identification number is an example of this type of data: a. Demographic data b. Clinical data c. Certification data d. Financial data - CORRECT ANSWER Financial data What is the data model that is most widely used to illustrate a relational database structure? a. Entity-relationship diagram (ERD) b. Object model c. Relational model d. Unified medical language system (UMLS) - CORRECT ANSWER Entity-relationship diagram ICD 10-PCS have how many characters? - CORRECT ANSWER 7 characters, and character can't be left blank. *If value does not exist for a given character, the "Z" is used. What are ICD-10-PCS codes used report? - CORRECT ANSWER used only for inpatient, hospital settings The MDS is a component of - CORRECT ANSWER Resident assessment instrument(RAI) and used to collect info about the residents risk factors and to plan ongoing care and treatment in the long term care facility. SOAP(Subjective, Objective, Assessment, and Plan) - CORRECT ANSWER Part of the POMR(problem oriented medical records). Soap notes are intended to improve quality and continuity of client services by enhancing communication among healthcare professionals Financial data - CORRECT ANSWER include details about the patient's occupation, employer, and insurance coverage. Entity relationship modeling - CORRECT ANSWER type of conceptual modeling. - modules that are abstract and encourage high-level problem structuring; *help establish a common ground for communication b/w users and developers. *ERD was developed to depict relational database structures. many-to-many relationship - CORRECT ANSWER In databases, a relationship in which one record in Table A can relate to many matching records in Table B, and vice versa. ex: patient to consulting physician. instance of patient there could be many instances of consulting physician because patient can be seen by more than one consulting physician, and for instance where one consulting physician there could be many patients. Root operation -division - CORRECT ANSWER cutting into a body part w/out drawing fluids or gases from the body part in order to sperate or transect a body part. What is a straight numerical filing system? - CORRECT ANSWER refers to the filing of records in exact ascending order according to medical records number. *records are filed in the following order: 12-23-75 12-34-29 12-35-71 13-42-14 14-32-79 If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? 2.4% 3.5% 4.6% 5.1% - CORRECT ANSWER 2.4% (3,545 x 100) divided by 15,000 = 2.36% = 2.4% Which of the following is NOT an advantage of a centralized filing system? a. There is less transportation time and effort when a facility operates from several sites. b. There is less duplication of effort to create, maintain, and store records. c. Record control and security are easier to maintain. d. There is decreased cost in space and equipment. - CORRECT ANSWER There is less transportation time and effort when a facility operates from several sites. In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26? A. 00-06-26 B. 02-06-26 C. 03-06-26 D. 99-99-25 - CORRECT ANSWER 00-06-26 Color coding of record folders is used to assist in the control of A. record tracking. B. loose reports. C. record completion. D. misfiles. - CORRECT ANSWER misfiles A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? A. 6 B. 8 C. 10 D. 12 - CORRECT ANSWER 12 200 units x 6 shelves per unit = 1,200 shelves total1, 200 shelves divided by 100 primary numbers (00-99) = 12 shelves per primary number Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital? A. terminal digit B. unit C. straight numeric D. serial unit - CORRECT ANSWER straight numeric *key word: consecutive Out of 2,543 records requested from the HIM Department, 2,375 were located. What is the filing accuracy rate? A. 6.61% B. 75.33% C. 89.01% D. 93.39% - CORRECT ANSWER 93.39% (2,375 records retrieved from proper locations x 100) divided by 2,543 records requested = 93.39% filing accuracy) Which set of records filed consecutively on a shelf displays terminal digit filing order? A. 00-79-99, 00-79-01, 99-78-99 B. 57-78-00, 57-78-01, 56-78-99 C. 99-05-26, 01-06-26, 49-04-02 D. 55-55-55, 33-33-33, 44-44-44 - CORRECT ANSWER 57-78-00, 57-78-01, 56-78-99 In the master patient index, which is filed by last name, Jill Thomas-Jones would be A. J-I-L-L-T-H-O-M-A-S-J-O-N-E-S B. T-H-O-M-A-S-J-O-N-E-S,J-I-L-L C. T-H-O-M-A-S,J-I-L-L-J-O-N-E-S D. J-O-N-E-S,J-I-L-L-T-H-O-M-A-S - CORRECT ANSWER T-H-O-M-A-S-J-O-N-E-S,J-I-L-L According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30? A. 99-98-30 B. 00-00-31 C. 01-00-31 D. 99-99-31 - CORRECT ANSWER 00-00-3 How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals require that patient health records be retained for at least ________ years unless a longer period is required by state or local laws. A. 3 B. 5 C. 7 D. 10 - CORRECT ANSWER 5????????? ***do reasearch Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be A. 5 years. B. 7 years. C. 10 years. D. either 5 or 7 years, as determined by the facility. - CORRECT ANSWER 7 Which of the following technologies works best with automated record-tracking systems to speed the data entry process? A. discharge lists B. bar codes C. compressible filing units D. computerized chart-out slips - CORRECT ANSWER bar codes A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased? A. 11 B. 12 C. 13 D. 14 - CORRECT ANSWER 14 2,540 + 400 = 2,940 inches needed 36 x 6 = 216 inches per unit 2,940 (inches needed) divided by 216 (inches per unit) = 13.61 shelves You must buy 14 units because you cannot purchase a 0.14 filing shelf. Microfilmed records are considered A. inadmissible evidence. B. never admissible as hearsay evidence. C. acceptable as courtroom evidence. D. not admissible as secondary evidence. - CORRECT ANSWER acceptable as courtroom evidence. [Show Less]
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RHIA Exam 393 Questions with Verified Answers,100% CORRECT
RHIA Exam 393 Questions with Verified Answers Where can you find guidelines for the retention and destruction of healthcare information? a. Institute... [Show More] of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards This functionality can result in confusion from incessant repetition of irrelevant clinical data. a. Change b. Amendment c. Copy and paste d. Deletion - CORRECT ANSWER c. Copy and paste Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons? a. Physician b. Master patient c. Procedure d. Disease and operation - CORRECT ANSWER a. Physician A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? a. Outpatient b. Emergency room c. Physician office d. Inpatient - CORRECT ANSWER d. Inpatient Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professional - CORRECT ANSWER c. Provider Which of the following represents data flow for a hospital inpatient admission? a. Registration > diagnostic and procedure codes assigned > services performed > charges recorded b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned c. Services performed > charges recorded > registration > diagnostic and procedure codes assigned d. Diagnostic and procedure codes assigned > registration > services performed > charges recorded - CORRECT ANSWER b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals? a. Ensuring the record is legible b. Identifying deficiencies early so they can be corrected c. Verifying that health professionals are providing appropriate care d. Checking to ensure bills are correct - CORRECT ANSWER b. Identifying deficiencies early so they can be corrected The process of providing proof of the authorship of health record documentation is called: a. Identification b. Standardization of data capture c. Standardization of abbreviations d. Authentication - CORRECT ANSWER d. Authentication Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record? a. Document name, media type, source system, electronic storage start date, stop printing start date b. Document name, media type c. Document name, medical record number, source system d. Document name, source system - CORRECT ANSWER a. Document name, media type, source system, electronic storage start date, stop printing start date According to the UHDDS definition, ethnicity should be recorded on a patient record as: a. Race of mother b. Race of father c. Hispanic, non-Hispanic d. Free-text descriptor as reported by patient - CORRECT ANSWER c. Hispanic, non-Hispanic Which of the following is a graphical display of the relationships between tables in a database? a. RDMS b. SQL c. ERD d. SAS - CORRECT ANSWER c. ERD The purpose of the data dictionary is to ________ definitions and ensure consistency of use. a. Identify b. Standardize c. Create d. Organize - CORRECT ANSWER b. Standardize It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. a. Training sessions b. Policies and procedures c. Verbally communicated instructions d. A supervisory committee - CORRECT ANSWER b. Policies and procedures Quality has several components, including appropriateness, technical excellence, ________, and acceptability. a. Accuracy of diagnosis b. Continuous improvement c. Connectivity d. Accessibility - CORRECT ANSWER d. Accessibility Assign the correct CPT code for the following procedure: Patient is admitted to move the skin pocket for their pacemaker. a. 33223, Relocation of skin pocket for implantable defibrillator b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) c. 33212, Insertion of pacemaker pulse generator only; with existing single lead d. 33222, Relocation of skin pocket for pacemaker - CORRECT ANSWER d. 33222, Relocation of skin pocket for pacemaker Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient's EHR. These different information systems that feed information into the EHR are known as: a. Interoperability b. Source systems c. Continuity of care records d. Clinical decision support systems - CORRECT ANSWER b. Source systems Of the following, what is the most likely to happen to the health records of a physician's patient when that physician leaves an office practice? a. It will be sent to the state department of health. b. It will be sent to outside storage. c. It will be destroyed. d. It will be retained by the practice. - CORRECT ANSWER d. It will be retained by the practice. Reviewing a health record for missing signatures and medical reports is called: a. Analysis b. Coding c. Assembly d. Indexing - CORRECT ANSWER a. Analysis A barrier to effective computer-assisted coding is the: a. Resistance of physicians b. Resistance of HIM professionals c. Poor quality of documentation d. Reduction of consistency without human coders - CORRECT ANSWER c. Poor quality of documentation To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following? a. Core measure b. Resident Assessment Instrument c. Precertification d. Record of transfer - CORRECT ANSWER b. Resident Assessment Instrument What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or is otherwise dying and unable to speak for themselves? a. Durable power of attorney b. Living consent form c. Informed consent d. Advance directive - CORRECT ANSWER d. Advance directive A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? I97.191 Other postprocedural cardiac functional disturbances following other surgery K43.9 Ventral hernia without obstruction or gangrene R00.1 Bradycardia, unspecified Z53.09 Procedure and treatment not carried out because of other contraindication SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralRepairAbdominalWallOpenNo DeviceNo Qualifier 0WQF0ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralInspectionPeritonealCavityOpenNo DeviceNo Qualifier 0WJG0ZZ a. K43.9, R00.1, Z53.09, 0WJG0ZZ b. K43.9, I97.191, R00.1, 0WJG0ZZ c. K43.9, 0WQF0ZZ d. K43.9, Z53.09, 0WQF0ZZ - CORRECT ANSWER a. K43.9, R00.1, Z53.09, 0WJG0ZZ A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension - CORRECT ANSWER a. Catheter-associated urinary tract infection A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n): a. Diabetes registry b. Cancer registry c. Immunization registry d. Trauma registry - CORRECT ANSWER c. Immunization registry A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of? a. Data collection b. Edit check c. Data reliability d. Hot spot - CORRECT ANSWER b. Edit check Which of the following are considered dimensions of data quality? a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency - CORRECT ANSWER a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency The statement "All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88" represents a possible case definition for what type of registry? a. Birth defect registry b. Cancer registry c. Diabetes registry d. Trauma registry - CORRECT ANSWER d. Trauma registry Mrs. Bolton is an angry patient who resents her physician "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is: a. Mean b. Noncompliant and hostile toward staff c. Belligerent and out of line d. A pain in the neck - CORRECT ANSWER b. Noncompliant and hostile toward staff When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source - CORRECT ANSWER a. Secondary data source Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source - CORRECT ANSWER c. Primary data source A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus A41.89 Other specified sepsis A41.9 Sepsis, unspecified organism B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding R10.9 Unspecified abdominal pain a. A41.89, K57.32, R10.9 b. A41.01, K57.32 c. A41.89, K57.32, B95.61 d. A41.9, K57.32 - CORRECT ANSWER b. A41.01, K57.32 A patient had a radical resection of soft tissue sarcoma of the left thigh. In ICD-10-PCS what would the root operation be for this procedure? a. Excision b. Repair c. Resection d. Destruction - CORRECT ANSWER a. Excision The data that describe other data in order to facilitate data quality are found in the: a. Data definition language b. Data dictionary c. Data standards d. Data definition - CORRECT ANSWER b. Data dictionary A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code for professional fee reporting? a. -79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period b. -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service c. -59, Distinct procedural service d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period - CORRECT ANSWER d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period A computer software program that supports a coder in assigning correct codes is called a(n): a. Encoder b. Grouper c. Automated coder d. Decision support system - CORRECT ANSWER a. Encoder The name of the government agency that has led the development of basic data sets for health records and computer databases is: a. The Centers for Medicare and Medicaid Services b. The National Committee on Vital and Health Statistics c. The American National Standards Institute d. The National Institute of Health - CORRECT ANSWER b. The National Committee on Vital and Health Statistics A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR ________. a. maintenance plan b. management plan c. attribute plan d. strategic plan - CORRECT ANSWER a. maintenance plan An alteration of the health information by modification, correction, addition, or deletion is known as a(n): a. Change b. Amendment c. Copy and paste d. Deletion - CORRECT ANSWER b. Amendment A patient born with a neural tube defect would be included in which type of registry? a. Birth defects b. Cancer c. Diabetes d. Trauma - CORRECT ANSWER a. Birth defects The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called: a. Information asset management b. Information management c. Information governance d. Enterprise information management - CORRECT ANSWER c. Information governance Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to: a. Have the administrator of the hospital complete them b. Have the charge nurse on the respective nursing units complete them c. Ask the chief of staff to complete them d. File the incomplete records with a notation about the physician's death - CORRECT ANSWER d. File the incomplete records with a notation about the physician's death What is a primary purpose for documenting and maintaining health records? a. Effective communication among caregivers for continuity of care b. Substantiate claims for reimbursement c. Provide evidence for malpractice lawsuits d. Contribute to medical science - CORRECT ANSWER a. Effective communication among caregivers for continuity of care The inpatient data set incorporated into federal law and required for Medicare reporting is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-term Care d. Health Plan Employer Data and Information Set - CORRECT ANSWER b. Uniform Hospital Discharge Data Set A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables? a. One-to-one b. One-to-many c. Many-to-many d. One-to-two - CORRECT ANSWER b. One-to-many The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of: a. Assisting coders to read physician handwriting b. Preventing potential medication errors due to misinterpretation c. Making terminology consistent in preparation for electronic records d. Identifying physicians who are dispensing large quantities of drugs - CORRECT ANSWER b. Preventing potential medication errors due to misinterpretation Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete - CORRECT ANSWER b. It provides greater detail A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: a. Spreadsheet b. Database c. File d. Data table - CORRECT ANSWER b. Database Regardless of the healthcare setting, accreditation and regulatory standards require a separate healthcare record for each: a. Family b. Individual patient c. Encounter with the facility d. Day of treatment - CORRECT ANSWER b. Individual patient A patient has HIV with disseminated candidiasis. What is the correct code assignment? B20 Human immunodeficiency virus [HIV] disease B37.0 Candidal stomatitis Oral thrush B37.7 Candidal sepsis Disseminated candidiasis Systemic candidiasis B37.89 Other sites of candidiasisCandidal osteomyelitis a. B20, B37.0 b. B37.7, B20 c. B20, B37.7 d. B20, B37.89, B37.7 - CORRECT ANSWER c. B20, B37.7 In long-term care, the resident's comprehensive assessment is based on data collected in the: a. UHDDS b. OASIS c. MDS d. HEDIS - CORRECT ANSWER c. MDS Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and: a. AMA b. OIG c. CMS d. WHO - CORRECT ANSWER c. CMS What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)? a. Face sheet b. Care plan c. Diagnosis plan d. Flow sheet - CORRECT ANSWER b. Care plan Which of the following is an example of a 1:1 relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to clinics d. Patients to hospital beds - CORRECT ANSWER d. Patients to hospital beds What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? a. Core measures b. Enhanced discharge planning c. Data mining d. Clinical practice guidelines - CORRECT ANSWER d. Clinical practice guidelines Which document is used in the long-term care setting that is not used in the acute-care setting? a. Progress notes b. Monthly summary c. Physician consultations d. Physician orders - CORRECT ANSWER b. Monthly summary Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? a. Case definition b. Case finding c. Follow-up d. Reporting - CORRECT ANSWER b. Case finding Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? a. Unit secretary working on the unit where the patient is located b. Nurse working on the unit where the patient is located c. Health information director d. Admissions registrars - CORRECT ANSWER b. Nurse working on the unit where the patient is located While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the: a. Reason for admission b. Activities of daily living c. Discharge diagnosis d. Reason for encounter - CORRECT ANSWER d. Reason for encounter The legal health record for disclosure consists of: a. Any and all protected health information data collected or used by a healthcare entity when delivering care b. Only the protected health information requested by an attorney for a legal proceeding c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings d. All of the data and information included in the HIPAA Designated Record Set - CORRECT ANSWER c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called: a. Default records b. Delinquent records c. Loose records d. Suspended records - CORRECT ANSWER b. Delinquent records When a healthcare entity destroys health records after the acceptable retention period has been met, a certificate of destruction is created. How long must the healthcare entity maintain the certificate of destruction? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER d. Permanently A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary - CORRECT ANSWER d. Data dictionary What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met? a. Qualitative analysis b. Legal record review c. Utilization analysis d. Ongoing record review - CORRECT ANSWER a. Qualitative analysis A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.8 Type 1 diabetes mellitus with unspecified complications I96 Gangrene, not elsewhere classified a. E08.52, I96 b. E10.52, I96 c. E10.8 d. E10.52 - CORRECT ANSWER d. E10.52 How do healthcare providers use the administrative data they collect? a. For regulatory, operational, and financial purposes b. For statistical data purposes c. For electronic health record tracking purposes d. For continuity of patient care purposes - CORRECT ANSWER a. For regulatory, operational, and financial purposes Which of the following is not an appropriate method for destroying paper-based health records? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual - CORRECT ANSWER a. Digital Which of the following is the appropriate method for destroying electronic data? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing Personal information about patients such as their names, ages, and addresses is considered what type of information? a. Clinical b. Administrative c. Operational d. Accreditation - CORRECT ANSWER b. Administrative Which of the following keywords precedes the listing of variables to be returned from an SQL query? a. SELECT b. SET c. DATA d. BY - CORRECT ANSWER a. SELECT Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? a. Uniform Hospital Discharge Data Set b. Data Elements for Emergency Department Systems c. Uniform Ambulatory Care Data Set d. Essential Medical Data Set - CORRECT ANSWER c. Uniform Ambulatory Care Data Set Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. a. 54401, Insertion of penile prosthesis; inflatable (self-contained) b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir c. 54440, Plastic operation of penis for injury d. 54400, Insertion of penile prosthesis, non-inflatable (semi-rigid) - CORRECT ANSWER a. 54401, Insertion of penile prosthesis; inflatable (self-contained) What tool is used to sort data in a variety of ways to assist in the study of certain data elements? a. Registries b. Indexes c. Clinical trials d. Statistical reports - CORRECT ANSWER b. Indexes Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived - CORRECT ANSWER d. Derived Data content standards are used to: a. Share data in the same way the users interpret data b. Share data is a unique way c. Share data between disparate systems d. Modify data - CORRECT ANSWER a. Share data in the same way the users interpret data What is the first consideration in determining how long records must be retained? a. The amount of space allocated for record filing b. The number of records c. The most stringent law or regulation in the state d. The cost of filing space - CORRECT ANSWER c. The most stringent law or regulation in the state Which of the following is a concept designed to help standardize clinical content for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED - CORRECT ANSWER a. Continuity of care record A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n): a. Implementation plan b. Information technology plan c. Migration path d. Transition strategy - CORRECT ANSWER c. Migration path Identify the level in the data model that describes how the data is stored within the database: a. Conceptual data model b. Physical data model c. Logical data model d. Data manipulation language - CORRECT ANSWER b. Physical data model According to the Medicare Conditions of Participation, how long must health records be retained? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER b. Five years Which of the following data management domains would be responsible for establishing standards for data retention and storage? a. Data architecture management b. Metadata management c. Data life cycle management d. Master data management - CORRECT ANSWER c. Data life cycle management Ensuring that only the most recent report is available for viewing is known as: a. Documentation integrity b. Authorship c. Validation d. Version control - CORRECT ANSWER d. Version control Which of the following makes the indexing of scanned health records more efficient by entering metadata automatically? a. Barcodes b. Backscanning c. OCE d. CPOE - CORRECT ANSWER a. Barcodes Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32405, Biopsy, lung or mediastinum, percutaneous needle b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) - CORRECT ANSWER b. 37609, Ligation or biopsy, temporal artery The practices or methods that defend against charges questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following? a. Authorship b. Validation c. Integrity d. Identification - CORRECT ANSWER a. Authorship [Show Less]
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RHIA Domain 1Exam 116 Questions with Verified Answers,100% CORRECT
RHIA Domain 1Exam 116 Questions with Verified Answers Primary responsibility of coder - CORRECT ANSWER Ensure quality of coded data Responsible for q... [Show More] uality and completion of discharge summary - CORRECT ANSWER Attending Physician Data set for px that does not require an overnight stay - CORRECT ANSWER Uniform Ambulatory Care Data Set Records not completed within designated timeframe - CORRECT ANSWER Delinquent Records Provide information not easily determined from looking at records - CORRECT ANSWER Secondary Data Sources Decision-making and authority over data-related matters - CORRECT ANSWER Data Governance Number assigned according to number of entry into a registry each year - CORRECT ANSWER Accession Number Includes information about trauma cases - CORRECT ANSWER DEEDS Problem-oriented frameworks for assessment after problems have been identified - CORRECT ANSWER Resident Assessment Protocols Snapshot of patient Disease processes Critical paths Clinical pathways - CORRECT ANSWER Care Plan Dimensions of Data Quality - CORRECT ANSWER Relevancy Granularity Timeliness Currency Accuracy Precision Consistency Barrier to computer-assisted coding - CORRECT ANSWER Poor quality of documentation Graphical display of relationships between tables in a database - CORRECT ANSWER ERD Accreditation and regulatory standards require a different record for each - CORRECT ANSWER patient Component of Resident Assessment Instrument - CORRECT ANSWER A standard minimum data set Documenting when and how a record was destroyed - CORRECT ANSWER Certificate of Destruction Before list of elements to be returned from a SQL query - CORRECT ANSWER SELECT Documenting depth and breadth of data in entity requires - CORRECT ANSWER Identifying the needs of all data consumers Document imaging is part of... - CORRECT ANSWER Record creation, capture, or receipt After ERD is implemented, an entity becomes... - CORRECT ANSWER Table Most important aspect of determining record retention - CORRECT ANSWER Statute of Limitations Record that follows a patient's care over time - CORRECT ANSWER Longitudinal Record Data collected on large populations and stored in databases - CORRECT ANSWER Aggregate Data Accessing and reviewing the work of colleagues in the same profession - CORRECT ANSWER Peer Review Mandating display format (ex: xxx-xx-xxxx) - CORRECT ANSWER Mask Contains diagnosis and summary of care already given - CORRECT ANSWER Transfer Record Data related to a patient's diagnosis and treatment - CORRECT ANSWER Clinical Discrepancies between two coders compromise - CORRECT ANSWER Reliability Discharge summary must be completed within - CORRECT ANSWER 30 days Discharge summary for transfers must be completed within - CORRECT ANSWER 24 hours Discharge summaries are not requires for LOS less than - CORRECT ANSWER 48 hours Example of M:M relationship - CORRECT ANSWER Patient to Consulting Physicians Chief Complaint - CORRECT ANSWER Reason for presentation Errors in medical record should not be - CORRECT ANSWER Obliterated Coded - CORRECT ANSWER Grouped into meaningful categories by classification system Retention Program - CORRECT ANSWER Inventory of records Format Location Preservation Period Principal Function of Health Records - CORRECT ANSWER Repository of clinical documentation relevant to patient care Common form of problem-oriented format - CORRECT ANSWER SOAP form of progress notes ER Record - CORRECT ANSWER Time and means of arrival Treatment record Discharge instructions Who owns records? - CORRECT ANSWER Healthcare org Abbreviations - CORRECT ANSWER Should only have one meaning ICD-10-PCS Null Character - CORRECT ANSWER Z Same order in any location - CORRECT ANSWER Universal H&P Exam - CORRECT ANSWER Must be placed in the record before a procedure is performed Compromising Authorship Integrity - CORRECT ANSWER Borrowing records from other sources Displaying past documentation as present Occlusion - CORRECT ANSWER Restricting blood flow Backlog in transcription - CORRECT ANSWER Write a detailed note about procedure Provider examines patient at request of another provider - CORRECT ANSWER Consultation Report In the absence of data dictionary - CORRECT ANSWER Establish data dictionary policy with associated standards Destruction of Paper Records - CORRECT ANSWER Shredding, Pulping, Pulverizing No degaussing No rounding up doses - CORRECT ANSWER Precision Paper records do not have - CORRECT ANSWER Built-in control mechanism No new H&P - CORRECT ANSWER Readmitted within 30 days for same condition Principal Procedure - CORRECT ANSWER Definitive treatment of main condition Vocabulary Standards - CORRECT ANSWER Standardizing medical terminology Analog Data - CORRECT ANSWER Photographic, Film Autoauthentication - CORRECT ANSWER Provider signs statement at all records are improved unless corrections made in time frame Not allowed HIM should check for record retention - CORRECT ANSWER State and federal law Continuity of Care Record - CORRECT ANSWER ASTM, for transitions between settings Not coded here - CORRECT ANSWER Excludes1 Migration Plan - CORRECT ANSWER Steps and process for adopting system Verbal Orders - CORRECT ANSWER Person receiving should read back to ensure accuracy Analysis - CORRECT ANSWER Translating data to info Database - CORRECT ANSWER Organized collection of data stored electronically Centralized - CORRECT ANSWER All patient stored in one system Abstracting - CORRECT ANSWER Compiling info from record into data set HEDIS - CORRECT ANSWER Insurance data set Validity - CORRECT ANSWER Error detection Ancillary - CORRECT ANSWER Biomedical research Diabetes - CORRECT ANSWER Only code diabetes with manifestation If biopsy and -ectomy - CORRECT ANSWER Code both Quantitative Analysis - CORRECT ANSWER identifying deficiencies LOINC - CORRECT ANSWER Identifying test results Auditing Integrity - CORRECT ANSWER Not knowing when modified CMS - CORRECT ANSWER Sits on ICD council with NCHS Inpatient - CORRECT ANSWER Code as if it exists Provider - CORRECT ANSWER Responsible for quality of documentation Authentication - CORRECT ANSWER Proof of authorship Disaster Recovery - CORRECT ANSWER In time of disaster, how do you document CMS Record Retention - CORRECT ANSWER 5 years CPT Codes - CORRECT ANSWER Pick one with or for optiond Degaussing - CORRECT ANSWER Destroying electronic data Information Governance - CORRECT ANSWER Org structures, policies, and procedures with info Standardized Data Sets - CORRECT ANSWER Data can be compared nationally Physician Index - CORRECT ANSWER Compare number and quality of patients with operation Source-Oriented - CORRECT ANSWER Traditional paper format from a hospital patient Hybrid Health Records - CORRECT ANSWER Records consisting of multiple electronic systems First Deliverable of LHR Project - CORRECT ANSWER List of LHR stakeholders Nonrepudiation - CORRECT ANSWER Practices to defend against charges questioning integrity Object-Oriented Database - CORRECT ANSWER Contains data and relationships in a single structure If physician dies - CORRECT ANSWER File records as incomplete with notice about death NCVHS - CORRECT ANSWER Developing basic data sets Stillborn - CORRECT ANSWER Use mother's record Important to enter data into database - CORRECT ANSWER To reveal patterns Accreditation standards keep - CORRECT ANSWER Retention and Destruction guidelines Index - CORRECT ANSWER Sorts data to assist in studying Maintenance Plan - CORRECT ANSWER Regular review of polocies and procedires Principal Dx - CORRECT ANSWER Not primary Standard Deviation - CORRECT ANSWER Sq Root of Variance Disruption in Unit Numbering - CORRECT ANSWER Continuity of care issues Discharge Instructions - CORRECT ANSWER Med, Diet, Follow-Up, Condition Dialysis - CORRECT ANSWER Peritonial= abd, Hemo = artificial CPOE - CORRECT ANSWER Reduces med errors HHC - CORRECT ANSWER Suitability of residence Physician Quality Measures - CORRECT ANSWER Assessment and Screening Courtesy - CORRECT ANSWER Occasional admitting Mortician - CORRECT ANSWER Files death certificates E/M - CORRECT ANSWER MDM Exam History HHC Components - CORRECT ANSWER Equip Discharge/Term Living Arrangement If you don't agree with dr. - CORRECT ANSWER Can find another Credentials Committee - CORRECT ANSWER Review credentials, behavior, and med staff appt -otomy - CORRECT ANSWER Open OP focuses on - CORRECT ANSWER Reason for encounter Integrated - CORRECT ANSWER All together in chronological order Extirpation - CORRECT ANSWER Pulling out Do Not Use Abbreviations - CORRECT ANSWER Preventing med errors [Show Less]
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RHIA EXAM PREP DOMAIN II|83 Questions with Verified Answers,100% CORRECT
RHIA EXAM PREP DOMAIN II|83 Questions with Verified Answers Master or Enterprise patient index - CORRECT ANSWER is critical to identifying patients and ... [Show More] ensuring proper record linkage The health record consist of - CORRECT ANSWER handwritten notes, transcribed reports, electronic data, digital images Continuity of care - CORRECT ANSWER is improved by the sharing of patient information between providers Standards and regulations - CORRECT ANSWER have a great impact on what is documented in the health record The American College of Surgeons (ACS) - CORRECT ANSWER developed the minimum standards for hospitals in the early 20th century. The Joint Commission succeeded the ACS in standardization The health record - CORRECT ANSWER is the major source of information about any healthcare facility and is routinely surveyed to obtain knowledge about the facilities care process or performance. State Licensure - CORRECT ANSWER establishes requirements for patient records content, format, retention and use. Licensure is required for healthcare facilities to remain in operation. By laws and rules are - CORRECT ANSWER developed by the medical staff and approved by the (BOT) board of trustees or governing body in the facility. Longitudinal health record - CORRECT ANSWER contains various encounters, records from numerous health care delivery settings. It is valuable because it reduces medical errors, duplication of testing and repetition. It improves decision making for providers and care for the patients The medical record is - CORRECT ANSWER maintained in two broad areas Administrative and demographic and clinical data The legal health record - CORRECT ANSWER must identify the sources, medium, paper images, video, or audio, and location Meaningful use - CORRECT ANSWER functional and quality reporting criteria 3 subsystems of the United States legal system - CORRECT ANSWER Judicial, Regulatory, and Administrative Judicial legal system - CORRECT ANSWER allows a wronged party to seek retribution Regulatory legal system - CORRECT ANSWER regulates how an action is met of seeking retribution Administrative legal system - CORRECT ANSWER controls government administrative operations such as licensing, accrediting bodies, Medicare, Medicaid, and federal and state government programs Federal Register - CORRECT ANSWER publishes revisions to existing administrative rules for healthcare related information updated by MCOP and HIPAA Civil Law - CORRECT ANSWER most healthcare encounters fall into this category HIPAA privacy rule - CORRECT ANSWER criminal provisions only have felony crimes Torts - CORRECT ANSWER harm through wrongful conduct and seeks compensation and to discourage the wrongdoer from continuing wrongful acts Three categories of tort liability exist - CORRECT ANSWER negligence, intentional torts, and products liability Accreditation Agencies - CORRECT ANSWER are offered through non-governmental agencies Hospital standards - CORRECT ANSWER are developed by Joint Commission Accreditation - CORRECT ANSWER is voluntary but can be a requirement for some licensures Joint Commission focus - CORRECT ANSWER is not legally mandated. the focus is on the entire hospital Medicare Condition of Participation - CORRECT ANSWER sets standards for hospitals and are government regulations 1965 Griswold v. Connecticut case - CORRECT ANSWER recognized the need/right to privacy California - CORRECT ANSWER recognized the right to privacy through its states constitution. 1996 HIPAA enacted by Congress - CORRECT ANSWER addresses fraud and abuse in the healthcare system The controlled substance act - CORRECT ANSWER controls the use of narcotics, depressants and stimulants. drugs are classified into schedules The Federal Food, Drug and Cosmetic Act - CORRECT ANSWER includes medical device amendments of 1976 and covers products, most equipments and supplies Retention periods for the health record - CORRECT ANSWER is determined by federal and state laws HIPAA - CORRECT ANSWER does not provide access to oral information, psychotherapy notes, information compiled for civil, criminal or administrative action Violation of HIPAA prior to 2/18/2009 - CORRECT ANSWER $100 per violation Violation of HIPAA after 2/18/2009 and (CE) covered entity did not know - CORRECT ANSWER not less than $100 or more than 50,000/ violation not to exceed 1.5 million during a calendar year HIPAA violation due to reasonable cause and not willful neglect - CORRECT ANSWER not less than $1,000 or more than $50,000/violation HIPAA violation due to willful neglect and corrected in a 30 day period - CORRECT ANSWER not less than 10,000 or more than 50,000/ per violation HIPAA violation due to wilfull neglect and not corrected - CORRECT ANSWER not less than $50,000/violation or more than 1.5 million / violation Beneficence - CORRECT ANSWER release of information to benefit the patient such as payment for a claim Non-maleficence - CORRECT ANSWER non-release of information to groups such as the media requesting information on a famous person Autonomy - CORRECT ANSWER ensures only the patient makes decisions regarding their health Justice - CORRECT ANSWER HIM applies rules fairly and consistently for all Implied Conscent - CORRECT ANSWER is giving in emergency situations where a patient lacks the capacity to communicate Privacy - CORRECT ANSWER is the right of a patient to control how much information is disclosed HIPAA defers - CORRECT ANSWER to state laws on issues regarding minors The Freedom of Information Act (FOIA) 1996 - CORRECT ANSWER is a federal law that applies to only federal agencies such as the military. Access to the information is given without an authorization The Device and Media Controls Standards - CORRECT ANSWER require organization to develop policies and procedure for the final disposition The Device and Medical Controls four specifications - CORRECT ANSWER disposal, media reuse, accountability, and data backup NPP - CORRECT ANSWER the notice of privacy practices The Notice of Privacy Practices regarding CE - CORRECT ANSWER must include in their statement example of (TPO) treatment, payment, and healthcare operations other disclosures permitted without authorization and individual rights CE - CORRECT ANSWER Covered Entity DRS - CORRECT ANSWER designated record set The designated record set - CORRECT ANSWER is a group of records maintained by or for a covered entity that records billing, or maintains enrollment, payment, claims adjudication which may be used to make decisions about an individual How long does the Covered entity have to respond to a request for phi maintained offsite - CORRECT ANSWER 60 days The first fundamental strategy in reducing security threats - CORRECT ANSWER is establishing a security organization The Security Rule - CORRECT ANSWER outlines a set of regulations that include administrative, technical and physical safeguards intended to ensure confidentiality, integrity, and avalibility of EPHI. The Privacy Rule (HIPAA) - CORRECT ANSWER allows reasonable cost-based charges for labor, postage, and supplies involved in photocopying health information for the patient. Humans - CORRECT ANSWER are the most common threat to health information integrity Psychotherapy notes - CORRECT ANSWER patients aren't allowEd the rights to access their own notes according to HIPAA privacy rule Incident reports - CORRECT ANSWER are not considered part of the health record Competent adults - CORRECT ANSWER and those who created a living will when of sound mind, even though now incompetent, have the right to refuse treatment Healthcare Integrity & protection Data bank - CORRECT ANSWER was created to collect info on the legal actions both civil and criminal taken against licensed healthcare providers HIE - CORRECT ANSWER health information exchange NHIN - CORRECT ANSWER National Health Information Network Exchange HITECH - CORRECT ANSWER Health Information Technology for Economic and Clinical Health Act Health Information exchange - CORRECT ANSWER is the electronic movement of health information among organizations according to standards and protocol National Health Information Network Exchange - CORRECT ANSWER allows patients to receive the best coordinated care wherever a patient presents for care Stage 1 meaningful use - CORRECT ANSWER requires providers to test the exchange of HIM using a secure encrypted process Stage 2 meaningful use - CORRECT ANSWER requires a provider to transmit 10 percent of its summary of care documents during transitions of care or for the purposes of referral Health Information Technology for Economic and Clinical Health Act - CORRECT ANSWER properly trains the workforce to be meaningful users of the EHR Models of health information exchange - CORRECT ANSWER centralized, decentralized and hybrid Centralized HIE model - CORRECT ANSWER single db, returns quicker results, a question of who owns the data, changes require multiple transactions and may not update all at once Decentralized HIE model - CORRECT ANSWER db is maintained at each participant facility, no question of ownership of data The Hybrid HIE model - CORRECT ANSWER has both centralized and federated models The ultimate goal of an HIE - CORRECT ANSWER is to enhance the quality and safety of patient care Interoperability - CORRECT ANSWER allows different information systems and software applications to communicate and exchange data ONC - CORRECT ANSWER OFFICE OF THE NATIONAL COORDINATOR for HEALTH INFORMATION TECHNOLOGY The office of the national coordinator for Health Info Technology - CORRECT ANSWER is a presidential directive developed to implement a strategic plan to guide implementation of interoperable HIT Paper to EHR - CORRECT ANSWER include the upgrade from legacy data sets toward a more comprehensive core data set for continuity of care CCR - CORRECT ANSWER continuity of care record CCD - CORRECT ANSWER continuity of care document Continuity of care record /document - CORRECT ANSWER ensures the most relevant and timely health information can be sent electronically from one provider to another HIE security and privacy requires - CORRECT ANSWER the use of usernames, passwords ro security tokens such as public key infrastructure (PKI), digital certifications to access the system [Show Less]
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RHIA Exam Prep - Domain 1|31 Questions with Verified Answers,100% CORRECT
RHIA Exam Prep - Domain 1|31 Questions with Verified Answers Problem-Oriented Health Record - CORRECT ANSWER A patient record in which clinical problems... [Show More] are defined and documented individually SOAP - CORRECT ANSWER An acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans. Case Management - CORRECT ANSWER 1. A process used by health professionals to manage a patient's healthcare; 2. the ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient. Minimum Data Set - CORRECT ANSWER Minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in a skilled nursing facility Outcomes and Assessment Information Set (OASIS) - CORRECT ANSWER A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs. Core Measure - CORRECT ANSWER Standardized performance measures developed to improve the safety and quality of healthcare Authentication - CORRECT ANSWER The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it Entity Relationship Diagram (ERD) - CORRECT ANSWER A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases Object - CORRECT ANSWER The basic component in an object-oriented database that includes both data and their relationships within a single structure. Relational Database - CORRECT ANSWER A type of database that stores data in predefined tables made up of rows and columns Unified Medical Language System (UMLS) - CORRECT ANSWER A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies Resident Assessment Protocols - CORRECT ANSWER In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items Case Mix Index - CORRECT ANSWER The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged Master Patient Index - CORRECT ANSWER A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death Health Record Matrix - CORRECT ANSWER Identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the health record Retention Schedule - CORRECT ANSWER A time line for various records retention based on factors such as federal and state laws, statutes of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations, and operational needs Required Contents of a Patient's Record Prior to a Surgical Procedure - CORRECT ANSWER 1. A report of a complete history; and 2. Physical examination conducted no more than seven days prior to the surgery Aggregate Data - CORRECT ANSWER Data collected on large populations of individuals and stored in databases. This is used to develop information about groups of patients. Accession Data - CORRECT ANSWER Data Governance - CORRECT ANSWER Decision making and authority over data-related matters. Structured Data - CORRECT ANSWER Data that is organized and easy to retrieve and to interpret by traditional databases and data models. Principal Function of Health Records - CORRECT ANSWER Serve as the repository of clinical documentation relevant to the care of individual patients. Financial Data - CORRECT ANSWER Includes details about the patient's occupation, employer, and insurance coverage and is collected at the time of treatment. Authorship - CORRECT ANSWER The origin of recorded information that is attributed to a specific individual or entity. Ownership of the Health Record - CORRECT ANSWER Granted to the healthcare provider who generates the record - it is the business record of the healthcare provider. Chief Complaint - CORRECT ANSWER The reason a patient is seeking medical care Unstructured Clinical Information - CORRECT ANSWER Clinical documentation that is entered into the patient record as text (such as written notes, dictated reports, and legal forms) Primary Responsibility of a Coder - CORRECT ANSWER Ensure the accuracy of coded data Required Elements of an Emergency Care Record - CORRECT ANSWER 1. time and means of the patient's arrival; 2. treatment rendered; and 3. Instructions at discharge Entity-relationship Diagram (ERD) - CORRECT ANSWER The data model that is most widely used to illustrate a relational database structure. Clinical Data - CORRECT ANSWER All documentation entered in the medical record relating to the patient's diagnosis and treatment. [Show Less]
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RHIA Domain 2|133 Questions with Verified Answers,100% CORRECT
RHIA Domain 2|133 Questions with Verified Answers Legal Health Record - CORRECT ANSWER Formal business record to be utilized during legal procedings ... [Show More] If privacy issues emerge... - CORRECT ANSWER Determine source of problem and issue HIPAA training If patient is unable to sign... - CORRECT ANSWER Implied Consent Psychiatric patients may view records if physician determines... - CORRECT ANSWER Seeing record is not harmful to their condition or treatment Facility Directory - CORRECT ANSWER General Condition Acknowledgement of admission HIPAA's Expert Determination and Safe Harbor - CORRECT ANSWER Deidentification Log-in with standard ID and password - CORRECT ANSWER Access Control Standard Legal Hold - CORRECT ANSWER Special tracking of patient records involved in litigation to ensure no changes are made Security Risk Analysis First Consideration - CORRECT ANSWER Consider entity's characteristics and environment Audit Trail - CORRECT ANSWER Reconstructing electronic events Entity Authentication - CORRECT ANSWER Reads pre-determined criteria to ensure a user is who they claim to be Password systems Inherent Weakness of a Safeguard - CORRECT ANSWER Vulnerability Informed Consent - CORRECT ANSWER Risks and benefits of procedure Alternatives Description of procedure Done by phyisician Ensuring employees understand security measures - CORRECT ANSWER Workforce Security Awareness Training Provides entities with structural framework to build a HIPAA security plan - CORRECT ANSWER Security Risk Analysis Pre-Employment Physicals - CORRECT ANSWER Not protected by HIPAA bc part of personnel record HIPAA identifier that has not been implemented - CORRECT ANSWER Individual Preventing theft of PHI - CORRECT ANSWER Facility Access Controls Improved security of EHR - CORRECT ANSWER Access Controls Audit Trails Authentication Systems Designated Record Set - CORRECT ANSWER Includes records from other hospitals that were involved in episode of care decisions HIPAA Record Retention - CORRECT ANSWER 6 years Rendering PHI unreadable and unusable to unauthorized individuals - CORRECT ANSWER Encryption and Destruction Goal of HIPAA Administrative Simplification - CORRECT ANSWER Standardizing electronic transmission of health data Technology policies, protocols, and access controls - CORRECT ANSWER Technical Safeguards Patient Accounting of Disclosures - CORRECT ANSWER Must include disclosure requires patient authorization HIPAA Training - CORRECT ANSWER Privacy and security training should not be seperated Darling vs. Charleston Community Memorial Hospital - CORRECT ANSWER Hospital is responsible for the quality of care given by its physicians Not a Business Associate Under HITECH - CORRECT ANSWER Housekeeping Fundraising solicitations may not - CORRECT ANSWER Target a specific group or diagnosis Most Constant Threat to Health Information Integrity - CORRECT ANSWER Humans Device and Media Controls - CORRECT ANSWER Security breaches from lack of wiping data from devices Employee Physical - CORRECT ANSWER Should report family history unless specifically excluded Virtual Privacy - CORRECT ANSWER Private tunnel with Internet as transport medium for secure transmission Role-Based - CORRECT ANSWER Access determined by employee's job title and responsibilities Administrative Safeguard - CORRECT ANSWER More people-focused in nature Most of the safeguards Healthcare Integrity and Protection Data Bank - CORRECT ANSWER Legal action taken against healthcare provider Privileged Communication - CORRECT ANSWER Between patient and provider based on medical condition Privacy - CORRECT ANSWER Patient can maintain control over certain personal information Authorizations - CORRECT ANSWER Must be signed for every disclosure of PHI Consent - CORRECT ANSWER Sound mind or legal directive Deidentified - CORRECT ANSWER Not protected by HIPAA Privacy Rule NPP - CORRECT ANSWER Only informational Patients can not object to TPO uses Must inform patients of disclosures to foundations Patient Review of Records - CORRECT ANSWER Cannot dictate place bc org is responsible for integrity Privacy Rule Identifier - CORRECT ANSWER Vehicle License Plate PCP - CORRECT ANSWER Patients cannot deny PCP access to their records Office of Civil Rights - CORRECT ANSWER Oversight and enforcement of HIPAA Workforce - CORRECT ANSWER Perform functions on behalf of covered entities and business associates Includes volunteers and external orgs When federal and state law are different - CORRECT ANSWER Choose the stricter one Addressable Security Rule - CORRECT ANSWER Should be implemented unless an entity determines it is not reasonable and appropriate 500 days - CORRECT ANSWER DHHS secretary must be informed of breaches greater than this Workforce Security Standard Addressable Standards - CORRECT ANSWER Authorization and supervision Workforce clearance procedures Termination procedures Spoilation - CORRECT ANSWER Destroying a record outside of destruction standards and regulations PHR - CORRECT ANSWER In LHR when used by org to provide treatment Granting Privileges - CORRECT ANSWER Defining what services providers may perform Most Common Security Threat - CORRECT ANSWER Internal to org Employees viewing own record - CORRECT ANSWER Violates minimum necessary, Must follow standard procedure Regulation - CORRECT ANSWER From admin agency of govt Security Incident Procedure Standard - CORRECT ANSWER Identifying and responding to security events Redisclosure - CORRECT ANSWER Releasing docs originally created by another provider/facility Willful and Knowing HIPAA violation - CORRECT ANSWER $250,000, 10 yrs in jail PDSA - CORRECT ANSWER Inform patients they are entitled to advanced directive and document presence Advance Directive - CORRECT ANSWER Must be followed even if patient is declared incompetent after it is made Divorced Parents - CORRECT ANSWER Only one must consent Trigger - CORRECT ANSWER System response and notification Info Access Mgmt Standard - CORRECT ANSWER Controlling access to workstation, transaction, program, or process Utilization Review - CORRECT ANSWER Use for Operations Sending records to physician - CORRECT ANSWER Disclosure Custodian of Health Records - CORRECT ANSWER Testifies to authenticity of records Amendments cannot be made on records not in - CORRECT ANSWER DRS Automatic Session Terminations - CORRECT ANSWER Minimizes data breaches when computer is unattended Person or Entity Authentication Standard - CORRECT ANSWER No unit level password Minimum Necessary - CORRECT ANSWER Define what staff needs to complete their role ROIs must be responded to within - CORRECT ANSWER 30 days If patient private pays - CORRECT ANSWER Can restrict insurance info to info Contingency Planning - CORRECT ANSWER Disaster Recovery Planning Not redisclosure - CORRECT ANSWER If external and within DRS Private Endeavours - CORRECT ANSWER Physician needs business associate agreement with hospital If patient requests hybrid - CORRECT ANSWER Give both forms Saying name in waiting room - CORRECT ANSWER Not a HIPAA violation, but change process Social Security Number - CORRECT ANSWER Never show on documentation Accidental Deaths - CORRECT ANSWER Reported to medical examiner Documentation Retention Guidelines - CORRECT ANSWER Admin Safeguard HIPAA Security Rule - CORRECT ANSWER Ensure confidentiality, integrity, and availability UHCDA - CORRECT ANSWER Spouse, adult child, parent, adult sibling Accounting of Disclosures Timeframe - CORRECT ANSWER 3 years Respondeat Superior - CORRECT ANSWER Employer is responsible for employees negligence Job Shadowing - CORRECT ANSWER Only in areas with no PHI No Info in Directory - CORRECT ANSWER Deny requests bc that is difficult to manage and HIPAA violation can occur Revokes ROI after release - CORRECT ANSWER Protected by privacy rule QI - CORRECT ANSWER Protected from disclosure Documentation of Security Policies - CORRECT ANSWER Six years from effect HIPAA Record Charges - CORRECT ANSWER State formula Best-Of-Breed - CORRECT ANSWER Best from each vendor then interface Federated-Consistent Databases - CORRECT ANSWER HIE operates like ASP Best-Of-Fit - CORRECT ANSWER One vendor Person Identification - CORRECT ANSWER HIE matches info to individual Parallel Processing - CORRECT ANSWER Paper processing occurs until EHR works as planned Messaging Standards - CORRECT ANSWER Support communication between applications Normalization - CORRECT ANSWER Breaking data elements into detail to retrieve data Median - CORRECT ANSWER Based on whole distribution Infrared Light - CORRECT ANSWER Connecting portable devices to network Patient Portal - CORRECT ANSWER Secure communication with provider PHI - CORRECT ANSWER Relates to ones condition Releasing to another faculity - CORRECT ANSWER Minimum necessary does not apply Accounting of disclosures contains - CORRECT ANSWER Info from infectious reporting Privacy Rule - CORRECT ANSWER Will preempt state law with medical record charges Two Factor Authentication System - CORRECT ANSWER Password and Swipe Card Patient Limiting Disclosure - CORRECT ANSWER Must accept request but not agree to it Don't report HIPAA violation if - CORRECT ANSWER No hard copy info Reporting Requirements - CORRECT ANSWER Not for competent adults Duces Tecum - CORRECT ANSWER Compels recipient to bring records to a legal proceding Not signed by plaintiff and defendant Business Record Exception - CORRECT ANSWER Record does not constitute hearsay PHI Breach - CORRECT ANSWER Must tell types of unsecured PHI that were involved Accounting of Disclosures - CORRECT ANSWER Ex: faxed to the bank Training in PHI - CORRECT ANSWER Every member of workforce must attend Federal Rules of Civil Procedure - CORRECT ANSWER e-discovery rules changed Security Audit - CORRECT ANSWER Helps entity ensure that info is only being accessed for org purposes Security Rule - CORRECT ANSWER Provisions for access in emergency Biggest Risk of Breaches - CORRECT ANSWER Laptop Theft Protecting Data Privacy - CORRECT ANSWER Defending or safeguarding patient data Charging for PHI - CORRECT ANSWER To make a copy Chain of Trust Partner Agreements - CORRECT ANSWER Admin provision for security measures Confidentiality - CORRECT ANSWER Limiting disclosures Minor - CORRECT ANSWER Authorized to release venereal info Info Policy - CORRECT ANSWER Openness of comm w/in org Over telephone with police - CORRECT ANSWER No info Best Monitoring System - CORRECT ANSWER Random sample of each employee monthly Even if employer is paying - CORRECT ANSWER They need auth Married Minor - CORRECT ANSWER Can consent for self When on phone with hospital - CORRECT ANSWER Confirm with callback and give all info Stark Law - CORRECT ANSWER No physician self referral Right to PHI - CORRECT ANSWER For as long as it is maintained Authorization Management - CORRECT ANSWER Limiting user access [Show Less]
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RHIA Domain 3 Exam Prep 56 Questions with Verified Answers,100% CORRECT
RHIA Domain 3 Exam Prep 56 Questions with Verified Answers A hospital is undergoing a major reconstruction project and a new director of nursing has bee... [Show More] n hired. At the same time, the nursing documentation component of the EHR has been implemented. The fact that nursing staff satisfaction scores have risen is: a. A result of anecdotal benefits of EHR b. A result of qualitative benefits of EHR c. A result of reconfiguration of the nursing units d. Uncertain due to existence of confounding variables - CORRECT ANSWER d. Uncertain due to existence of confounding variables In this situation there are too many changes occurring at the same time to determine what is improving the nursing staffing satisfaction scores. Any one item could be the reason for the improvement. To evaluate the impact of the electronic health record (EHR) nursing documentation component, a benefits realization study should have been utilized. This would have studied the impact of the EHR component before and after implementation (Amatayakul 2017, 106). If a health plan analyst wanted to determine if the readmission rates for two hospitals were statistically different, what is the null hypothesis? a. The readmission rates are not equal. b. The readmission rates are equal. c. The readmission rate for one hospital is larger than the other. d. The readmission rate for one hospital is smaller than the other. - CORRECT ANSWER b. The readmission rates are equal. The first step in statistical hypothesis testing is defining the null and alternative hypotheses. The null hypothesis is the status quo. In this example the readmission rates are equal would be the null hypothesis showing no relationship between the two hospitals (White 2016a, 65). What architectural model of health information exchange allows participants to access data in point-to-point exchange? a. Consolidated b. Federated—consistent databases c. Federated—inconsistent databases d. Switch - CORRECT ANSWER c. Federated—inconsistent databases The Federated—inconsistent databases—model for HIE includes multiple enterprises agreeing to connect and share specific information in a point-to-point manner (Amatayakul 2017, 417-418). Which of the following lists represents recommended core data elements for the master patient index? a. Date of birth, revenue code, accession number, and address b. Name, address, revenue code, and accession number c. Name, gender, address, and date of birth d. Gender, address, accession number, and charge code - CORRECT ANSWER c. Name, gender, address, and date of birth A master patient index (MPI) is an index of known patients within a single organization whose visits are linked together by a single identifier, typically the medical records number. Some recommended core data elements for the MPI are: name, address, gender, date of birth, and many others. Accession number, revenue code, and charge code are not recommended core data elements for the MPI (Reynolds and Sharp 2016, 130). A technique that describes an interaction between a user and a system is called a(n): a. Use case analysis b. RHIO c. Test case d. Use description - CORRECT ANSWER a. Use case analysis A use case analysis is a technique that describes an interaction between a user and a system. A use case diagram displays the relationship among actors and use cases. The two main components of a use case diagram are use cases and actors. An actor represents a user or another system that will interact with the system being modeled. A use case is an external view of the system that represents some action the user might perform in order to complete a task (Oachs 2016, 824-825). Consumer informatics is focused on ________ a. Consumer activation b. Information structures and processes c. Personalized medicine d. Engagement - CORRECT ANSWER b. Information structures and processes Consumer health informatics is a field devoted to informatics from multiple consumer or patient views and includes patient-focused informatics, health literacy, and consumer education, with a focus on information structures and processes that empower consumers to manage their own health (AMIA 2015; Sandefer 2016b, 425). Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was: a. 0.05% b. 2% c. 5% d. 20% - CORRECT ANSWER c. 5% The gross death rate is the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. The gross death rate is calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including deaths, for the same time period: 25/500 = 0.05 × 100 = 5% (Palkie 2016b, 296). For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - CORRECT ANSWER a. Structured data If an EHR is to provide clinical decision support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364). Assume you are the manager of a 10-physician group primary care practice. The physicians are interested in contracting with an application service provider to develop and manage patient records electronically. Which of the following statements is an indication that an application service provider (ASP) may be a good idea for this practice? a. The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor. b. The practice wants an electronic medical record system and wants to get into the IT management business as well. c. The practice would like to have the system up and running in a relatively short period of time (less than four months). d. The practice is not looking to purchase any additional hardware needed for an electronic medical record system. - CORRECT ANSWER a. The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor. In an application service provider (ASP) model, there is much less upfront capital outlay and fewer IT staff required in-house. In fact, the ASP acquisition strategy may be considered essentially a financing model (Amatayakul 2016, 402). In addition to bar codes on health record documents, what other forms of recognition characteristics enhance the accuracy of form indexing features? a. Access controls b. COLD c. OCR d. Workflow - CORRECT ANSWER c. OCR The capability to retrieve documents from an electronic document management system (EDMS) is determined by the underlying technology used to store the documents. In addition to bar codes on medical record documents, optical character recognition (OCR) may be available to enhance the accuracy of indexing features on forms (Sandefer 2016a, 352). To reduce the effect of a server crash in an EHR environment, it is advisable to: a. Set up redundant systems b. Have a storage area network c. Store data in RAID d. Have an inventory of all systems - CORRECT ANSWER a. Set up redundant systems To achieve availability, an EHR must have full redundancy as well as backup and network redundancy. This means that there is a duplication of all data, hardware, cables, or other components of the system. Should the primary server crash, the system switches over to the second server and can continue processing (Sayles and Kavanaugh-Burke 2018, 228). A possible justification for building an information system in-house rather than purchasing one from a vendor is that: a. It is cheaper to buy than to build b. The facility has development teams they do not want to give up c. Integration of systems will be easier d. Vendor products are not comprehensive enough - CORRECT ANSWER b. The facility has development teams they do not want to give up Most organizations recognize that commercial products can meet their needs and that most of these products will far surpass the functionality that could be self-developed. Still, some organizations want to at least consider the build option. Some physicians are intrigued with developing their own perfect system, and some hospitals have development teams they do not want to give up. An organization's decision to build or buy should be based on a careful review of the marketplace. Currently, it is more expensive to undertake self-development. Unless self-development is coupled with a vendor partnership that leads to commercialization, a self-developed system can be a drawback when attempting to integrate with commercial products as the organization grows, merges, or acquires affiliates (Amatayakul 2017, 191). Which data collection program is the basis for the CMS value-based purchasing program? a. Leapfrog b. HEDIS c. Hospital Compare d. HCUP - CORRECT ANSWER c. Hospital Compare Hospital Compare reports on 139 measures of hospital quality of care for heart attack, heart failure, pneumonia, and the prevention of surgical infections. The data available at Hospital Compare is reported by hospitals to meet the requirements of the Medicare Value Based Purchasing program (White 2016a, 188). In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? a. Account level b. MS-DRG level c. MDC level d. MS-DRG triples, pairs, and singles - CORRECT ANSWER c. MDC level The focused review indicated areas of risk related to lower weighted MS-DRGs from triple and pair combinations which may be the result of a coder missing secondary diagnoses. A focused audit based on this specific potential problem area could help to identify these cases. Optimization seeks the most accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive (Hunt 2016, 286). You want to graph the number of deaths due to prostate cancer from 2010 through 2017. Which graphic tool would you use? a. Frequency polygon b. Histogram c. Line graph or plot d. Pie chart - CORRECT ANSWER c. Line graph or plot A line graph or plot is used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the number of prostate cancer deaths (Marc 2016, 546). Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area? a. Serial-unit filing system b. Serial filing system c. Unit filing system d. Terminal-digit filing system - CORRECT ANSWER d. Terminal-digit filing system In a terminal-digit filing system, records are filed according to a three-part number made up of two-digit pairs. The basic terminal-digit filing system contains 10,000 divisions, made up of 100 sections ranging from 00 to 99 with 100 divisions within each section ranging from 00 to 99. In a terminal-digit filing system, the shelving units (filing space) are equally divided into 100 sections (Reynolds and Sharp 2016, 128-129). Which of the following is the statistic that would be used to explore the relationship between length of stay and patient age? a. Mean b. Correlation c. Predictive modeling d. Variance - CORRECT ANSWER b. Correlation Correlation is the statistic that is used to describe the association or relationship between two variables. In the healthcare setting, we may note that length of stay and charges are highly related or correlated (White 2016b, 526-527). 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. This data is called a(n): a. Indicator b. Measurement c. Assessment d. Outcome - CORRECT ANSWER a. Indicator An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2019, 143). Which of the following statements is true of structured query language (SQL)? a. It is both a data manipulation and data back-up mechanism. b. It defines data elements and manipulates and controls data. c. It is the computer language associated with document imaging. d. Users are not able to query a relational database. - CORRECT ANSWER b. It defines data elements and manipulates and controls data. Structured query language (SQL) includes both data dictionary language and data manipulation language components and is used to create and manipulate relational databases (Sayles and Kavanaugh-Burke 2018, 29). Which of the following basic services provided by a health information exchange (HIE) entity matches identifying information to an individual? a. Consent management b. Person identification c. Record locator d. Identity management - CORRECT ANSWER b. Person identification Because there is no mandated unique patient identifier, ensuring that the HIE organization can identify the right patient as it seeks to exchange information is a process of identity matching (Amatayakul 2017, 419). A database will be created solely for use in a research study that is being conducted. Which of the following is best suited for this scenario? a. Relational database model b. Data repository c. Data mart d. Data warehouse - CORRECT ANSWER c. Data mart A data mart is a subset of the data warehouse designed for a single purpose or specialized use. The data mart performs the same type of analysis as a data warehouse; however, the scope of the data is narrower (Sayles and Kavanaugh-Burke 2018, 38). The relationship between patient gender and readmission to the hospital is best displayed using a: a. Frequency chart b. Contingency table c. Bar chart d. Pie chart - CORRECT ANSWER b. Contingency table Contingency tables are a useful method for displaying the relationship between two categorical variables. Contingency tables are often referred to by the number of rows and columns (White 2016a, 64). Working with the healthcare entity's integration team to ensure that ADT interfaces are properly built and tested is the responsibility of the: a. MPI manager b. EHR analyst c. IT manager d. Electronic forms manager - CORRECT ANSWER a. MPI manager Monitoring and managing a master patient index (MPI) also requires constant vigilance from the organization, including oversight, evaluation, and correction of errors. The overall responsibility of maintaining the MPI should be centralized and given to an individual who is detail oriented, is properly trained, has access to adequate tools, and is well versed in the organization's policies and procedures for MPI maintenance. Working with the organization's integration team to ensure ADT interfaces are properly built and tested is a key responsibility of the MPI manager (Reynolds and Sharp 2016, 130). In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? a. DICOM b. IEEE 1073 c. LOINC d. X12N - CORRECT ANSWER d. X12N X12N refers to standards adopted for electronic data interchange. In order for transmission of healthcare data between a provider and payer, both parties must adhere to these standards (Sayles and Kavanaugh-Burke 2018, 211). Dr. Jones comes into the HIM department and requests that the HIM director pull all of his records from the previous year in which the principal diagnosis of myocardial infarction was indicated. Where would the HIM director begin to pull these records? a. Disease index b. Master patient index c. Operative index d. Physician index - CORRECT ANSWER a. Disease index A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each patient's diagnoses are converted from a verbal description to a numerical code, usually using a coding system such as the International Classification of Diseases (ICD) (Sharp and Madlock-Brown 2016, 172). In which of the following does an analyst perform exploratory data analysis to determine trends and identify patterns in the data set? a. Data quality b. Data mining c. Record analysis d. Inferential statistics - CORRECT ANSWER b. Data mining In data mining, the analyst performs exploratory data analysis to determine trends and identify patterns in the data set (White 2016b, 531). A protocol to pass data from the system of one vendor to the information system of another vendor is called: a. OLAP b. Integration c. TCP/IP d. Interface - CORRECT ANSWER d. Interface An interface is software that works between two or more systems to enable the two systems to share data (Amatayakul 2016, 402). A report developed by a PI team on the occurrence of methicillin-resistant Staphylococcus aureus infection in a neonatal intensive care unit was subsequently used by the perinatal morbidity and mortality committee in a monthly review of infant morbidity. Access to this report was possible because it was housed in the organization's: a. Information warehouse b. Comparative performance data c. PI database d. Computer hard drive - CORRECT ANSWER a. Information warehouse Information warehouses allow organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities (Shaw and Carter 2019, 350). This statistical inference measures both the strength of a relationship between two variables and the functional relationship between them. a. Correlation b. T-test c. Simple linear regression d. Standard deviation - CORRECT ANSWER c. Simple linear regression Simple linear regression (SLR) is another type of statistical inference that not only measures the strength of the relationship between two variables, but also estimates a functional relationship between them. SLR may be used when one of the two variables of interest is dependent on the other (White 2016b, 527-528). COLD/ERM Technology - CORRECT ANSWER Computer output laser disk/enterprise report management (COLD/ERM) technology electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print-stream originated. COLD/ERM technology not only electronically stores the report-formatted documents but also distributes them with fax, e-mail, web, and traditional hard copy print processes (Sandefer 2016a, 350). An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis? a. The average wait time is shorter on weekends. b. The average wait time is longer on weekends. c. The average wait time is different on weekends and weekdays. d. The average wait time is the same on weekends and weekdays. - CORRECT ANSWER b. The average wait time is longer on weekends. The alternative hypothesis is the compliment of the null hypothesis and typically requires some action to be taken. In this scenario, the analyst is comparing emergency department wait times between weekends and weekdays. The alternative hypothesis would be that the average wait time is longer on weekends (White 2016a, 65). DICOM Standard - CORRECT ANSWER The Digital Imaging and Communications in Medicine (DICOM) standard supports retrieval of information from imaging devices and equipment to diagnostic and review workstations as well as short-term and long-term storage systems (Amatayakul 2017, 404-405). This analytic technique is being used by CMS to assist in prepayment audits? a. Descriptive statistics b. Graphical analysis c. Exploratory data analysis d. Predictive modeling - CORRECT ANSWER d. Predictive modeling Predictive modeling applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are applied to historical data to learn the patterns in the data. These patterns are used to create models of what is most likely to occur (White 2016a, 7; White 2016b, 531). HIPAA mandated that healthcare business partners and covered entities implement a common standard for data and information transfer. That standard is: a. ICD-10-CM b. HL7 c. ASC X12 N d. CPT - CORRECT ANSWER c. ASC X12 N HIPAA mandates that healthcare-covered entities and business partners implement a common standard (ASC X12N) for the transfer of information and accept the standard-based electronic transaction. This regulation does not apply to the transfer of data and information within a healthcare organization, but it does apply to the transfer of data and information external to and between healthcare organizations (Sayles and Kavanaugh-Burke 2018, 211). Which application uses statistical techniques to determine the likelihood of certain events occurring together? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering - CORRECT ANSWER a. Predictive modeling Predictive modeling applies statistical techniques to determine the likelihood of certain events occurring together (White 2016a, 7-8). In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? a. Unit numbering b. Index unit numbering c. Serial-unit numbering d. Serial numbering - CORRECT ANSWER a. Unit numbering Unit numbering storage is a health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters (Reynolds and Sharp 2016, 128). Data mining is a process that involves which of the following? a. Using reports to measure outcomes b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns c. Producing summary reports for management to run the daily activities of the healthcare entity d. Producing detailed reports to track productivity - CORRECT ANSWER b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns In data mining, the analyst performs exploratory data analysis to determine trends and identify patterns in the data set. Data mining is sometimes referred to as knowledge discovery (White 2016b, 531). In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n): a. Primary key interface (PKI) b. Application programming interface (API) c. Continuity of care record (CCR) d. Record locator service (RLS) - CORRECT ANSWER d. Record locator service (RLS) The HIE's record locator service (RLS) manages the pointers to the information on the servers of the HIE participants. The pointers in a RLS can include a person identification number (person ID) and metadata. The RLS does not provide information about the record, it merely points to where it might be found. Data are not stored in a centralized database and records are only provided when queried (McCann 2016, 454). A healthcare entity remains committed to purchasing a vendor's product, which the entity finds solid in its financial and administrative applications but weaker in clinical applications. What is the term for this strategy? a. Bridge b. Best-of-fit c. Best-of-breed d. Legacy - CORRECT ANSWER b. Best-of-fit The opposite of best-of-breed is best-of-fit. In this situation, virtually (though not absolutely) all applications are provided by a single vendor. This frequently makes it easier to add new applications from that vendor, but potentially even more difficult to add products from other vendors. Many organizations find their best-of-fit financial or administrative and operational system vendor is not as strong in EHR as they would desire. Alternatively, best-of-breed organizations find it difficult and costly to sustain this approach (Amatayakul 2017, 72-73). The probability of making a Type I error based on a particular set of data is called the ________. a. Sampling value b. Hypothesis test c. A-probability d. P-value - CORRECT ANSWER d. P-value The probability of making a Type I error based on a particular set of data is called the p-value (White 2016b, 514). Protocols that support communication between applications are often referred to as: a. Application program b. Interface code c. Messaging standards d. Source code - CORRECT ANSWER c. Messaging standards Within healthcare, standard protocols that support communication between nonintegrated applications are often referred to as messaging standards, also called interoperability standards or data exchange standards. Messaging standards provide the tools to map proprietary formats to one another and more easily accomplish the exchange of data (Amatayakul 2017, 400-401). Which of the following is an effective method of evaluating responses to a request for proposal (RFP)? a. Testing the new system b. Negotiating contracts with all vendors and assessing the best price c. Attending user group meetings d. Visiting sites that use the systems of product competitors - CORRECT ANSWER c. Attending user group meetings Formal and informal mechanisms should be used to evaluate each vendor and its products. For example, the project team may hold vendor presentations, check references, attend user group meetings, and make site visits to other facilities that use the product. The purpose of these activities is to gather as much relevant information as possible to make an informed decision (Amatayakul 2017, 202-204). Which graph is the best choice to use when exploring the relationship between length of stay and charge for a set of patients? a. Line graph b. Bar chart c. Pie chart d. Scatter diagram - CORRECT ANSWER d. Scatter diagram A scatter diagram is a data analysis tool used to plot points of two variables suspected of being related to each other in some way (Oachs 2016, 816-817). All computers on this type of network receive the same message at the same time, but only one computer at a time can transfer information; and if one segment of the network goes down, the entire network is affected. a. Star topology b. Ring topology c. Bus topology d. Logical topology - CORRECT ANSWER c. Bus topology Bus topology is the simplest network topology, connecting one device to another along a "backbone." A major disadvantage is that the central cable is a single point of failure. If this cable fails for any reason then the entire network goes down (Johns 2015, 57). A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? a. Content analysis b. Effect size review c. Psychometric assay d. Secondary analysis - CORRECT ANSWER d. Secondary analysis Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586). The user needs a list of all of the patients that were diagnosed a cerebral infarction or a cerebral hemorrhage. This is an example of a situation in which what type of search should be used? a. Structured query language b. Wildcard search c. Truncation d. Boolean search - CORRECT ANSWER d. Boolean search Boolean search capabilities such as "and," "or," and "not" may be used in the QBE database to narrow down the data to specifically what the user needs. In this example the query could retrieve patients who had a diagnosis cerebral infarction or cerebral hemorrhage and find all of them (Sayles and Kavanaugh-Burke 2018, 29). The process of preventing the spread of communicable diseases in compliance with applicable legal requirements is performed in this quality management function. a. Infection control b. Clinical quality assessment c. Utilization management d. Risk management - CORRECT ANSWER a. Infection control The medical staff and the healthcare organization should work together to provide an environment that reduces the risk of infections in both patients and healthcare providers. The healthcare organization should support activities that look for, prevent, and control infections. An infection review is done with the involvement of the medical staff. Information is collected regularly on endemic and epidemic healthcare-associated infections. As appropriate, the healthcare organization must report significant information to both internal groups and public health agencies (Shaw and Carter 2019, 179). Last year, 73,249 people died from diabetes mellitus in the United States. The total number of deaths from all causes was 2,443,387, and the total population was 288,356,713. Calculate the proportionate mortality ratio for diabetes mellitus. a. 0.003 b. 10.94 c. 0.09 d. 3.0 - CORRECT ANSWER d. 3.0 The proportionate mortality ratio (PMR) is a measure of mortality due to a specific cause for a specific time period. In the formula for calculating the PMR, the numerator is the number of deaths due to a specific disease for a specific time period, and the denominator is the number of deaths from all causes for the same time period. The proportionate mortality ratio for diabetes mellitus = 73,249/2,443,387 = 0.03 × 100 = 3.0% (AHIMA 2017, 192; Edgerton 2016, 484-485). During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30 percent of the nursing home's population. This rate represents the: a. Distribution b. Frequency c. Incidence d. Prevalence - CORRECT ANSWER c. Incidence The incidence rate is a computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same time period (Oachs and Watters 2016, 1009). You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use? a. Bar graph b. Histogram c. Line graph d. Pie chart - CORRECT ANSWER a. Bar graph Bar charts are used to display data from one or more variables. The bars may be drawn vertically or horizontally. Bar charts are used for nominal or ordinal variables. In this case, you would be displaying the average length of stay by service and then within each service have a bar for each gender (Horton 2017, 257-258). Online or real-time transaction processing (OLTP) is a functional requirement for a: a. Data repository b. Data mart c. Data display d. Data dictionary - CORRECT ANSWER a. Data repository Data repositories in healthcare organizations require tools designed to perform intricate data searches and retrievals using online or real-time transaction processing (OLTP) (Amatayakul 2017, 306-307). HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors. But that information often 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? a. Administration b. Registration or patient access c. Risk management d. Radiology and laboratory - CORRECT ANSWER b. Registration or patient access A review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. Although health information management (HIM) departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors, that information may never be shared with the registration department. If the registration staff is not aware of the errors, how can they begin to proactively prevent the errors from occurring in the first place? Registration process improvement activities can eventually reduce work for HIM departments. In addition, monitoring new duplicates is a critical process, and tracking reports should be created and implemented. Identifying and reporting MPI errors is important; however, tracking who made the error and why will decrease the number of duplicates (Reynolds and Sharp 2016, 130-131). Tina is the EMPI coordinator for Smithtown Healthcare, a large medical center with many satellite clinics. Because so many patients visit the clinics, sometimes new health record numbers are mistakenly assigned to them (even though they may already have a number) when they register for a particular service. As the EMPI coordinator, Tina performs all of the following tasks as part of her regular job duties except: a. Unmerging overlays b. Merging duplicate records c. Confirming the health record contains all patient visits d. Verifying insurance status - CORRECT ANSWER d. Verifying insurance status The challenge for facilities is to maintain a correct and current MPI so that each patient has a unique identifier number. Duplication and overlays and overlap are major problems. Healthcare facilities have hired HIM professionals as EMPI coordinators to clean and maintain EMPI systems to ensure that the correct information on the correct patient is available to the provider and others who need it. Verifying insurance status would not be part of the job duties of an EMPI coordinator (Reynolds and Sharp 2016, 130). What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user? a. Clinical data repository b. Data exchange standard c. Central processor d. Digital system - CORRECT ANSWER a. Clinical data repository A clinical data repository is a centralized database that captures, sorts, and processes patient data and then sends it back to the user (Amatayakul 2017, 24). In carrying out the strategic plan for health IT, the step that describes what is needed to achieve the plan's goals is: a. Environmental scan b. Project plan c. Requirements analysis d. Risk analysis - CORRECT ANSWER c. Requirements analysis Requirements analysis is the step that identifies, in detail, the precise requirements needed for both health information technology (that is, hardware and software) and operational components (people, policy, and process) of the health information system to meet the goals specified in the strategic plan (Amatayakul 2016, 400). The term used to describe breaking data elements into the level of detail needed to retrieve the data is: a. Normalization b. Data definitions c. Primary key d. A database management system - CORRECT ANSWER a. Normalization When developing the data elements that go into a database, the fields should be normalized. Normalization is breaking the data elements into the level of detail desired by the facility. For example, last name and first name should be in separate fields as should city, state, and zip code (Sayles and Kavanaugh-Burke 2018, 34). [Show Less]
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RHIA Exam - Domain V| 41 Questions with Verified Answers,100% CORRECT
RHIA Exam - Domain V| 41 Questions with Verified Answers Which of the following is not a characteristic of strategy? - CORRECT ANSWER A description of s... [Show More] pecific implementation plans Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? - CORRECT ANSWER Tracer metholodogy Employees covered by the provisions of the Fair Labor Standards Act (FLSA) are called ___ employees: - CORRECT ANSWER Nonexempt The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a(n): - CORRECT ANSWER Unfavorable variance of $2,000 Agreements that are reached in a participant agreement or vendor contract should be developed into: - CORRECT ANSWER Operational policies Strategic thinkers exhibit which of the following skills? - CORRECT ANSWER The ability to gain a powerful core of healthcare entity supporters and customers Kelly's husband is being transferred to a new position in another state. Kelly has to resign her position as director of HIM at Memorial Hospital, a job she has enjoyed for five years. This is an example of what type of employee turnover? - CORRECT ANSWER Voluntary The following information was abstracted from Community Hospital's balance sheet. *see Q. 172 Practice Exam 1 - pg 38 for table A vendor selling a large dollar amount of goods to this hospital on credit would: - CORRECT ANSWER Be somewhat concern because the ratio is less than one half Community Hospital is evaluating the following three investments. Which one has the highest profitability index? *see Q. 173 Practice Exam 1 - pg. 39 for table - CORRECT ANSWER All three are equally profitable What type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation? - CORRECT ANSWER Voluntary Review An accrediting agency's published rules, which serve as the basis for comparative assessment during the review or survey process, are called: - CORRECT ANSWER Accreditation standards In the HIM department at Memorial Hospital, each newly hired coder spends an afternoon with a medical biller. The coder follows the biller as they complete job tasks to get an idea of how coding and billing impact one another. This is an example of what type of on-the-go training? - CORRECT ANSWER Job shadowing The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called: a. Environmental assessment b. Operations improvement planning c. Strategic management d. Employement assessment - CORRECT ANSWER Environmental assessment What term is used to represent a difference between the budgeted amount and he actual amount of a line item that is not expected to reverse itself during a subsequent period? a. Permanent variance b. Fixed cost c. Temporary variance d. Flexible cost - CORRECT ANSWER Temporary variance In order to expedite basic performance improvement team functioning, the team should: a. use unstructured brainstorming b. perform force field analysis c. established ground rules d. use structured brainstorming - CORRECT ANSWER establish ground rules Identifying future health information needs for a healthcare entity and projecting specific initiatives required to meet those needs is part of: a. Data modeling b. Policy development c. Strategic planning d. Workflow modeling - CORRECT ANSWER Strategic planning What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals? a. Accredidation organizations b. Certification organizations c. State licensure agencies d. Conditions of Participation agencies - CORRECT ANSWER State Licensure agencies Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? a. Compromise b. Collaborative confrontation c. Control d. Constructive confrontation - CORRECT ANSWER Constructive confrontation The Hay method is used to measure the three levels of major compensable factors: the know-how, problem-solving, and accountability requirements of each position. This sytem is used for: a. Job evaluation b. Interview applicants c. Performance measurement d. Work scheduling - CORRECT ANSWER Job evaluaton For contract to be valid, it must include three elements. Which of the following is one of those elements? a. Assumption of Risk b. Consideration c. Statute of limitations d. Notice of liability - CORRECT ANSWER Consideration Caroline is interviewing candidates for a supervisor of release of information position. She asks each candidate to explain how they would prepare a record in answer to a subpoena. This is what type of interview question? a. Behavior b. Job knowledge c. Situational d. Work requirement - CORRECT ANSWER Job knowledge The health information services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. The manager has each employee complete a form identifying the amount of time he or she spend each dat on various tasks. What is this tool called? a. Serial work distribution tool b. Work distribution chart c. Check sheet d. Flow process chart - CORRECT ANSWER Work distribution chart Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status? a. Compliance b. Deem status c. Document review d. performance improvement - CORRECT ANSWER Complaince Which of the following is an example of a budget used as a controlling set? - CORRECT ANSWER Responding to a monthly budget variance report One of the most common issues that healthcare organizations fail to do well in the strategic process is: - CORRECT ANSWER Execute the implementation plan The percent of antibiotics administered immediately prior to open reduction and internal fixation (ORIF) surgeries or the percent of deliveries accomplished by cesarean section are examples of what type of performance measure? - CORRECT ANSWER Process measure At the end of March, the HIM department has a YTD payroll budget of $100,000. The actual YTD amount paid is $95,000 because a coder resigned in February. For the past two months, the position has been filled through outsourcing. Therefore, the actual YTD amount for consulting services is $5,000, although no money was budgeted for consulting services. The reporting threshold for variances is 4%. The fiscal year-end is December. What is the best description of the payroll variance for this year? A. Favorable, permanent B. Unfavorable, permanent C. Favorable, temporary D. Unfavorable, temporary - CORRECT ANSWER Unfavorable, permanent At the end of March, the HIM department has a YTD payroll budget of $100,000. The actual YTD amount paid is $95,000 because a coder resigned in February. For the past two months, the position has been filled through outsourcing. Therefore, the actual YTD amount for consulting services is $5,000, although no money was budgeted for consulting services. The reporting threshold for variances is 4%. The fiscal year-end is December. Which one the variances will the HIM director be required to explain? - CORRECT ANSWER Both the payroll and consulting services variances All of the following are risks that must be considered when entering into an outsourcing contract except: - CORRECT ANSWER Efficient productivity When implementing health information management training, detemrining who needs to be trained, who should do the training, how much training is required, and how the training will be accomplished is the responsibility of: - CORRECT ANSWER The implementation team Coders at Medical Center Hospital are expected to do a high volume of coding. Their department also includes a clerical support person who handles phone calls, pulls and files records to be coded, and maintains productivity logs. An abstract clerk enters coded data into the health information system. This is an example of ________ work division. - CORRECT ANSWER Serial Monitoring incidents of patient's falls can be used to measure effectiveness of hospital staff. This type of indicator would be considered a(n) _____. - CORRECT ANSWER Clinical measure In preparation for the implementation of an electronic health record (EHR), Ruth spends most of her training time in the EHR test system clicking through screens and developing workflows. Ruth is most likely what type of sensory learner? - CORRECT ANSWER Kinesthetic Before the on-site survey team leaves the healthcare facility they meet with the organization's leadership team and provide a report of their findings. This meeting is called _____. - CORRECT ANSWER Exit conference At Community Health Services, each budget cycle provides the opportunity to continue or discontinue services based on available resources so that every department or activity must be justified and prioritized annually in order to effectively allocate resources. Community Health uses what type of operational budget? - CORRECT ANSWER Zero-based An implementation plan is developed to ensure successful executive and includes: - CORRECT ANSWER Strategies, goals, and objectives As part of the CARF accreditation process, reviewers examine policies and procedures, administrative rules and regulations, administrative records, human resource records, and the case records of patients. This process is called: - CORRECT ANSWER Document review Which tool is used to determine the most critical areas for training and education for a group of employees? - CORRECT ANSWER Needs analysis Which of the following is a statement made by one party to induce abother party to enter into a contract? - CORRECT ANSWER Warranty Sarah is not clear about why she needs to collect so much data as she performs her HIM job. Sarah's manager explains that the basic premise behind collecting job analysis data is to determine the job requirements and delineate appropriate _____________and _____________. - CORRECT ANSWER Position classification; grade level assignments Which of the following would not be included in a healthcare entity's strategic profile? - CORRECT ANSWER Nature of its threats and opportunities [Show Less]
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