RHIA Domain 1Exam 116 Questions with Verified Answers
Primary responsibility of coder - CORRECT ANSWER Ensure quality of coded data
Responsible for
... [Show More] quality 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]