RHIA Exam 2: 104 Questions with Verified Answers
Data elements for emergency department systems - CORRECT ANSWER DEEDS
Minimum data set - CORRECT
... [Show More] ANSWER 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]