RHIA EXAM 25 Questions with Verified Answers
Quantitative analysis - CORRECT ANSWER HIM professionals analyze medical records for any missing
... [Show More] reports, 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]