RHIA Exam 267 Questions with Verified Answers
A method of documenting nurses' progress notes by recording only abnormal or unusual findings or
... [Show More] deviations 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]