RHIA Exam 292 Questions with Verified Answers
An audit trail is a good tool for which of the following? - CORRECT ANSWER Reconstructing electronic
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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]