RHIA Exam 393 Questions with Verified Answers
Where can you find guidelines for the retention and destruction of healthcare information?
a.
... [Show More] Institute of Medicine
b. Municipal regulations
c. HIPAA
d. Accreditation standards - CORRECT ANSWER d. Accreditation standards
This functionality can result in confusion from incessant repetition of irrelevant clinical data.
a. Change
b. Amendment
c. Copy and paste
d. Deletion - CORRECT ANSWER c. Copy and paste
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?
a. Physician
b. Master patient
c. Procedure
d. Disease and operation - CORRECT ANSWER a. Physician
A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records?
a. Outpatient
b. Emergency room
c. Physician office
d. Inpatient - CORRECT ANSWER d. Inpatient
Who is responsible for ensuring the quality of health record documentation?
a. Board of directors
b. Administrator
c. Provider
d. Health information management professional - CORRECT ANSWER c. Provider
Which of the following represents data flow for a hospital inpatient admission?
a. Registration > diagnostic and procedure codes assigned > services performed > charges recorded
b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned
c. Services performed > charges recorded > registration > diagnostic and procedure codes assigned
d. Diagnostic and procedure codes assigned > registration > services performed > charges recorded - CORRECT ANSWER b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned
Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals?
a. Ensuring the record is legible
b. Identifying deficiencies early so they can be corrected
c. Verifying that health professionals are providing appropriate care
d. Checking to ensure bills are correct - CORRECT ANSWER b. Identifying deficiencies early so they can be corrected
The process of providing proof of the authorship of health record documentation is called:
a. Identification
b. Standardization of data capture
c. Standardization of abbreviations
d. Authentication - CORRECT ANSWER d. Authentication
Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record?
a. Document name, media type, source system, electronic storage start date, stop printing start date
b. Document name, media type
c. Document name, medical record number, source system
d. Document name, source system - CORRECT ANSWER a. Document name, media type, source system, electronic storage start date, stop printing start date
According to the UHDDS definition, ethnicity should be recorded on a patient record as:
a. Race of mother
b. Race of father
c. Hispanic, non-Hispanic
d. Free-text descriptor as reported by patient - CORRECT ANSWER c. Hispanic, non-Hispanic
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS - CORRECT ANSWER c. ERD
The purpose of the data dictionary is to ________ definitions and ensure consistency of use.
a. Identify
b. Standardize
c. Create
d. Organize - CORRECT ANSWER b. Standardize
It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records.
a. Training sessions
b. Policies and procedures
c. Verbally communicated instructions
d. A supervisory committee - CORRECT ANSWER b. Policies and procedures
Quality has several components, including appropriateness, technical excellence, ________, and acceptability.
a. Accuracy of diagnosis
b. Continuous improvement
c. Connectivity
d. Accessibility - CORRECT ANSWER d. Accessibility
Assign the correct CPT code for the following procedure: Patient is admitted to move the skin pocket for their pacemaker.
a. 33223, Relocation of skin pocket for implantable defibrillator
b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
c. 33212, Insertion of pacemaker pulse generator only; with existing single lead
d. 33222, Relocation of skin pocket for pacemaker - CORRECT ANSWER d. 33222, Relocation of skin pocket for pacemaker
Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient's EHR. These different information systems that feed information into the EHR are known as:
a. Interoperability
b. Source systems
c. Continuity of care records
d. Clinical decision support systems - CORRECT ANSWER b. Source systems
Of the following, what is the most likely to happen to the health records of a physician's patient when that physician leaves an office practice?
a. It will be sent to the state department of health.
b. It will be sent to outside storage.
c. It will be destroyed.
d. It will be retained by the practice. - CORRECT ANSWER d. It will be retained by the practice.
Reviewing a health record for missing signatures and medical reports is called:
a. Analysis
b. Coding
c. Assembly
d. Indexing - CORRECT ANSWER a. Analysis
A barrier to effective computer-assisted coding is the:
a. Resistance of physicians
b. Resistance of HIM professionals
c. Poor quality of documentation
d. Reduction of consistency without human coders - CORRECT ANSWER c. Poor quality of documentation
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?
a. Core measure
b. Resident Assessment Instrument
c. Precertification
d. Record of transfer - CORRECT ANSWER b. Resident Assessment Instrument
What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or is otherwise dying and unable to speak for themselves?
a. Durable power of attorney
b. Living consent form
c. Informed consent
d. Advance directive - CORRECT ANSWER d. Advance directive
A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment?
I97.191 Other postprocedural cardiac functional disturbances following other surgery
K43.9 Ventral hernia without obstruction or gangrene
R00.1 Bradycardia, unspecified
Z53.09 Procedure and treatment not carried out because of other contraindication
SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralRepairAbdominalWallOpenNo DeviceNo Qualifier
0WQF0ZZ
SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralInspectionPeritonealCavityOpenNo DeviceNo Qualifier
0WJG0ZZ
a. K43.9, R00.1, Z53.09, 0WJG0ZZ
b. K43.9, I97.191, R00.1, 0WJG0ZZ
c. K43.9, 0WQF0ZZ
d. K43.9, Z53.09, 0WQF0ZZ - CORRECT ANSWER a. K43.9, R00.1, Z53.09, 0WJG0ZZ
A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA?
a. Catheter-associated urinary tract infection
b. Cerebral vascular accident
c. COPD
d. Hypertension - CORRECT ANSWER a. Catheter-associated urinary tract infection
A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n):
a. Diabetes registry
b. Cancer registry
c. Immunization registry
d. Trauma registry - CORRECT ANSWER c. Immunization registry
A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of?
a. Data collection
b. Edit check
c. Data reliability
d. Hot spot - CORRECT ANSWER b. Edit check
Which of the following are considered dimensions of data quality?
a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency
b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency
c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency
d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency - CORRECT ANSWER a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency
The statement "All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88" represents a possible case definition for what type of registry?
a. Birth defect registry
b. Cancer registry
c. Diabetes registry
d. Trauma registry - CORRECT ANSWER d. Trauma registry
Mrs. Bolton is an angry patient who resents her physician "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is:
a. Mean
b. Noncompliant and hostile toward staff
c. Belligerent and out of line
d. A pain in the neck - CORRECT ANSWER b. Noncompliant and hostile toward staff
When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n):
a. Secondary data source
b. Reliable data source
c. Primary data source
d. Unreliable data source - CORRECT ANSWER a. Secondary data source
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:
a. Secondary data source
b. Aggregate data source
c. Primary data source
d. Reliable data source - CORRECT ANSWER c. Primary data source
A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.89 Other specified sepsis
A41.9 Sepsis, unspecified organism
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding
R10.9 Unspecified abdominal pain
a. A41.89, K57.32, R10.9
b. A41.01, K57.32
c. A41.89, K57.32, B95.61
d. A41.9, K57.32 - CORRECT ANSWER b. A41.01, K57.32
A patient had a radical resection of soft tissue sarcoma of the left thigh. In ICD-10-PCS what would the root operation be for this procedure?
a. Excision
b. Repair
c. Resection
d. Destruction - CORRECT ANSWER a. Excision
The data that describe other data in order to facilitate data quality are found in the:
a. Data definition language
b. Data dictionary
c. Data standards
d. Data definition - CORRECT ANSWER b. Data dictionary
A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code for professional fee reporting?
a. -79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period
b. -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
c. -59, Distinct procedural service
d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period - CORRECT ANSWER d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period
A computer software program that supports a coder in assigning correct codes is called a(n):
a. Encoder
b. Grouper
c. Automated coder
d. Decision support system - CORRECT ANSWER a. Encoder
The name of the government agency that has led the development of basic data sets for health records and computer databases is:
a. The Centers for Medicare and Medicaid Services
b. The National Committee on Vital and Health Statistics
c. The American National Standards Institute
d. The National Institute of Health - CORRECT ANSWER b. The National Committee on Vital and Health Statistics
A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR ________.
a. maintenance plan
b. management plan
c. attribute plan
d. strategic plan - CORRECT ANSWER a. maintenance plan
An alteration of the health information by modification, correction, addition, or deletion is known as a(n):
a. Change
b. Amendment
c. Copy and paste
d. Deletion - CORRECT ANSWER b. Amendment
A patient born with a neural tube defect would be included in which type of registry?
a. Birth defects
b. Cancer
c. Diabetes
d. Trauma - CORRECT ANSWER a. Birth defects
The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called:
a. Information asset management
b. Information management
c. Information governance
d. Enterprise information management - CORRECT ANSWER c. Information governance
Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to:
a. Have the administrator of the hospital complete them
b. Have the charge nurse on the respective nursing units complete them
c. Ask the chief of staff to complete them
d. File the incomplete records with a notation about the physician's death - CORRECT ANSWER d. File the incomplete records with a notation about the physician's death
What is a primary purpose for documenting and maintaining health records?
a. Effective communication among caregivers for continuity of care
b. Substantiate claims for reimbursement
c. Provide evidence for malpractice lawsuits
d. Contribute to medical science - CORRECT ANSWER a. Effective communication among caregivers for continuity of care
The inpatient data set incorporated into federal law and required for Medicare reporting is the:
a. Ambulatory Care Data Set
b. Uniform Hospital Discharge Data Set
c. Minimum Data Set for Long-term Care
d. Health Plan Employer Data and Information Set - CORRECT ANSWER b. Uniform Hospital Discharge Data Set
A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables?
a. One-to-one
b. One-to-many
c. Many-to-many
d. One-to-two - CORRECT ANSWER b. One-to-many
The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of:
a. Assisting coders to read physician handwriting
b. Preventing potential medication errors due to misinterpretation
c. Making terminology consistent in preparation for electronic records
d. Identifying physicians who are dispensing large quantities of drugs - CORRECT ANSWER b. Preventing potential medication errors due to misinterpretation
Unstructured data may be preferred over structured data because:
a. It does not require processing
b. It provides greater detail
c. Clinicians know how to enter it
d. It is more complete - CORRECT ANSWER b. It provides greater detail
A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a:
a. Spreadsheet
b. Database
c. File
d. Data table - CORRECT ANSWER b. Database
Regardless of the healthcare setting, accreditation and regulatory standards require a separate healthcare record for each:
a. Family
b. Individual patient
c. Encounter with the facility
d. Day of treatment - CORRECT ANSWER b. Individual patient
A patient has HIV with disseminated candidiasis. What is the correct code assignment?
B20 Human immunodeficiency virus [HIV] disease
B37.0 Candidal stomatitis
Oral thrush
B37.7 Candidal sepsis
Disseminated candidiasis
Systemic candidiasis
B37.89 Other sites of candidiasisCandidal osteomyelitis
a. B20, B37.0
b. B37.7, B20
c. B20, B37.7
d. B20, B37.89, B37.7 - CORRECT ANSWER c. B20, B37.7
In long-term care, the resident's comprehensive assessment is based on data collected in the:
a. UHDDS
b. OASIS
c. MDS
d. HEDIS - CORRECT ANSWER c. MDS
Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and:
a. AMA
b. OIG
c. CMS
d. WHO - CORRECT ANSWER c. CMS
What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)?
a. Face sheet
b. Care plan
c. Diagnosis plan
d. Flow sheet - CORRECT ANSWER b. Care plan
Which of the following is an example of a 1:1 relationship?
a. Patients to hospital admissions
b. Patients to consulting physicians
c. Patients to clinics
d. Patients to hospital beds - CORRECT ANSWER d. Patients to hospital beds
What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options?
a. Core measures
b. Enhanced discharge planning
c. Data mining
d. Clinical practice guidelines - CORRECT ANSWER d. Clinical practice guidelines
Which document is used in the long-term care setting that is not used in the acute-care setting?
a. Progress notes
b. Monthly summary
c. Physician consultations
d. Physician orders - CORRECT ANSWER b. Monthly summary
Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?
a. Case definition
b. Case finding
c. Follow-up
d. Reporting - CORRECT ANSWER b. Case finding
Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication?
a. Unit secretary working on the unit where the patient is located
b. Nurse working on the unit where the patient is located
c. Health information director
d. Admissions registrars - CORRECT ANSWER b. Nurse working on the unit where the patient is located
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the:
a. Reason for admission
b. Activities of daily living
c. Discharge diagnosis
d. Reason for encounter - CORRECT ANSWER d. Reason for encounter
The legal health record for disclosure consists of:
a. Any and all protected health information data collected or used by a healthcare entity when delivering care
b. Only the protected health information requested by an attorney for a legal proceeding
c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings
d. All of the data and information included in the HIPAA Designated Record Set - CORRECT ANSWER c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings
Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called:
a. Default records
b. Delinquent records
c. Loose records
d. Suspended records - CORRECT ANSWER b. Delinquent records
When a healthcare entity destroys health records after the acceptable retention period has been met, a certificate of destruction is created. How long must the healthcare entity maintain the certificate of destruction?
a. Two years
b. Five years
c. Ten years
d. Permanently - CORRECT ANSWER d. Permanently
A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n):
a. Accreditation manual
b. Core content
c. Continuity of care record
d. Data dictionary - CORRECT ANSWER d. Data dictionary
What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met?
a. Qualitative analysis
b. Legal record review
c. Utilization analysis
d. Ongoing record review - CORRECT ANSWER a. Qualitative analysis
A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment?
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.8 Type 1 diabetes mellitus with unspecified complications
I96 Gangrene, not elsewhere classified
a. E08.52, I96
b. E10.52, I96
c. E10.8
d. E10.52 - CORRECT ANSWER d. E10.52
How do healthcare providers use the administrative data they collect?
a. For regulatory, operational, and financial purposes
b. For statistical data purposes
c. For electronic health record tracking purposes
d. For continuity of patient care purposes - CORRECT ANSWER a. For regulatory, operational, and financial purposes
Which of the following is not an appropriate method for destroying paper-based health records?
a. Burning
b. Shredding
c. Pulverizing
d. Degaussing - CORRECT ANSWER d. Degaussing
To ensure authentication of data entries, which type of signature is the most secure?
a. Digital
b. Electronic
c. Handwritten
d. Virtual - CORRECT ANSWER a. Digital
Which of the following is the appropriate method for destroying electronic data?
a. Burning
b. Shredding
c. Pulverizing
d. Degaussing - CORRECT ANSWER d. Degaussing
Personal information about patients such as their names, ages, and addresses is considered what type of information?
a. Clinical
b. Administrative
c. Operational
d. Accreditation - CORRECT ANSWER b. Administrative
Which of the following keywords precedes the listing of variables to be returned from an SQL query?
a. SELECT
b. SET
c. DATA
d. BY - CORRECT ANSWER a. SELECT
Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay?
a. Uniform Hospital Discharge Data Set
b. Data Elements for Emergency Department Systems
c. Uniform Ambulatory Care Data Set
d. Essential Medical Data Set - CORRECT ANSWER c. Uniform Ambulatory Care Data Set
Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence.
a. 54401, Insertion of penile prosthesis; inflatable (self-contained)
b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
c. 54440, Plastic operation of penis for injury
d. 54400, Insertion of penile prosthesis, non-inflatable (semi-rigid) - CORRECT ANSWER a. 54401, Insertion of penile prosthesis; inflatable (self-contained)
What tool is used to sort data in a variety of ways to assist in the study of certain data elements?
a. Registries
b. Indexes
c. Clinical trials
d. Statistical reports - CORRECT ANSWER b. Indexes
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?
a. Original
b. Source
c. Protected
d. Derived - CORRECT ANSWER d. Derived
Data content standards are used to:
a. Share data in the same way the users interpret data
b. Share data is a unique way
c. Share data between disparate systems
d. Modify data - CORRECT ANSWER a. Share data in the same way the users interpret data
What is the first consideration in determining how long records must be retained?
a. The amount of space allocated for record filing
b. The number of records
c. The most stringent law or regulation in the state
d. The cost of filing space - CORRECT ANSWER c. The most stringent law or regulation in the state
Which of the following is a concept designed to help standardize clinical content for sharing between providers?
a. Continuity of care record
b. Interoperability
c. Personal health record
d. SNOMED - CORRECT ANSWER a. Continuity of care record
A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n):
a. Implementation plan
b. Information technology plan
c. Migration path
d. Transition strategy - CORRECT ANSWER c. Migration path
Identify the level in the data model that describes how the data is stored within the database:
a. Conceptual data model
b. Physical data model
c. Logical data model
d. Data manipulation language - CORRECT ANSWER b. Physical data model
According to the Medicare Conditions of Participation, how long must health records be retained?
a. Two years
b. Five years
c. Ten years
d. Permanently - CORRECT ANSWER b. Five years
Which of the following data management domains would be responsible for establishing standards for data retention and storage?
a. Data architecture management
b. Metadata management
c. Data life cycle management
d. Master data management - CORRECT ANSWER c. Data life cycle management
Ensuring that only the most recent report is available for viewing is known as:
a. Documentation integrity
b. Authorship
c. Validation
d. Version control - CORRECT ANSWER d. Version control
Which of the following makes the indexing of scanned health records more efficient by entering metadata automatically?
a. Barcodes
b. Backscanning
c. OCE
d. CPOE - CORRECT ANSWER a. Barcodes
Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center.
a. 32405, Biopsy, lung or mediastinum, percutaneous needle
b. 37609, Ligation or biopsy, temporal artery
c. 20206, Biopsy, muscle, percutaneous needle
d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) - CORRECT ANSWER b. 37609, Ligation or biopsy, temporal artery
The practices or methods that defend against charges questioning the integrity of the data and documents are called:
a. Authentication
b. Security
c. Accuracy
d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation
The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following?
a. Authorship
b. Validation
c. Integrity
d. Identification - CORRECT ANSWER a. Authorship [Show Less]