RHIA EXAM PREP 169 Questions with Verified Answers
A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is
... [Show More] now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure?
a. Destruction
b. Extirpation
c. Fragmentation
d. Release - CORRECT ANSWER b. Extirpation
***Taking or cutting out solid matter from a body part
Which type of data consists of *factual details* a *aggregated or summarized* from a group of health records that provides *no means to identify specific patients*?
a. Orginal
b. Source
c. Protected
d. Derived - CORRECT ANSWER d. Derived
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
When a healthcare entity destroys the health records after the acceptable retention period has been met, a *certificate of destruction* is created. How long must the healthcare entity maintain the the certificate of destruction?
a. Two years
b. Five years
c. Ten years
d. Permanently - CORRECT ANSWER d. Permanently
Which of the following processes is an ancillary function of the health record?
a. Admitting and registration information
b. Billing and reimbursement
c. Patient assessment and care planning
d. Biomedical research - CORRECT ANSWER d. Biomedical research
***Ancillary function- medical services or supplies that are not provided by acute care hospitals, doctors, or healthcare professionals
What are LOINC codes used for?
a. Identifying test results
b. Reporting test results
c. Identifying tests unique to a specific company
d. Reporting a code for reimbursement - CORRECT ANSWER a. Identifying test results
Logical Observation Identifiers, Names and Codes (LOINC) is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results.
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on:
a. Reason for admission
b. Activities of daily living
c. Discharge diagnosis
d. Reason for encounter - CORRECT ANSWER d. Reason for encounter
The inpatient data set that has been incorporated into federal law and is *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
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
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
***Care plan is required for patients in a LTCH
Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin are all examples of:
a. Auto-authentication fields
b. Metadata
c. Data
d. Information fields - CORRECT ANSWER b. Metadata
Data content standards are used to:
a. Share data in the same way the users interpret data
b. Share data in 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
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
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
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
Who is responsible for ensuring the quality of health record documentation?
a. Board of directors
b. Administrator
c. Provider
d. Health information management professionals - CORRECT ANSWER c. Provider
A diagnosis described as "possible," "likely," or "rule out" is reported as if present for which type of patient records?
a. Outpatient
b. Inpatient
c. Emergency room
d. Physician office - CORRECT ANSWER b. Inpatient
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
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
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
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 plan
d. Transition strategy - CORRECT ANSWER c. Migration plan
Which of the following is the appropriate method for destroying electronic data?
a. Burning
b. Shredding
c. Pulverizing
d. Degaussing - CORRECT ANSWER d. Degaussing
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?
a. Chief data officer
b. Data definition steward
c. Data production steward
d. Auditing integrity - CORRECT ANSWER b. Data definition steward
Because a health record contains *patient-specific data* and information about a patient that has been documented by the professionals who provided care or service 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
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
Secondary data source provide information that is _____ available by looking at individual health records.
a. Not easily
b. Easily
c. Often
d. Never - CORRECT ANSWER a. Not easily
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
***MDS- federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents
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
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
A critical 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
***Data dictionary- descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology
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
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 (CMS)
b. The National Committee on Vital and Health Statistics (NCVHS)
c. The American National Standards institute (ANSI)
d. The National Institute of Health (NIH) - CORRECT ANSWER b. The National Committee on Vital and Health Statistics (NCVHS)
Which of the following is a concept designed to help standardize *c*linical *c*ontent for sharing between providers?
a. Continuity of care record
b. Interoperability
c. Personal health record
d. SNOMED - CORRECT ANSWER a. Continuity of care record
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
Where can you find guidelines for the *retention and destruction* of healthcare information?
a. Institute of Medicine
b. Municipal regulations
c. HIPAA
d. Accreditation standards - CORRECT ANSWER d. Accreditation standards
To practice medicine, medical school students must pass a test before they can obtain a:
a. Degree
b. Licensure
c. Residency
d. Specialty - CORRECT ANSWER b. Licensure
Which of the following is a mechanism that *records and examines activity* in information systems?
a. eSignature laws
b. Security audits
c. Minimum necessary rules
d. Access controls - CORRECT ANSWER b. Security audits
The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence?
a. The care provided to the patient
b. Identification of the record as the one subpoenaed
c. The qualifications of the treating physicians
d. Identification of the standard of care used to treat the patient - CORRECT ANSWER b. Identification of the record as the one subpoenaed
Ensuring that data have been modified or accessed only by individuals who are authorized to do so, is a function of data:
a. Data integrity
b. Data quality
c. Data granularity
d. Logging functions - CORRECT ANSWER a. Data integrity
Mr Martin has asked his physician's office to review a copy of his PHI. His request must be responded to no later than _________ after the request is made.
a. 90 days
b. 60 days
c. 30 days
d. 6 weeks - CORRECT ANSWER c. 30 days
The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI:
a. For as long as it is maintained
b. For six years
c. Forever
d. For 12 months - CORRECT ANSWER a. For as long as it is maintained
Under the HIPAA Security Rule, these types of safeguards have to do with *protecting the environment*:
a. Administrative
b. Physical
c. Security
d. Technical - CORRECT ANSWER b. Physical
Which of the following controls external access to a network?
a. Access controls
b. Alarms
c. Encryption
d. Firewall - CORRECT ANSWER d. Firewall
Which of the following must be reported to the medical examiner?
a. Burns
b. Accidental deaths
c. Causes of injury
d. Morbidity - CORRECT ANSWER b. Accidental deaths
A visitor sign-in sheet to a computer area is an example of what type of control?
a. Administrative
b. Audit
c. Facility access
d. Workstation - CORRECT ANSWER c. Facility access
Which of the following is an *administrative safeguard* action?
a. Facility access control
b. Documentation retention guidelines
c. Maintenance control
d. Media reuse - CORRECT ANSWER b. Documentation retention guidelines
Authorization management involves:
a. The process used to protect the reliability of a database
b. Limiting user access to a database
c. Allowing unlimited use of the database
d. Developing definitions for database elements - CORRECT ANSWER b. Limiting user access to a database
Per HITECH an *accounting of disclosures* must include disclosures made during the previous:
a. 10 years
b. 6 years
c. 3 years
d. 1 year - CORRECT ANSWER c. 3 years
The age of majority in most states is:
a. 16 and older
b. 17 and older
c. 18 and older
d. 21 and older - CORRECT ANSWER c. 18 and older
Employees in the Hospital Business Office may have legitimate access to patient health information *without patient authorization* based on what HIPAA standard/principle?
a. Minimum necessary
b. Compound authorization
c. Accounting of disclosures
d. Preemption - CORRECT ANSWER a. Minimum necessary
Generally, policies addressing the confidentiality of quality improvement (QI) committee data (minutes, actions, and so forth) state that this kind of data is:
a. Protected from disclosure
b. Subject to release with patient authorization
c. Generally available to interested parties
d. May not be reviewed or released to external reviewers such as the Joint Commission - CORRECT ANSWER a. Protected from disclosure
Covered entities must retain documentation of their security policies for at least:
a. Five years
b. Five years from the date of origination
c. Six years from the date when last in effect
d. Six years from the date of the last incident - CORRECT ANSWER c. Six years from the date when last in effect
Under HIPAA, when is the patient's written authorization required to release their healthcare information?
a. For purposes related to treatment
b. For purposes related to payment
c. For administrative healthcare operations
d. For any purpose unrelated to treatment, payment, or healthcare operations - CORRECT ANSWER d. For any purpose unrelated to treatment, payment, or healthcare operations
The confidentiality of incident reports is generally protected in cases when the report is filed in:
a. The nursing notes
b. The patient's health record
c. The physician's progress notes
d. The hospital risk manager's office - CORRECT ANSWER d. The hospital risk manager's office
Which one of the following has access to personally identifiable data *without authorization* or subpoena?
a. Law enforcement in a criminal case
b. The patient's attorney
c. Public health departments for disease reporting purposes
d. Workers' compensation for disability claim settlement - CORRECT ANSWER c. Public health departments for disease reporting purposes
An original goal of HIPAA Administrative Simplification was to standardize:
a. Privacy notices given to patients
b. The electronic transmission of health data
c. Disclosure of information for treatment purposes
d. The definition of PHI - CORRECT ANSWER b. The electronic transmission of health data
Which of the following is considered a two-factor authentication system?
a. User ID and password
b. User ID and voice scan
c. Password and swipe card
d. Password and PIN - CORRECT ANSWER c. Password and swipe card
Which of the following is a "public interest and benefit" exception to the authorization requirement?
a. Payment
b. PHI regarding victims of domestic violence
c. Information requested by a patient's attorney
d. Treatment - CORRECT ANSWER b. PHI regarding victims of domestic violence
Under the Privacy Rule, which of the following must be included in a patient accounting of disclosures?
a. State-mandated report of a sexually transmitted disease
b. Disclosure pursuant to a patient's signed authorization
c. Disclosure necessary to meet the national security or intelligence requirements
d. Disclosure for payment purposes - CORRECT ANSWER a. State-mandated report of a sexually transmitted disease
What information process must be the legal counsel of Smithville Hospital perform in order to prepare for a lawsuit against the hospital?
a. Information governance
b. E-discovery
c. Transparency
d. Enterprise information management - CORRECT ANSWER b. E-discovery
What is the most common method for implementing entity authentication?
a. Personal identification number
b. Biometric identification systems
c. Token systems
d. Password systems - CORRECT ANSWER d. Password systems
A _____ helps a healthcare entity proactively ensure that the information they store and maintain is only being accessed in the *normal course of business*.
a. Contingency plan
b. Workflow analysis
c. Documentation audit
d. Security audit - CORRECT ANSWER d. Security audit
E discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended with legislation?
a. Federal Rules of Evidence
b. State Rules of Evidence
c. Federal Rules of Civil Procedure
d. State Rules of Civil Procedure - CORRECT ANSWER c. Federal Rules of Civil Procedure
Which of the following presents the greatest risk of large-scale health information breaches?
a. Unlocked rooms
b. Computer monitors positioned toward high-traffic areas
c. Unattended computer workstations
d. Laptop theft - CORRECT ANSWER d. Laptop theft
What type of safeguards comprise over half of all the safeguards included in the security rule?
a. Physical safeguards
b. Technical safeguards
c. Administrative safeguards
d. Security safeguards - CORRECT ANSWER c. Administrative safeguards
What is the most constant threat to health information integrity?
a. Natural threats
b. Environmental threats
c. Internal disaster
d. Humans - CORRECT ANSWER d. Humans
This data collection tool is used when one needs to gather data on sample observations in order to detect patterns.
a. Check sheet
b. Ordinal data tool
c. Balance sheet
d. Nominal data tool - CORRECT ANSWER a. Check sheet
To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of *reliability check* is called:
a. Precision
b. Recheck
c. Interrater
d. Construct - CORRECT ANSWER c. Interrater
Which of the following terms is defined as the *proportion of people* in a population who have a particular disease at a specific point in time or over a specified period of time?
a. Prevalence
b. Incidence
c. Frequency
d. Distribution - CORRECT ANSWER a. Prevalence
This type of chart is used to *focus attention on any variation in the process* and helps the team to determine whether that variation is normal or a result of special circumstances.
a. Pareto chart
b. Pie chart
c. Control chart
d. Line chart - CORRECT ANSWER c. Control chart
***Control chart- measures key processes over time
Which application uses statistical techniques to *determine the likelihood of certain events occurring together*?
a. Predictive modeling
b. Standard deviation
c. T-test
d. Serial numbering - CORRECT ANSWER a. Predictive modeling
This statistical inference measure both the *strength* of a *relationship* between two variables and the functional relationship between them.
a. Correlation
b. T-test
c. Simple linear regression
d. Standard deviation - CORRECT ANSWER c. Simple linear regression
This type of data display tool is used to illustrate *frequency distributions* of *continuous variables*, such as *age and length of stay (LOS)*
a. Bar graph
b. Histogram
c. Pie chart
d. Scatter diagram - CORRECT ANSWER b. Histogram
How long should the master patient index be maintained?
a. For at least 5 years
b. For at least 10 years
c. For at least 25 years
d. Permanently - CORRECT ANSWER d. Permanently
A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the:
a. Mean
b. Mode
c. Standard deviation
d. Standard variance - CORRECT ANSWER c. Standard deviation
A current key function in the health information field whereby *data is turned into useful information* is:
a. Data mining
b. Decision analysis
c. Clinical decision support
d. Data analytics - CORRECT ANSWER d. Data analytics
What tern is used for a *centralized database* that captures, sorts, and processes patient data and then sends it back to the user?
a. Clinical data repository
b. Data exchange standard
c. Central processor
d. Digital system - CORRECT ANSWER a. Clinical data repository
The _____ is a standardized assessment of *consumer perspectives* regarding healthcare access and quality in hospitals.
a. HCAHPS
b. CG-CAHPS
c. AHRQ-CAHPS
d. ONC-CAHPS - CORRECT ANSWER a. HCAHPS
Hospital Consumer Assessment of Healthcare Providers
The Administrative Simplification portion of Title II of HIPAA addresses which of the following?
a. Creating standardized forms for release of information throughout the industry
b. Computer memory requirements for health plans maintaining patient health information
c. Security regulations for personal health records
d. Uniform standards for transaction and code sets - CORRECT ANSWER d. Uniform standards for transaction and code sets
A ____ is a *range of values*, such that the probability of that range covering the true value of a parameter is a set of probability or confidence.
a. Confidence interval
b. Hypothesis
c. Proportion
d. Median - CORRECT ANSWER a. Confidence interval
Which index, often considered the *most important resource in a healthcare facility*, is a database of patients within a facility or associated group of facilities?
a. Facility-specific index
b. Disease index
c. Master patient index
d. Operation index - CORRECT ANSWER c. Master patient index
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
Change management includes:
a. Identifying problems
b. Being available to listen to staff
c. Redesigning processes
d. Educating staff on new processes - CORRECT ANSWER b. Being available to listen to staff
Reviewing claims to ensure appropriate coding for deserved payments is one method of:
a. Achieving legitimate optimization
b. Improving documentation
c. Ensuring compliance
d. Using data monitors - CORRECT ANSWER a. Achieving legitimate optimization
The purpose of Regional Extension Centers is to:
a. Implement meaningful use
b. Support providers in adopting EHR with technical assistance
c. Develop standards for HI systems
d. Provide funding for expanding the adoption of HI technology - CORRECT ANSWER b. Support providers in adopting EHR with technical assistance
Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area?
a. Serial-unit filing system
b. Serial filing system
c. Unit filing system
d. Terminal-digit filing system - CORRECT ANSWER d. Terminal-digit filing system
Where can you find guidelines for the retention and destruction of healthcare information?
a. Institute of Medicine
b. Municipal regulations
c. HIPAA
d. Accreditation standards - CORRECT ANSWER d. Accreditation standards [Show Less]