RHIA Exam Prep 35 Questions with Verified Answers
What term is used in reference to objective descriptions of processes, procedures, people, and
... [Show More] other observable objects and activities? - CORRECT ANSWER Data
Which of the following processes is an ancillary function of the health record? - CORRECT ANSWER Biomedical Research
What term is used in reference to electronically accessed information that provides physicians with pertinent health information beyond the health record itself? - CORRECT ANSWER Clinical Practice Guidelines
To which of the following authorities do hospitals report vital statistics? - CORRECT ANSWER National Vital Statistics System
An attempt to contain hospital inpatient costs and improve quality by restructuring services is called: - CORRECT ANSWER Patient-focused care
What organization was established in 1847 to represent the interests of physicians across the United States? - CORRECT ANSWER American Medical Association
Today, to practice medicine, medical school students must pass a test before they can obtain a: - CORRECT ANSWER License
For healthcare organizations, this modern process began with the adoption of the Minimum Standards: - CORRECT ANSWER Accreditation
Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? - CORRECT ANSWER Credentialing
Which of the following is a mechanism that records and examines activity in information systems? - CORRECT ANSWER Audit controls
Which of the following is the goal of quantitative analysis performed by HIM professionals? - CORRECT ANSWER Identifying deficiencies early so they can be completed
What are LONIC codes used for? - CORRECT ANSWER Identifying test results
While the focus of inpatient data collection is on the principle diagnosis, the focus of outpatient data collection is on the: - CORRECT ANSWER Reason for encounter
The inpatient data set incorporated into federal law and required for Medicare reporting is the: - CORRECT ANSWER Uniform Hospital Discharge Data Set
In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? - CORRECT ANSWER X12N
This 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 LTCH. - CORRECT ANSWER Care Plan
Which of the following is a component of the Resident Assessment Instrument? - CORRECT ANSWER A standard Minimum Data Set
Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? - CORRECT ANSWER Nurse working on the unit where the patient is located
Who is responsible for ensuring the quality of health record documentation? - CORRECT ANSWER Provider
Of the following, what is the most likely to happen to the health records of a physician's patient when a physician leaves an office practice? - CORRECT ANSWER It will be retained by the practice
Which health record format is arranged in chronological order with documentation from various sources intermingled? - CORRECT ANSWER Electronic
Staff disagreements within the health record should be: - CORRECT ANSWER Avoided
Mrs. Bolton is an angry patient who resents her physicians "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: - CORRECT ANSWER Noncompliant and hostile toward staff
The___is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for Long-term Care (MDS). - CORRECT ANSWER Resident Assessment Instrument
One technology used for computer-assisted coding is: - CORRECT ANSWER Natural language processing
A barrier to effective computer-assisted coding is the: - CORRECT ANSWER Poor quality of documentation
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
A coding supervisor checks coding quality each month by having two or more coders code the same set of records and then comparing the results. This process addresses the data quality element of: - CORRECT ANSWER Reliability
A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is: - CORRECT ANSWER Continuity of Care Record
A consumer interested in comparing the performance of health plans should review data from: - CORRECT ANSWER HEDIS
Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and: - CORRECT ANSWER CMS
A computer software program that supports a coder in assigning correct codes is called a(n): - CORRECT ANSWER Encoder
Diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? - CORRECT ANSWER Inpatient
Patient has HIV with disseminated candidiasis; what is the correct code assignment? - CORRECT ANSWER 042, 112.5
A 65 year old woman was admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? - CORRECT ANSWER 038.11, 562.11 [Show Less]