RHIA Exam Review 116 Questions with Verified Answers
Which one of the following actions would NOT be included int he professional obligations of the
... [Show More] health information practitioner that lead to responsible handling of patient health information?
A. Educate consumers about their rights and responsibilities regarding the use of their personal health information.
B. Extend privacy and security principles into all aspects of the data use, access, and control program adopted in the organization.
C. Honor the patient-centric direction of the national agenda.
D. Take a compromising position toward optimal interpretation of nonspecific regulations and laws. - CORRECT ANSWER D. Take a compromising position toward optimal interpretation of nonspecific regulations and laws
If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the
A. date of birth.
B. date of admission.
C. social security number.
D. mother's maiden name. - CORRECT ANSWER A. date of birth
Which of the following is NOT a step in developing a health record retention schedule?
A. conducting an inventory of the facility's records
B. determining the format and location of storage
C. assigning all records the same retention period
D. destroying records that are no longer needed - CORRECT ANSWER C. assigning all records the same retention period
What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79?
A. terminal digit
B. straight numeric
C. social security number
D. middle digit - CORRECT ANSWER B. straight numeric
If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate?
A. 2.4%
B. 3.5%
C. 4.6%
D. 5.1% - CORRECT ANSWER A. 2.4%
(3,545 x 100) divided by 15,000 = 2.36% = 2.4%
Which of the following is NOT an advantage of a centralized filing system?
A. There is less transportation time and effort when a facility operates from several sites.
B. There is less duplication of effort to create, maintain, and store records.
C. Record control and security are easier to maintain.
D. There is decreased cost in space and equipment. - CORRECT ANSWER A. There is less transportation time and effort when a facility operates from several sites.
In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26?
A. 00-06-26
B. 02-06-26
C. 03-06-26
D. 99-99-25 - CORRECT ANSWER A. 00-06-26
The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions would be most effective in reducing the delay in retrieval of requested records?
A. Offer a prize to the employee who locates the requested records first.
B. Review and possibly reengineer the retrieval process to decrease retrieval time.
C. Allow the requesters to retrieve the record themselves.
D. Increase file area staff to include one additional file clerk devoted to pulling records for the emergency room. - CORRECT ANSWER B. Review and possibly reengineer the retrieval process to decrease retrieval time.
Which one of the following is NOT an advantage of a computerized master patient index?
A. It allows access to data alphabetically, phonetically, or by date of birth, social security number, medical record, or billing number.
B. It solves most space and retrieval problems.
C. It provides other departments with immediate access to the information maintained in the master patient index.
D. Duplication of patient registration can never occur. - CORRECT ANSWER D. Duplication of patient registration can never occur.
Color coding of record folders is used to assist in the control of
A. record tracking.
B. loose reports.
C. record completion.
D. misfiles. - CORRECT ANSWER D. misfiles.
Information found in which of the following would not be considered secondary data?
A. disease index
B. implant registry
C. health record
D. National Practitioner Data - CORRECT ANSWER C. health record
Under the Patient Self-Determination Act of 1990, evidence of advance directives
A. are required to be documented in the health record.
B. are not required to be documented int he health record.
C. require a doctor's approval.
D. must be prepared by an attorney. - CORRECT ANSWER A. are required to be documented in the health record.
A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number?
A. 6
B. 8
C. 10
D. 12 - CORRECT ANSWER D. 12
200 units x 6 shelves per unit = 1,200 shelves total
1,200 shelves divided by 100 primary numbers (00-99) = 12 shelves per primary number
A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken?
A. Return inactive records to each individual patient.
B. Destroy records of all deceased patients.
C. Destroy inactive records that exceed the statute of limitations.
D. Maintain the records indefinitely in hard copy. - CORRECT ANSWER C. Destroy inactive records that exceed the statute of limitations.
Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital?
A. terminal digit
B. unit
C. straight numeric
D. serial unit - CORRECT ANSWER C. straight numeric
What is the chief criterion for determining record inactivity?
A. Medicare's definition of inactivity
B. amount of space available for storage of newer records
C. efficiency of microfilming
D. preference of the medical staff - CORRECT ANSWER B. amount of space available for storage of newer records
Out of 2,543 records requested from the HIM Department, 2,375 were located. What is the filing accuracy rate?
A. 6.61%
B. 75.33%
C. 89.01%
D. 93.39% - CORRECT ANSWER D. 93.39%
(2,375 records retrieved from proper locations x 100) divided by 2,543 records requested = 93.39% filing accuracy
Which set of records filed consecutively on a shelf displays terminal digit filing order?
A. 00-79-99, 00-79-01, 99-78-99
B. 57-78-00, 57-78-01, 56-78-99
C. 99-05-26, 01-06-26, 49-04-02
D. 55-55-55, 33-33-33, 44-44-44 - CORRECT ANSWER B. 57-78-00, 57-78-01, 56-78-99
In the master patient index, which is filed by last name, Jill Thomas-Jones would be
A. J-I-L-L-T-H-O-M-A-S-J-O-N-E-S
B. T-H-O-M-A-S-J-O-N-E-S,J-I-L-L
C. T-H-O-M-A-S,J-I-L-L-J-O-N-E-S
D. J-O-N-E-S,J-I-L-L-T-H-O-M-A-S - CORRECT ANSWER B. T-H-O-M-A-S-J-O-N-E-S,J-I-L-L
According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30?
A. 99-98-30
B. 00-00-31
C. 01-00-31
D. 99-99-31 - CORRECT ANSWER B. 00-00-31
How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals require that patient health records be retained for at least ________ years unless a longer period is required by state or local laws.
A. 3
B. 5
C. 7
D. 10 - CORRECT ANSWER B. 5
Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be
A. 5 years.
B. 7 years.
C. 10 years.
D. either 5 or 7 years, as determined by the facility. - CORRECT ANSWER B. 7 years
Which of the following technologies works best with automated record-tracking systems to speed the data entry process?
A. discharge lists
B. bar codes
C. compressible filing units
D. computerized chart-out slips - CORRECT ANSWER B. bar codes
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased?
A. 11
B. 12
C. 13
D. 14 - CORRECT ANSWER D. 14
2,540 + 400 = 2,940 inches needed
36 x 6 = 216 inches per unit
2,940 (inches needed) divided by 216 (inches per unit) = 13.61 shelves
You must buy 14 units because you cannot purchase a 0.14 filing shelf.
Microfilmed records are considered
A. inadmissible evidence.
B. never admissible as hearsay evidence.
C. acceptable as courtroom evidence.
D. not admissible as secondary evidence. - CORRECT ANSWER C. acceptable as courtroom evidence.
A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2016. Which of the following indices would be the best source in locating the needed records?
A. master patient index
B. physician index
C. disease index
D. operation index - CORRECT ANSWER C. disease index
Which item is collected and maintained in the organ transplant registry?
A. vaccine manufacturer
B. histocompatibility information
C. cytogenetic results
D. stage at the time of diagnosis - CORRECT ANSWER B. histocompatibility information
Which of the following is NOT a mandatory disclosure according to the HIPAA Privacy Rule?
A. emergencies concerning public health
B. quality assurance reviews by authorized authorities
C. instances concerning victims of domestic violence
D. reporting of traffic fatalities - CORRECT ANSWER D. reporting of traffic fatalities
Which of the following should NOT be included in the documentation of record destruction?
A. statement that records were destroyed in the normal course of business
B. method of destruction
C. signature of the individuals supervising and witnessing the destruction
D. dates not covered in destruction - CORRECT ANSWER D. dates not covered in destruction
If the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number?
A. 8
B. 10
C. 12
D. 100 - CORRECT ANSWER A. 8
8 shelves per unit x 100 units = 800 total shelves
800 shelves divided by 100 primary digits (00-99) = 8 shelves per primary digit
Which of the following is NOT a consideration when implementing a disaster plan?
A. Include disaster training in staff orientation.
B. Establish a plan for conducting drills.
C. Provide staff with tools needed to implement the plan.
D. Test the disaster plan only once. - CORRECT ANSWER D. Test the disaster plan only once.
Which of the following lists is in correct alphabetical order?
A. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip; Ferlazzo, J.
B. Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P. Ferlazzo, Joshua Philip
C. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, J.; Ferlazzo, Joshua Philip
D. Ferlazzo, Joshua A.; Ferlazzo, B.; Ferlazzo, Joshua; Ferlazzo, Joshua Philip - CORRECT ANSWER B. Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip
Mary Schnering was admitted to Community Hospital on 10/3/15 and assigned a record number of 54-47-53. The patient was later admitted on 1/14/16 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering/filing system is being used at Community Hospital?
A. serial-unit
B. serial
C. unit
D. terminal digit - CORRECT ANSWER A. serial-unit
Capital Health Center is moving to a new facility in December 2016. The CEO is projecting a conversion to an electronic health record system by then. This new facility will not include space for filing of paper-based health records. Which of the following items would not be considered when planning this conversion?
A. changing role of department functions and work flow
B. challenges of maintaining records that are partially paper and partially electronic
C. whether to scan older paper records
D. relationship with the microfilm vendor - CORRECT ANSWER D. relationship with the microfilm vendor
What microform should the HIM practitioner select if the records must be unitized and color-coded for filing purposes?
A. roll microfilm
B. cartridge
C. jacket microfilm
D. cassette - CORRECT ANSWER C. jacket microfilm
What is the business of buying and selling information as a commodity?
A. information brokering
B. e-health consumerism
C. telehealth
D. competitive data - CORRECT ANSWER A. information brokering
At Community Hospital the average admission will create a file that will take up 0.25 inch of file space. Each new ER record requires 0.125 inch of file space. Approximately 25,000 new patients are admitted per year and 15,000 ER patients are treated per year. The shelving cost is $1.05 per filing inch. How much money should be allocated for storage space in next year's budget?
A. $8,531.25
B. $8,125.00
C. $853.25
D. $1,875.00 - CORRECT ANSWER A. $8,531.25
25,000 inpatients x 0.25 inch/record = 6,250 inches
15,000 ER patients x 0.125 inch/record = 1,875 inches
6,250 inches + 1,875 inches = 8,125 total inches of filing space/year
8,125 total inches x $1.05/filing inch = $8,531.25 budget allocation for storage space
On his 12/23/16 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous number assigned to Mr. Robinson during a 9/1/16 admission was 07-10-47. In a serial numbering/filing system, how would these records be filed?
A. Both records are combined under 07-10-47.
B. Both records are combined under 07-23-38.
C. Each admission is filed under its own number.
D. Previous records are brought forward and filed under the latest number issued. - CORRECT ANSWER C. Each admission is filed under its own number.
The same patient was admitted on three different occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be used given the following information?
Admitted 5/04/16 Patty Miller 23-33-56
Admitted 6/05/16 P. J. Miller 25-56-88
Admitted 9/27/16 Patricia Miller 27-12-12
A. Void the first and last numbers and file all admissions under 25-56-88.
B. Delete all previous numbers and assign a completely new number.
C. Void the first two numbers and file all admission under 27-12-12.
D. Void the last two numbers and file all admissions under 23-33-56. - CORRECT ANSWER D. Void the last two numbers and file all admissions under 23-33-56.
The health care providers in an acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should
A. staff the department with personnel 24 hours a day.
B. be on call every evening and weekends for emergency requests.
C. train security guards to retrieve records after the department closes.
D. arrange for records to be retrieved at 7:00 AM every morning. - CORRECT ANSWER A. staff the department with personnel 24 hours a day.
As a prerequisite in the implementation of an electronic health record, what process would facilitate automatic indexing?
A. redesigning forms to include bar codes
B. removing portions of the patient record that will not be scanned
C. converting all microfilm to optical disk format
D. scanning only emergency room records initially - CORRECT ANSWER A. redesigning forms to include bar codes
Which of the following is NOT a data retrieval tool?
A. light pen
B. SQL
C. color, animation, sound icons
D. screen design - CORRECT ANSWER A. light pen
A HIM Department wants to buy new open-shelf filing units for its file expansion. Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average record is 1-inch thick. How many filing units should be purchased?
A. 2
B. 4
C. 6
D. 8 - CORRECT ANSWER C. 6
33 inches per shelf x 6 shelves per unit = 198 linear filing inches per unit
1,000 records x 1 inch per record = 1,000 inches of records to be filed
1,000 (inches of records needed) divided by 198 inches per unit = 5.05 filing units
In order to provide for the total expansion, 6 filing units need to be purchased.
Which of the following statements is FALSE when addressing characteristics of the legal health record in an electronic document management system?
A. The storage media used and the format of the scanned documents must protect data from loss and damage.
B. The storage format must be efficient, manageable, and in compliance with laws and regulations.
C. The backup and disaster recovery process is certified to ensure that all data can be recovered.
D. Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems. - CORRECT ANSWER D. Direct electronic interfaces from ancillary department systems to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems.
Which of the following is NOT a document input device in the electronic document management system?
A. scanner
B. bar codes
C. printer
D. touch screen - CORRECT ANSWER C. printer
The master patient index must, at a minimum, include sufficient information to
A. summarize the patient's medical history.
B. list all physicians who have ever treated the patient.
C. uniquely identify the patient.
D. justify the patient's hospital bill. - CORRECT ANSWER C. uniquely identify the patient.
Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital?
A. National Practitioner Data Bank
B. Healthcare Integrity and Protection Data Bank
C. MEDPAR file
D. State Administrative Data Bank - CORRECT ANSWER A. National Practitioner Data Bank
It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed?
A. discharge summaries
B. physician names
C. nursing notes
D. dates of admission, discharge, and encounters - CORRECT ANSWER D. dates of admission, discharge, and encounters
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?
A. statute of limitations
B. volume of research
C. readmission rate
D. department staffing - CORRECT ANSWER D. department staffing
Which of the following is NOT a benefit of the electronic document management system in the HIM department?
A. online availability of information
B. multiuser simultaneous access
C. decreased use of computer technology
D. system security and confidentiality - CORRECT ANSWER C. decreased use of computer technology
Which of the following is an advantage of straight numeric filing over terminal digit filing?
A. All sections of the file expand uniformly.
B. The training period is short.
C. Work can be evenly distributed, causing accountability for accuracy in each of the 100 sections.
D. Inactive records can be purged evenly. - CORRECT ANSWER B. The training period is short.
Which one of the following is NOT an electronic document management system component?
A. scanner
B. file server
C. laser printer
D. reader-printer - CORRECT ANSWER D. reader-printer
Which of the following items is the health information manager primarily concerned with when purchasing file guides?
A. cost and color
B. durability and visibility
C. cost and visibility
D. color and durability - CORRECT ANSWER B. durability and visibility
Palm Beach Healthcare Center has been in operation for 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admissions per year from now on. There are 2,500 linear feet of filing space available and half is being used. The facility expects a 30% readmission rate. If a unit numbering/filing system is used, how many file folders will be needed for the next year?
A. 1,800
B. 1,860
C. 4,340
D. 6,200 - CORRECT ANSWER C. 4,340
6,000 admissions (year currently) + 200 additional admissions/year = 6,200 total admissions next year
6,200 total admissions x 30% readmission rate = 1,860 readmissions next year
6,200 - 1,860 readmissions = 4,340 new file folders needed for next year
As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to
A. install a computerized access control panel.
B. hire a security guard to monitor entrance to the file area.
C. convert from a terminal digit filing system to serial unit filing.
D. utilize a sign-in and sign-out log for admittance to the file area. - CORRECT ANSWER A. install a computerized access control panel
Which one of the following is NOT a technical security control employed by electronic health record systems?
A. audit trails
B. data encryption protocols
C. user-based access controls
D. automatic logon - CORRECT ANSWER D. automatic logon
The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information?
A. patient register
B. disease index
C. operation index
D. birth defects register - CORRECT ANSWER C. operation index
A major consideration in a hospital or facility closure is to
A. notify all patients to pick up their original records by the date of closure.
B. seek approval for destruction of all records with a last date of treatment over 3 years ago.
C. ensure that authorized parties have access to the information as provided by law.
D. arrange for donating the records to an HIA/HIT education program for student use. - CORRECT ANSWER C. ensure that authorized parties have access to the information as provided by law.
What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program?
A. 70%
B. 80%
C. 90%
D. 100% - CORRECT ANSWER C. 90%
In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing?
A. who completes the list of what records are to be stored
B. what are the billing terms
C. who will purge inactive files for transfer
D. confidentiality policies and liability concerns - CORRECT ANSWER D. confidentiality policies and liability concerns
Which index is used by the HIM department to link the patient's name and number in relation to access and retention of the patient record?
A. physician index
B. disease index
C. master patient index
D. operation index - CORRECT ANSWER C. master patient index
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long?
A. age of majority plus statute of limitation
B. 10 years after the most recent encounter
C. 10 years after the age of majority
D. permanently - CORRECT ANSWER A. age of majority plus statute of limitation
A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?
A. overwriting data with a series of characters
B. disk reformatting
C. magnetic degaussing
D. overwriting the backup tapes - CORRECT ANSWER C. magnetic degaussing
Which of the following statements would be found in the laboratory report section of the health record?
A. BUN reported as 20 mg
B. Morphine sulfate gr. 1/4 q.4h. for pain
C. IV sodium Pentothal 1% started at 9:05 AM
D. TPR recorded g.h. for 12 hours - CORRECT ANSWER A. BUN reported as 20 mg
Which of the following is a disadvantage of terminal digit filing as compared to straight numeric filming?
A. File personnel are crowded in the highest numbers.
B. Inactive records are pulled from one common area.
C. The training period is slightly longer.
D. Files expand at the end of the umber series, requiring back shifting. - CORRECT ANSWER C. The training period is slightly longer.
What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms?
A. past medical history
B. social and personal history
C. chief complaint
D. review of systems - CORRECT ANSWER D. review of systems
Electronic health record built-in tools that can make data capture easier include all but which one of the following?
A. data dictionaries
B. flow process charts
C. automated quality measures
D. clinical decision support systems - CORRECT ANSWER B. flow process charts
If the department staff are having trouble locating the terminal digit sections quickly, the supervisor could add more
A. outguides.
B. file guides.
C. requisitions.
D. staff. - CORRECT ANSWER B. file guides.
The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should
A. issue a copy of the birth certificate from the patient's record.
B. direct the request to the state's office of vital records.
C. direct the request to the attending physician.
D. issue a copy of the newborn's record. - CORRECT ANSWER B. direct the request to the state's office of vital records.
A surgeon requests the name of a patient he admitted on January 11, 2017. Which of the following would be used to retrieve this information?
A. physician index
B. number index
C. R-ADT system
D. operation index - CORRECT ANSWER C. R-ADT system
Of 750 records filed during the week, 75 were not located. What is the filing error rate?
A. 10%
B. 90%
C. 0.1%
D. 0.9% - CORRECT ANSWER A. 10%
Where in the health record would the following statement be located?
"Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"?
A. operative report
B. pathology report
C. anesthesia report
D. radiology report - CORRECT ANSWER B. pathology report
Which of the following is NOT a factor to consider when developing a record retention program?
A. legal requirements as determined by statute of limitations
B. record usage in the facility determined by health care provider activity
C. reimbursement guidelines
D. cost of space to maintain paper records - CORRECT ANSWER C. reimbursement guidelines
When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?
A. audit control
B. person or entity authentication
C. transmission security
D. access control - CORRECT ANSWER D. access control
When evaluating an outside contract microfilm company, all but which of the following are important factors to rate?
A. cost
B. emergency returns
C. storage after filming
D. cache memory - CORRECT ANSWER D. cache memory
Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements?
A. method of destruction or disposal
B. time that will elapse between acquisition and destruction or disposal
C. safeguards against breaches
D. the hospital's liability insurance in specified amounts - CORRECT ANSWER D. the hospital's liability insurance in specified amounts
The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of?
A. concurrency
B. access
C. integrity
D. cost - CORRECT ANSWER B. access
When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow?
A. Security training is provided to all levels of staff.
B. Patients are not educated about their right to confidentiality of health information.
C. The information system encourages mass copying, printing, and downloading of patient records.
D. When paper-based records are no longer needed, they are bundled and sent to a recycling center. - CORRECT ANSWER A. Security training is provided to all levels of staff.
Which of the following features should NOT be considered when designing screens to capture quality health data?
A. a prompt for more information
B. built-in alerts to notify users of possible errors
C. the use of abbreviations on data fields
D. left to right and bottom to top formatting - CORRECT ANSWER D. left to right and bottom to top formatting
When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT
A. state laws and licensing standards.
B. Communities of Practice requirements.
C. needs of patients.
D. Medicare requirements. - CORRECT ANSWER B. Communities of Practice requirements.
Case finding methods for patients with diabetes include a review of all but which one of the following?
A. health plans
B. CPT diagnostic codes
C. billing data
D. medication lists - CORRECT ANSWER B. CPT diagnostic codes
What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft?
A. budget
B. disaster
C. case management
D. patient care - CORRECT ANSWER B. disaster
Which of the following is NOT an alternative storage method for paper-based records?
A. microfilm
B. optical imaging
C. computer
D. outguide - CORRECT ANSWER D. outguide
Which of the following issues would be of LEAST concern when storing health records in off-site storage?
A. operating hours of the storage facility
B. safety and confidentiality procedures
C. filing order of the records
D. procedure for request of a record in an emergency - CORRECT ANSWER C. filing order of the records
The HIM Department maintains 500,000 records and responds to 5,000 requests for records in a given period of time. What is the record usage rate?
A. 0.01%
B. 1%
C. 5%
D. 10% - CORRECT ANSWER B. 1%
(5,000 x 100) divided by 500,000 = 1%
Which one of the following is NOT a data retrieval tool?
A. color
B. sound
C. point-and-click fields
D. icons - CORRECT ANSWER C. point-and-click fields
When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract?
A. who performs record preparation
B. provision for destruction of original records
C. type of reader or printer needed to view the microfilm
D. confidentiality of information being filmed - CORRECT ANSWER C. type of reader or printer needed to view the microfilm
What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital?
A. storing the records off-site at a cost of $25,000 per year
B. scanning all 250,000 records for a cost of $195,000
C. purging and storing all death records off-site at a cost of $20,000 per year
D. destroying all records older than 3 years for a cost of $50,000 - CORRECT ANSWER B. scanning all 250,000 records for a cost of $195,000
The total number of records filed during the month is 2,500 and, upon completion of a filing accuracy study, 90 records were not found. What is the accuracy rate for filing?
A. 1%
B. 4%
C. 28%
D. 96% - CORRECT ANSWER D. 96%
2,500 - 90 = 2,410
(2,410 x 100) divided by 2,500 = 96.4% filing accuracy
A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the
A. accuracy of analyzing records.
B. number of incomplete records.
C. inclusion of late reports.
D. tracking of release of information requests. - CORRECT ANSWER C. inclusion of late reports.
According to AHIMA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently?
A. physician index
B. register of births
C. register of surgical procedures
D. register of deaths - CORRECT ANSWER A. physician index
For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which of the following elements?
A. unique and serialized transaction number
B. location of destruction
C. patient notification
D. acceptance of fiduciary responsibility - CORRECT ANSWER C. patient notification
The steps in developing a record retention program include all but which of the following?
A. determining the storage format and location
B. notifying the courts of the destruction
C. assigning each record a retention period
D. destroying records that are no longer needed - CORRECT ANSWER B. notifying the courts of the destruction
A health care facility as received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the
A. newborn records.
B. state bureau of vital statistics.
C. maternal records.
D. birth defects registry. - CORRECT ANSWER D. birth defects registry.
An example of a primary data source is the
A. physician index.
B. health record.
C. cancer registry.
D. hospital statistical report. - CORRECT ANSWER B. health record
Which of the following is NOT considered a challenge in the adoption of an electronic health record system?
A. design of the work flow and processes
B. physician willingness to adopt
C. contribution to the quality of patient care
D. individual state legal and regulatory issues - CORRECT ANSWER C. contribution to the quality of patient care
Fetal monitoring strips are part of the _________ record and should be maintained _________.
A. newborn's; 10 years past the age of majority
B. mother's; according to the length of time required for a minor's records
C. newborn's; according to the time period specified in the state's statute of limitations
D. mother's; 10 years - CORRECT ANSWER B. mother's; according to the length of time required for a minor's records
Which one of the following would NOT be a strategy when purchasing an electronic health record system?
A. Recognize stakeholders from different organizational levels and engage them appropriately.
B. Determine return on investment or cost-benefit analysis.
C. Identify system requirements.
D. Broaden the vendor field and select several vendors of choice. - CORRECT ANSWER D. Broaden the vendor field and select several vendors of choice.
How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained?
A. 5
B. 7
C. 30
D. permanently - CORRECT ANSWER C. 30
What data cannot be retrieved from the MEDPAR?
A. ICD-10-CM diagnosis codes
B. Charges broken down by specific types of services
C. Non-Medicare patient data
D. Data on the provider - CORRECT ANSWER C. Non-Medicare patient data
Which of the following is NOT a major management challenge in the storage and retention of electronic health record systems?
A. following state and federal laws and accreditation requirements when developing retention and destruction policies
B. keeping technology updated in order to retrieve data
C. ensuring that health information can be retrieved in a timely manner
D. maintaining the paper-based storage system - CORRECT ANSWER D. maintaining the paper-based storage system
General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity?
A. desktop publishing
B. word processing
C. database management system
D. command interpreter - CORRECT ANSWER C. database management system
The Director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Director's response?
A. decreased clinical documentation errors
B. increased work efficiency
C. faster access to health data
D. elimination of the need for expensive desktop computers - CORRECT ANSWER D. elimination of the need for expensive desktop computers
The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed?
A. Visit corporate headquarters of the vendor.
B. Perform a vendor reference check.
C. Read consumer reports before buying.
D. Test the software prior to purchase. - CORRECT ANSWER D. Test the software prior to purchase.
Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate all but which of the following?
A. security controls and access privileges of staff
B. policies and procedures developed to safeguard privacy and security
C. use of a back-up system
D. salary for the database administrator - CORRECT ANSWER D. salary for the database administrator
Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used?
A. HTML
B. SQL
C. XML
D. data dictionary - CORRECT ANSWER B. SQL
The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they more through the completion process. What departmental function is this most useful for?
A. release of information
B. coding
C. chart tracking
D. transcription - CORRECT ANSWER C. chart tracking
The hospital administrator is making a strategic decision by queering various institutional databases for information. What type of system is the hospital administrator using?
A. electronic health record system
B. results reporting system
C. financial information system
D. executive information system - CORRECT ANSWER D. executive information system
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using?
A. intranet
B. extranet
C. Internet
D. clinical information system - CORRECT ANSWER D. clinical information system
The HIM practitioner's duty to retain health information via the archiving and storage of health data includes all but which of the following?
A. strategies that consider accessibility, natural disasters, and innovations in storage technology
B. strategies ensuring that inactive records are as secure as active records
C. a retention plan for multiple volumes of records
D. a retention plan for financial data - CORRECT ANSWER D. a retention plan for financial data
As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system?
A. authentication
B. encryption
C. disaster recovery plan
D. stonewall - CORRECT ANSWER D. stonewall
Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(an)
A. interfaced system.
B. integrated system.
C. OLAP.
D. standard. - CORRECT ANSWER A. interfaced system.
The function of a(an) ________ is limited to data retrieval.
A. electronic health record
B. executive information system
C. database management system
D. clinical data repository - CORRECT ANSWER D. clinical data repository
The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry?
A. Enhanced databases will provide information for improved clinical care.
B. Training will be offered by the hospital.
C. Those physicians not in compliance will be denied admitting privileges.
D. Multiple users will not have access to the same information simultaneously. - CORRECT ANSWER A. Enhanced databases will provide information for improved clinical care.
University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs?
A. application service provider model
B. clinical workstation
C. IBM Medical Information Systems Program
D. legacy system - CORRECT ANSWER A. application service provider model
A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would
A. be filed in a health record created for the infant.
B. be filed in the mother's record.
C. be retained in a separate file in the administrative offices.
D. not be retained in hospital records. - CORRECT ANSWER B. be filed in the mother's record. [Show Less]