RHIA Practice Exam Questions Domain 1 with Verified Answers
A method of documenting nurses' progress notes by recording only abnormal or unusual
... [Show More] findings or deviations from the prescribed plan of care is called:
a. Problem-oriented progress notes
b. Charting by exception
c. Consultative notations
d. Open charting - CORRECT ANSWER Charting by exception
Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
a. Data accuracy
b. Data consistency
c. Data accessibility
d. Data comprehensiveness - CORRECT ANSWER Data consistency
Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data:
a. Research
b. Reference
c. Coded
d. Demographic - CORRECT ANSWER Coded
Which of the following is an acceptable means of authenticating a record entry:
a. The physician's assistant signs for the physician
b. The HIM clerk stamps entries with the physician's signature stamp
c. The charge nurse signs the physician name
d. The physician personally signs the entry - CORRECT ANSWER The physician personally signs the entry
All documentation entered in the health record relating to the patients diagnosis and treatment are considered this type of data:
a. Clinical
b. Financial
c. Identification
d. Secondary - CORRECT ANSWER Clinical
In a long term care setting, these are problem-oriented frameworks for additional patient based on problem identification items (triggered conditions):
a. Resident Assessment Protocols (RAPs)
b. Resident Assessment Instrument (RAI)
c. Utilization Guidelines (UG)
d. Minimum Data Set (MDS) - CORRECT ANSWER Resident Assessment Protocols (RAPs)
Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a:
a. Case-mix index
b. Master patient index
c. Health record matrix
d. Retention program - CORRECT ANSWER retention program
What is the principal function of health records?
a. Determine the appropriate function of health records
b. Serve as the repository of clinical documentation relevant to the care of individual patients
c. Provide information for performance improvement activities
d. Support billing and reimbursement processes - CORRECT ANSWER Serve as the repository of clinical documentation relevant to the care of individual patients
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
a. Administrative information
b. Demographic information
c. Progress notes
d. Uniform data sets - CORRECT ANSWER Uniform data sets
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:
a. Case-mix index
b Master patient index
c. Health record matrix
d. Retention schedule - CORRECT ANSWER Health record matrix
Which of the following materials are required elements in an emergency care record?
a. Patient's instructions at discharge & a complete medical history
b. Time & means of the patient's arrival, treatment rendered, and instructions at discharge
c. Time & means of the patient's arrival, patients complete medical history, and instructions at discharge.
d. Treatment rendered, instructions at discharge, and the patient's complete medical history - CORRECT ANSWER Time & mean of the patient's arrival, treatment rendered, and instructions at discharge
Charting by exception - CORRECT ANSWER a method of documenting only abnormal or unusual findings or deviations from the prescribed plan of care.
*Purpose of charting by exception is to reduce repetitive recordkeeping and documentation of normal events.
What is coded data? - CORRECT ANSWER data that is translated into standard nomenclature(the devising or choosing of names for things, especially in a science or other discipline) of classification so that it may be aggregated, analyzed and compared.
What is a resident assessment protocols (RAPs)? - CORRECT ANSWER forms a critical link to decisions about care planning and provide guidance on how to synthesize assessment info w/in a comprehensive assessment.
*RAPs guidelines help facility staff evaluate triggered conditions.
*Triggers target conditions for additional assessment and review, as warranted by Minimum Data Set(MDS) item responses.
Once a legal health record(LHR) is defined, its best practice is to create a: - CORRECT ANSWER health record matrix because it identifies and tracks the physical location of each paper document and the source of each electronic document that consists in the LHR.
In a relational data base, which of the following is an example of many to many relationship?
a. Patients to hospital admissions
b. Patients to consulting physicians
c. Patients to hospital records
d. Primary care physician to patients - CORRECT ANSWER Patients to consulting physicians
What is a relational database? - CORRECT ANSWER A group of database tables that is connected or linked by a defined relationship that ties the information together.
In ICD-10-PCS, what value is used if there is a character that does not apply to a given code?
a. X
b. -
c. 0
d. Z - CORRECT ANSWER Z
Which is considered a unique identifier in the relational database patient table?
a. Patient last name
b. Patient last name & first name
c. Patient date of birth
d. Patient number - CORRECT ANSWER Patient number
Which of the following is used by a long term facility to GATHER info about SPECIFIC health status factors and includes info about specific risk factors in the resident's care?
a. Case management
b. Minimum Data Set
c. Outcomes and assessment information set
d. Core measure abstracting - CORRECT ANSWER Minimum Data Set
minimum data set - CORRECT ANSWER a standard established by health care institutions that specifies the information that must be collected from every patient
Dr. Collins admitted Ms.Smith to University Hospital. Blue cross insurance will pay Ms.Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Ms.Smith?
a. Ms.Smith
b. Blue cross
c. University Hospital
d. Dr. Collins - CORRECT ANSWER University Hospital
Documenting the full depth and breadth of data use in a healthcare entity requires:
a. Identifying all of the data consumers
b. Identifying the needs of data consumers
c. Understanding all of the functionality requirements
d. Performing a gap analysis - CORRECT ANSWER Identifying the needs of data consumers
The most recognizable component of the problem-oriented health record is:
a. The problem list as an index
b. The initial plan
c. The SOAP form of progress notes
d. The database - CORRECT ANSWER The SOAP form of progress notes
A 45 year old women is admitted for blood loss anemia due to dysfunctional uterine bleeding. How would you code?
D25.9 Leiomyoma of uterus, unspecified
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D62 Acute posthemorrhagic anemia
N93.8 Other specified abnormal uterine and vaginal bleeding
a. D50.0, N93.8
b. D62, N93.8
c. N93.8, D50.0
d. D50.0, D25.9 - CORRECT ANSWER N93.8, D50.0 (always code due to/secondary condition AFTER the primary)
The insured party's member identification number is an example of this type of data:
a. Demographic data
b. Clinical data
c. Certification data
d. Financial data - CORRECT ANSWER Financial data
What is the data model that is most widely used to illustrate a relational database structure?
a. Entity-relationship diagram (ERD)
b. Object model
c. Relational model
d. Unified medical language system (UMLS) - CORRECT ANSWER Entity-relationship diagram
ICD 10-PCS have how many characters? - CORRECT ANSWER 7 characters, and character can't be left blank.
*If value does not exist for a given character, the "Z" is used.
What are ICD-10-PCS codes used report? - CORRECT ANSWER used only for inpatient, hospital settings
The MDS is a component of - CORRECT ANSWER Resident assessment instrument(RAI) and used to collect info about the residents risk factors and to plan ongoing care and treatment in the long term care facility.
SOAP(Subjective, Objective, Assessment, and Plan) - CORRECT ANSWER Part of the POMR(problem oriented medical records).
Soap notes are intended to improve quality and continuity of client services by enhancing communication among healthcare professionals
Financial data - CORRECT ANSWER include details about the patient's occupation, employer, and insurance coverage.
Entity relationship modeling - CORRECT ANSWER type of conceptual modeling. - modules that are abstract and encourage high-level problem structuring;
*help establish a common ground for communication b/w users and developers.
*ERD was developed to depict relational database structures.
many-to-many relationship - CORRECT ANSWER In databases, a relationship in which one record in Table A can relate to many matching records in Table B, and vice versa.
ex:
patient to consulting physician.
instance of patient there could be many instances of consulting physician because patient can be seen by more than one consulting physician, and for instance where one consulting physician there could be many patients.
Root operation -division - CORRECT ANSWER cutting into a body part w/out drawing fluids or gases from the body part in order to sperate or transect a body part.
What is a straight numerical filing system? - CORRECT ANSWER refers to the filing of records in exact ascending order according to medical records number.
*records are filed in the following order:
12-23-75
12-34-29
12-35-71
13-42-14
14-32-79
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?
2.4%
3.5%
4.6%
5.1% - CORRECT ANSWER 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 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 00-06-26
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 misfiles
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 12
200 units x 6 shelves per unit = 1,200 shelves total1,
200 shelves divided by 100 primary numbers (00-99) = 12 shelves per primary number
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 straight numeric
*key word: consecutive
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 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 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 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 00-00-3
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 5????????? ***do reasearch
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 7
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 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 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 acceptable as courtroom evidence. [Show Less]