RHIA Prep Test 110 Questions with Verified Answers
This committee makes recommendations to the governing board for appoints to the medical staff -
... [Show More] CORRECT ANSWER executive
physicians who deliver most of the medical care in hospitals and who site on committees are - CORRECT ANSWER active staff
accreditation organization which accredits health information educational programs is - CORRECT ANSWER CAHIIM
which component, group has ultimate authority and is responsible for providing quality care to patients? - CORRECT ANSWER governing board
which organization was the first to require a medical record on each patient and developed standards for its content? - CORRECT ANSWER American college of surgeons
what documents specify the principles and policies by which both medical staff and governing board agree to abide by - CORRECT ANSWER bylaws
which hospital department is responsible for arranging a transfer to a nursing home? - CORRECT ANSWER social service
which professional association organized to resolve inconsistencies and standardized medical education for the practice of medicine? - CORRECT ANSWER AMA
physicians are licensed to practice by... - CORRECT ANSWER the state in which they practice
which organization currently sets voluntary standards for hospitals pertaining to quality health care? - CORRECT ANSWER JC
cost of care is based on the patient's ability to pay - CORRECT ANSWER sliding scale
numbering system will generate gaps in filing space when records are pulled forward to the most recent medical record number assigned to patient - CORRECT ANSWER serial-unit numbering
What is the format of the progress notes of a problem oriented medical record? - CORRECT ANSWER SOAP
ASTM developed a standard to provide guidance for collection of data for the purpose of.. - CORRECT ANSWER computerizing the patient record
primary purpose of quantitative analysis - CORRECT ANSWER to have a complete medical record
what resource provides standard definitions for inpatient data commonly collected in acute care hospitals? - CORRECT ANSWER UHDDS
What is aggregate data? - CORRECT ANSWER data combined from several measurements
ex: data the media uses to report on health info of epidemiological interest to the public
when records are analyzed for deficiencies on the unit while the patient is still in house, this is called? - CORRECT ANSWER concurrent analysis
confirmation of the diagnosis and treatment options from another physician within the same specialty is called? - CORRECT ANSWER a second opinion
cancer registries can be accredited by? - CORRECT ANSWER ACS
case files of cancer patients are abstracted when - CORRECT ANSWER patient is diagnoses and/or treated
a graph most frequently used to present continuous data? - CORRECT ANSWER histogram
the filing system used in an electronic environment? - CORRECT ANSWER straight numeric
assessment of nursing productivity is usually based on - CORRECT ANSWER inpatient service days
full time responsibility for the operation of a hospital is delegated by the governing board to the - CORRECT ANSWER CEO
the system of numbering in which a patient receives a number on his first admission to the hospital and retains that number on all subsequent admissions to the hospital is - CORRECT ANSWER unit
what is the function of CAHIIM - CORRECT ANSWER accrediting college educational programs
quantitative analysis purpose - CORRECT ANSWER complete medical record
qualitative analysis purpose - CORRECT ANSWER consistent medical record
standards are published by the JC for all types of facilities except? - CORRECT ANSWER public health
purpose of a two digit modifier - CORRECT ANSWER 1. append to either CPT or HCPCS level II services
2. they indicate a service or procedure that has been altered but doesn't change description
Coding rule for coding outpatient dx documented as probable, suspected, rule out conditions - CORRECT ANSWER it should not be coded as if they are established.
first organization to implement minimum standards for hospitals - CORRECT ANSWER ACS
What are three things HITECH has encouraged/required the use of - CORRECT ANSWER 1. meaningful use
2. Health Information Exchanges
3. EHRs
what is benchmarking - CORRECT ANSWER comparing something against a certain standard
NPDB - CORRECT ANSWER national practitioner data bank
maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed health providers
HIPDB - CORRECT ANSWER healthcare integrity and protection data bank
maintains reports on civil judgement, criminal conventions of licensed healthcare providers, federal and state licensing and certification actions, and exclusions from participation in federal or state healthcare programs
HEDIS - CORRECT ANSWER healthcare effectiveness data and information set
measures performance on important dimensions of care and service. allows health plans to see where they need to focus their improvement efforts
NCQA - CORRECT ANSWER National committee for quality assurance
non profit organization dedicated to improving healthcare quality
physician query - CORRECT ANSWER requesting clarification for inconsistent, ambiguous, or incomplete documentation for coding
nomenclature - CORRECT ANSWER naming system controlled by rules
clinical interface technology - CORRECT ANSWER systematic collection of health care related phrases that can be converted to structured data elements recognized between computer programs
UMLS - CORRECT ANSWER unified medical language system
converts terms from one vocabulary to another to enable information exchange between databases and systems
how length of stay can affect the hospital's finances under PPS - CORRECT ANSWER the longer the patient stays, the more money the hospital loses. if the patient's stay is less than average LOS the hospital will not make as much money as they expect
encoder - CORRECT ANSWER converts information from one code to another and keeps standardization
groupers - CORRECT ANSWER computer programs that assign patients to case-mix groups and have an algorithm that determines the patient groups
RAC - CORRECT ANSWER recovery audit contractor
they ensure correct payments are made to providers and facilities by Medicare part A&B claims
COLA - CORRECT ANSWER cost of living adjustment
DSH - CORRECT ANSWER disproportionate share hospital
GAF - CORRECT ANSWER geographical adjustment factor
AHRQ - CORRECT ANSWER agency for healthcare research and quality
a US government agency that functions as a part of the dept of Health & Human Services to support research to help improve the quality of healthcare
When defining the LHR in a healthcare entity, it is best practice to establish a policy statement of the LHR along with? - CORRECT ANSWER health record matrix
the insured party's member identification number is an example of what kind of data - CORRECT ANSWER financial data
what type of information makes it easy for hospitals to compare and combine the contents of multiple patient records - CORRECT ANSWER uniform data sets
in a LTC setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items - CORRECT ANSWER resident assessment protocols (RAPs)
decision making and authority over data-related matters is known as: - CORRECT ANSWER data governance
abbreviations in the health record... - CORRECT ANSWER should have only one meaning
In ICD 10, what value is used if there is a character that doesn't apply to a given code? - CORRECT ANSWER Z
primary responsibility of a coder - CORRECT ANSWER ensure quality of coded data
what is the data model most widely used to illustrate a relational database structure? - CORRECT ANSWER entity-relationship diagram
name the proper ways to destroy paper records - CORRECT ANSWER pulverize, shred, burn, pulp
examples of metadata - CORRECT ANSWER name of element
definition
application in which the data element is found
locator key
ownership
entity relationships
what are LOINC codes used for? - CORRECT ANSWER identifying test results
the inpatient data set incorporated into federal law and required for Medicare reporting is the - CORRECT ANSWER UHDDS
What is the desired outcome of analyzing data for a specific purpose? - CORRECT ANSWER information
root operation - extirpation - CORRECT ANSWER taking or cutting out solid matter from a body part
penalties for HIPAA violations can be: - CORRECT ANSWER civil and criminal
how long does the hospital have to respond to request for information? - CORRECT ANSWER 30 days
when ownership of a physician practice changes.. - CORRECT ANSWER the health records of the practice may be transferred as assets
When should adoption records only be released? - CORRECT ANSWER by court order
HIPAA retention standard for maintaining a record on a deceased patient is - CORRECT ANSWER 50 years
Stark Law/Federal Physician Self-Referral Statute - CORRECT ANSWER prohibits physicians ordering services for Medicare patients from entities in which the physician or an immediate family member has a financial relationship
What are reported to the medical examiner? - CORRECT ANSWER accidental deaths
Type of technology that focuses on data security - CORRECT ANSWER firewalls
a visitor sign-in sheet to a computer area is an example of what type of control? - CORRECT ANSWER facility access
ensuring that data have been access or modified only by those authorized to do so is a function of: - CORRECT ANSWER data integrity
firewall - CORRECT ANSWER controls external access to a network
authorization management involves: - CORRECT ANSWER limiting user access to a database
authorization management - CORRECT ANSWER protecting the security and privacy of data in the database
user access control, usage monitoring
name an administrative safeguard action - CORRECT ANSWER documentation retention guidelines
under HIPAA, these types of safeguards have to do with protecting the environment: - CORRECT ANSWER physical
one of the four requirements a CE must adhere to in order to be in compliance with HIPAA - CORRECT ANSWER ensure the:
confidentiality
integrity
availability of ePHI
Rank the next-of-kin in the following order for medical decision making purposes - CORRECT ANSWER Spouse
adult child
parent
adult sibling
Per HITECH, breach notification requirements, what is the threshold for the immediate notification of each individual? - CORRECT ANSWER 500 individuals affected
Per HITECH, an accounting of disclosures must include disclosures made during the previous: - CORRECT ANSWER 3 years
What does not have to be included in a CE's NPP - CORRECT ANSWER patient's signature and email
let the master answer - CORRECT ANSWER respondeat superior
employees in the hospital business office may have legitimate access to patient health info without patient authorization based on what HIPAA principle - CORRECT ANSWER minimum necessary
CEs must retain documentation of their security policies for at least: - CORRECT ANSWER 6 years from the date when last in effect
regarding an individual's right of access per HIPAA, a CE... - CORRECT ANSWER may require individuals to make their requests in writing
Administrative Simplification portion of Title II of HIPAA addresses which of the following? - CORRECT ANSWER uniform standards for transactions and code sets
An original goal of HIPAA administrative simplification was to standardize: - CORRECT ANSWER the electronic transmission of health data
technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: - CORRECT ANSWER technical safeguards
name a "public interest and benefit" exception to the authorization requirement - CORRECT ANSWER PHI regarding victims of domestic violence
most common method for implementing entity authentication - CORRECT ANSWER password systems
what is a two factor authentication system - CORRECT ANSWER something you know, have, are
Ex: password and swipe card
when should an e discovery response team be formed? - CORRECT ANSWER well in advance of any litigation
a subpoena duces tecum compels the recipient to - CORRECT ANSWER bring records to a legal proceeding
Business record exception - CORRECT ANSWER the rule under which a record is determined to not be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge
if a breach occurs, which of the following must be provided to the individual whose PHI has been breached? - CORRECT ANSWER the types of unsecured PHI that were involved
e-discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended which legislation? - CORRECT ANSWER Federal Rules of Civil Procedure
a valid subpoena duces tecum seeking health records does not have to - CORRECT ANSWER be signed by the plaintiff and defendant
which landmark legal case established the responsibility of the hospital for the quality of care given by its physician? - CORRECT ANSWER Darling vs Charleston Community Memorial Hospital
what type of safeguards compromise over half of all of the safeguards included in the Security Rule? - CORRECT ANSWER administrative safeguards
within context of data security, protecting data privacy means defending or safeguarding: - CORRECT ANSWER access to information
what is the most constant threat to health information integrity? - CORRECT ANSWER humans
res ipsa loquitur - CORRECT ANSWER the thing speaks for itself
Safe Medical Devises Act requires the reporting of injuries due to medical devices to whom? - CORRECT ANSWER FDA
components of a late entry - CORRECT ANSWER should be documented as late entry
should include date/time entry was made
should be documented ASAP
which doctrine do courts apply indicating that they are unwilling to revisit issues of previously settled cases? - CORRECT ANSWER res judicata [Show Less]