RHIT Exam Prep Domain 1

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Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:
Data sets
Data elements
Electronic data interchange
Bills of mortality

Data Set

In long-term care, the resident's care plan is based on data collected in the?
UHDDS
OASIS
MDS
HEDIS

MDS (Minimum Data Set)

Which of the following statements describes alphabetical filing?
File the record alphabetically by first name, followed by last name alphabetically and then alphabetically by middle name
File the record alphabetically by the last name, followed by alphabetical order of the first name, and then alphabetical order of the middle initial
File the record alphabetically by the name, followed by the middle initial and then the first name
File the record alphabetically by last name only

File the record alphabetically by the last name, followed by alphabetical order of the first name, and then alphabetical order of the middle initial

In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail?
Account level
MS-DRG level
MDC level
MS-DRG triples, pairs, and singles

MS-DRG triples, pairs, and singles

The home health prospective payment system uses the _____________ data set for patient assessments.
HEDIS
OASIS
MDS
UHDDS

Outcomes and Assessment Information Set (OASIS)

Evaluate the following sequence of numbers. What filing system is being used if these numbers represent health record numbers of three records filed together within a filing system?
36-45-99
37-45-99
38-45-99
Straight numerical
Terminal digit
Middle digit
Unit

Terminal Digit

Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and UACDS?
They define minimum data elements to be collected
They provide a complete and exhaustive list of data elements that must be collected
They provide a framework for data collections to which an individual facility can add data items
The federal government recommends, but does not mandate, implementation of most of the data sets

They provide a complete and exhaustive list of data elements that must be collected.

An important early step in designing an EHR is to develop a(n) _________________ in which the characteristics of each data element are defined.
Accreditation manual
Core content
Continuity of care record
Data dictionary

Data dictionary

The RHIT supervisor for the filing and retrieval section of the Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day?
6 hours per day
10 hours per day
15 hours per day
25 hours per day

25 hours per day

In which of the following systems are all encounters or patient visits filed or linked together?
Serial numbering system
Unit numbering system
Straight numerical filing system
Middle-digit filing system

Unit numbering system

In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the ________________ file.
Incomplete record
Permanent
Temporary
Remote storage

Incomplete record

A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is which of the following?
Continuity of Care Record
Minimum Data Set
Ambulatory Care Data Set
Uniform Hospital Discharge Data Set

Continuity of Care Record

Which of the following filing methods is considered the most efficient?
Alphabetical filing
Alphanumeric filing
Straight numeric filing
Terminal-digit filing

Terminal-digit filing

Incorporating a workflow function in an electronic information system would help support which of the following?
Tasks that need to be performed in a specific sequence
Moving patients from point to point
Registration of patients
Making computer output available to laser disk

Tasks that need to be performed in a specific sequence

A healthcare system wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would be the best application to perform this function?
Database
Data warehouse
Spreadsheet
WAN

Data warehouse

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?
Media control
Integrity
Mitigation
Audit controls

Integrity

A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. Which of the following is the first resource she should use?
UHDDS
UACDS
MDS
ORYX

UHDDS

The MPI is necessary to physically locate health records within a paper-based storage system for all types of filing systems, EXCEPT which of the following?
Alphabetical
Middle-digit
Termination-digit
Straight numerical

Alphabetical

Which of the following is a request from a clinical area to check out a health record?
Outguide folder
Requisition
MPI
Patient registry

Requisition

Which of the following tools is usually used to track health records that have been removed from their permanent storage locations?
Deficiency slips
Master patient indexes
Outguides
Requisition slips

Outguides

The primary purpose of a minimum data set in healthcare is?
Recommend common data elements to be collected in health records
Mandate all data that must be contained in a health record
Define reportable data for federally funded programs
Standardize medical vocabulary

Recommend common data elements to be collected in health records.

The data set designed to organized data for public release about the outcomes of care is which of the following?
UHDDS
DEEDS
MDS
HEDIS

HEDIS, The Health Plan Employer Data and Information Set is sponsored by the National Committee for Quality Assurance (NCQA).

Which of the following is a disadvantage of alphabetic filing?
Easy to train new personnel to file
Uneven expansion of file shelves or cabinets
Ease of creation
Relies on an index or authority key

Uneven expansion of file shelves or cabinets.

Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for?
Government regulations
Core data elements
Privacy controls
Technology requirements

Core data elements

Data serves two purposes in health care. The first is to identify data elements to be collected about each patient, what is the second?
Provide uniform data definitions
Guide efforts toward computerization
Determine statistical formulas
Provide a research database

Provide uniform data definitions

Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called _____________ standards:
Vocabulary
Structure and content
Transaction
Security

Structure and content

Which of the following best describes data comprehensiveness?
Data is correct
Data is easy to obtain
Data includes all required elements
Data is reliable

Data includes all required elements

Identify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."
Medical laboratory report
Pathology report
Physical examination
Physician orders

Medical laboratory report

A nurse is responsible for which of the following types of acute-care documentation?
Operative report
Medication record
Radiology report
Therapy assessment

Medication record

A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a problem-oriented health record progress note would this be written?
Subjective
Objective
Assessment
Plan

Subjective, entry relates significant information in the patient's words of from the patient's point of view.

Which of the following indexes and databases includes patient-identifiable information?
MEDLINE
Clinical trials database
Master patient/population index
UMLS

Master patient/population index

Which of the following represents an example of data granularity?
A progress note recorded at or near the time of the observation
An acceptable range of values defined for a clinical characteristic
A numerical measurement carried out to the appropriate decimal place
A health record that includes all of the required components

A numerical measurement carried out to the appropriate decimal place

In which department or unit is the health record number usually assigned?
HIM
Patient registration
Nursing
Billing

Patient registration

Which of the following is an example of clinical data?
Admitting diagnosis
Date and time of admission
Insurance information
Health record number

Admitting diagnosis

Which of the following provides a system for classifying morbidity and mortality information for statistical purposes?
Current Procedural Terminology
Healthcare Common Procedure Coding System
International Classification of Diseases, Ninth Revision, Clinical Modification
Systematized Nomenclature of Medicine Clinical Terminology

International Classification of Diseases, Ninth Revision, Clinical Modification

A notation for a hypertensive patient in a physician ambulatory care progress notes reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written?
Subjective
Objective
Assessment
Plan

Assessment

Which of the following is the primary weakness of the paper-based health record?
Difficulty to provide availability to a number of providers at the same time
Poor communication tool
Difficulty in documenting healthcare processes
Lack of available resources

Difficulty to provide availability to a number of providers at the same time

Identify where the following information would be found in the acute care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."
Anesthesia report
Physician progress notes
Operative report
Recovery room record

Operative report

Mrs. Jones' admitting data indicates that her birth date was March 21, 1948. On the discharge summary, Mrs. Jones' birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Jones' health record?
Data completeness
Data consistency
Data accessibility
Data comprehensiveness

Data consistency

Given the following file numbers, which are arranged in terminal digit filing order?
43-42-00
52-43-00
64-55-01
70-41-00
43-42-00
64-55-00
70-41-00
52-43-01
70-41-00
43-42-00
64-55-00
52-43-00
52-43-01
43-42-00
64-55-00
70-41-00

70-41-00
43-42-00
64-55-00
52-43-00

Dr. Smith entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
Data completeness
Data relevancy
Data currency
Data precision

Data currency

Which one of the following is used to plot the points for two variables that may be related to each other in some way?
Force-field analysis
Pareto chart
Root cause analysis
Scatter diagram

Scatter diagram

Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?
Current Procedural Terminology
Healthcare Common Procedure Coding System
International Classification of Diseases, Ninth Revision, Clinical Modification
Systematized Nomenclature of Medicine Clinical Terminology

Systematized Nomenclature of Medicine Clinical Terminology

What is the difference between data and information?
Data represents basic facts, while information represents meaning.
Data is expressed in numbers, while information is expressed in words.
Information must be kept confidential, while data is meant to be shared.
Information is about people, while data is about things.

Data represents basic facts, while information represents meaning.

Which of the following is not a characteristic of high-quality healthcare data?
Data relevancy
Data currency
Data consistency
Data accountability

Data accountability

Which of the following elements is not a component of most patient records?
Patient identification
Clinical history
Invoice for services
Test results

Invoice for services

Which of the following allows a user to insert, update, delete, and query data from a database?
C++
C
Java
SQL

SQL

Which of the following best describes data accessibility?
Data is correct
Data is easy to obtain
Data includes all required elements
Data is reliable

Data is easy to obtain

The attending physician is responsible for which of the following types of acute-care documentation?
Consultation report
Discharge summary
Laboratory report
Pathology report

Discharge summary

Which of the following is a primary purpose of the health record?
Document patient care delivery
Regulation of healthcare facilities
Aid in education of nurses and physicians
Assist in process redesign

Document patient care delivery

Which of the following is the information identifying the patient (such as name, health record number, address, and telephone number)?
Accession data
Indicator data
Reference data
Demographic data

Demographic data

Which of the following function in the cancer registry involves review of disease indexes, pathology reports, and radiation therapy reports?
Case-finding
Case definition
Follow-up
Reporting

Case-finding

Which of the following is data that is included in vital statistics?
Research projects in which new treatments and tests are investigated to determine whether they are safe and effective
Births, deaths, fetal deaths, marriages, and divorces
Medicare claims
ICD diagnoses codes

Births, deaths, fetal deaths, marriages, and divorces

Which of the following terms refers to the incidence of death?
Classification
Morbidity
Mortality
Vital statistics

Mortality

A secondary purpose of a health record would include.
Support for provider reimbursement
Support for patient self-management activities
Support for research
Support for patient care delivery

Support for research

Which of the following developed messaging standards for electronic data interchange in healthcare?

HL7
IEE
The Joint Commission
CMS

HL7

Within a particular time period, which of the following contains a list maintained in diagnosis coded number order of patients discharged from a facility?
Physician index
Master patient index
Disease index
Operation Index

Disease index

In a quantitative analysis review, it was found that a doctor dictated a discharge summary on 02/15/10. The patient, however, was discharged two days later. What is the best course of action to take?
Request that the physician dictate another discharge summary
Have the record analyst note the date discrepancy
Request the physician dictate an addendum to the discharge summary.
File the record as complete since the discharge summary includes all of the pertinent patient information.

Request the physician dictate an addendum to the discharge summary.

What is the mean for the following frequency distribution: 10, 15, 20, 25, 25?
47.5
20
19
95

19

If 6 patients stay in the hospital a total of 28 days, which of the following would result in the calculation of 28 divided by 6?
Average length of stay
Total length of stay
Patient length of stay
Average patient census

Average length of stay

When is a record considered a primary data source?
Contains information about the patient that has been documented by the professionals who provided care to the patient
Contains data abstracted from a patient record
Includes data stored in a computer system
Contains data that is entered into a disease-oriented database

Contains information about the patient that has been documented by the professionals who provided care to the patient

The accession number is what in a cancer registry?
Identifies all of the cases of cancer treated in a given year
Is the number assigned to each case as it is entered into a cancer registry
Identifies the pathologic diagnosis of an individual cancer
Is the number assigned for the diagnosis of a cancer patient entered into the cancer registry

Is the number assigned to each case as it is entered into a cancer registry

What is the length of stay for Mr. Martin if he was admitted to the hospital on March 21 and was discharged on April 1?
5 days
10 days
11 days
15 days

11 days

Medical procedures, supplies, products, and services are promoted through uniform reporting and statistical data collection by which of the following?
Current Procedural Terminology
Healthcare Common Procedure Coding System
International Classification of Diseases, Ninth Revision, Clinical Modification
International Classification of Diseases for Oncology, Third Edition

Healthcare Common Procedure Coding System

A family practitioner requests the opinion of a physician specialist in gastroenterology who examines the patient and reviews the patient's health record. What type of report would the physician specialist record his/her findings, impressions, and recommendations?
Consultation
Medical history
Physical examination
Progress notes

Consultation

Which of the following is the most prevalent trend in the collection of secondary databases?
Increased use of encryption technology
Increased used of encoders
Increased use of automated data entry
Widespread implementation of electronic medical records

Increased use of automated data entry

In the development of a hospital trauma data registry, which of the following data sets would be most beneficial?
DEEDS
UACDS
MDS Version 2.0
OASIS

DEEDS

What would be a HIM director's first steps to ensure that data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system?
Call the EHR vendor and ask to review the system's data dictionary
Identify data content requirements for all areas of the organization
Call a meeting of all department directors to get their input
Contact CMS to determine what data sets are required to be collected

Identify data content requirements for all areas of the organization

What is the range in a frequency distribution where the lowest value is 5 and the highest value is 20?
5 to 20
15
7.5
20 to 5

15

Data from the MDS for long-term care is utilized by which of the following?

Centers for Medicare and Medicaid Services (CMS)
Home health hospice agencies
Home health agencies
Rehabilitation facilities

Centers for Medicare and Medicaid Services (CMS)

The following would be documented in which part of an acute care record:
"Spoke with attending in regards to my assessment. Provided adoption and counseling information. Spoke to CPS in regards to a referral. Case manager is to meet with patient and family."
Admission note
Nursing note
Physician progress note
Social work note

Social work note

The patient health record is utilized as a data source by which of the following database from the National Health Care Survey?
National Health Provider Inventory
National Ambulatory Medical Care Survey
National Employer Health Insurance Survey
National Infectious Disease Inventory

National Ambulatory Medical Care Survey

A hospital is concerned about the difficulty in retrieving health records for patient care and legal purposes. Some of its data are stored electronically while the remainder is stored on paper. The hospital knows it will be several years before it will be able to implement an entire EHR system and go paperless. Given this information, which of the following would be the best solution for the hospital to ensure that all of the data for patient data is retrieved when needed?
Continue with the current system
Implement a document scanning system for storage of the paper record
Implement a microfilm system for storage and retrieval of the paper records
Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system

Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system

Which of the following graphic techniques would you utilize to display the number of deaths due to breast cancer for the years 1998-2008?
Table
Histogram
Line graph
Bar chart

Line graph

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