RHIA Practice Exam 1
Terms in this set (161)
Smith was admitted to a nursing facility with the following information: "patient is being admitted for Organic brain syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the:
A 65-year-old white male was admitted to the hospital 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory eval of CBC and UA. The x-ray revealed possible problems and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered. The chief complaint was:
Smith's admitting data indicates that her birthdayis 5/21/14. On the discharge summary, Smith's birth date is recorded as July 21. What quality element is missing from Mrs. Smith's health record?
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:
Health record matrix
Erin is the HIM director at anywhere hospital. She is teaching a class to clinicians about proper documentation in the health record. what should she instruct them to do:
Leave existing entries intact. Label late entries as being late. Ensure the legal signature of an individual making a correction accompanies the correction.
All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data:
Data that have been grouped into meaningful categories according to a classification system are referred to as ________ data.
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 elements of a:
What is the principal function of health records?
Serve as the repository of clinical documentation relevant to the care of individual patients
The insured party's member identification number is an example of what type of data:
What part of the problem-oriented medical record is used by many facilities that have adopted the whole problem-oriented format?
The SOAP progress notes
What materials are required element in an emergency care record?
Time and means of the patient's arrival, treatment rendered, and instructions at discharge
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health record
uniform data set
What is a unique identifier in the relational database patient table
What is used by a long-term facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care?
minimum data set
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items:
Documenting the full depth and breadth of data use in a healthcare entitiy requires:
Identifying the needs of data consumers
What is an example of a M-M relationship?
Patients to consulting physicians
What is a M-M relationship?
Many to many
Mrs. Smith was admitted to a hospital by Dr. Collins. Mrs. Smith's hospital bill was paid by Blue Cross insurance. Upon discharge from the hospital, who owns the health record of Mrs. Smith?
Decision making and authority over data-related matters is known as:
Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication. Abbreviations in the health record:
Should only have one meaning
In ICD-10-PCS what value is used if there is a character that does not apply to a given code?
The primary responsibility of a coder is to:
ensure quality of coded data
Documentation including the the date of action, method of action, description of the disposed record series of numbers or items, services dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:
certificate of destruction
What is the data model that is most widely used to illustrate a relational database structure?
Entity-relationship diagram (ERD)
Anywhere hospital has mandated that the social security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a:
What is a system in which the patient health record is kept in the same order on the nursing station and in the complete record?
Data that are collected on large populations of individuals and stored in databases are referred to as:
The data elements in a patient's automated laboratory result are examples of:
According to JC accreditation standards, what document must be placed in the patient's record before a surgical procedure may be performed?
Report of history and physical examination
Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information?
It can exist in separate and multiple paper-based or electronic systems
Data mapping is used to harmonize data sets or code sets. The code or data set from which the map originates is the:
The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called:
Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:
unstructured clinical information
A significant challenge when handling hybrid records is complicated by the fact that:
The requirements, regulations, and constraints of EHRs and paper records must be met
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:
The legal health record for disclosure consists of:
The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings
A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach?
Device and media controls
A clinic has a contract with the city government to perform all new employee physicals and work injury evaluations. Is it appropriate that a patient's family history of cancer be reported to the employer?
Yes, unless the employer has allowed for such exclulsion
An outpatient laboratory routinely mails the results of health screening exams to its patients. The lab has received numerous complaints from patients who have received another patient's health information. Even though multiple complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. How should the privacy officer for this healthcare entity respond to this situation?
Determine why the lab results are being sent to incorrect patients, and train the laboratory staff on HIPAA privacy rule.
Anywhere hospital's coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA security rule. What type of network uses a private tunnel through the internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely?
What does an audit trail check for?
Unauthorized access to a system
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
What statements about a firewall are true?
It is a system or combination of systems that support an access control policy between two networks.
The most common place to find a firewall is between the healthcare entity's internal network and the internet.
A firewall can limit internal users from accessing various portions of the internet.
When a patient collapses upon arrival at the entrance to an emergency department, what type of treatment authorization is in effect?
What type of access safeguard is more people-focused in nature?
What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?
The incident report likely becomes discover able because it is mentioned in a discover able document
What legal doctrine was established by the Darling v Charleston Community Hospital case of 1965?
Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers?
Healthcare integrity and protection data bank
Mary smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician?
The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:
Who has the legal right to refuse treatment.
Someone who is over 18 and of sound mind. Someone who is over 18 and has created a living will prior to becoming incompetent
Mrs. Davis is preparing to undergo hernia repair surgery at Deaconess Hospital. Select the best statement;
The surgeon should obtain Mrs. Davis' informed consent.
St. Joesph's hospital has a psychiatric service on the sixth floor. A 31-year-old male has come to the HIM department and requested to see a copy of his medical record. He has told the clerk he was a patient of Dr. Schmidt, a psychiatrist, and was on the 6th floor of the hospital for 2 months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is:
Allow the patient to access his record if, after contracting his physician his physician does not feel it will be harmful to the patinet.
Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given:
general condition and acknowledgement of admission
The privacy rule generally requires documentation related to its requirements to be retained:
Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the options listed, what is the best course of action?
Inform Dr. Smith that he cannot access his daughter's health record without her signed authoization allowing him access to the record.
Medical information loses PHI status and is no longer protected by the HIPAA privacy rule when it:
Linda Wallace is being admitted to the hospital. She is presented with a Notice of Privacy Practices. In the notices, it is explained that her PHI will be used and disclosed for treatment, payment, and operations purposes. Linda states that she does not want her PHI used for these purposes;
The hospital is not required to honor her wishes in this situation, as the notice of privacy practices is informational only.
Sally Mitchell was treated for kidney stones at Graham Hospital last year. Now she wants to review her medical record in person. She has requested to view them by herself in a closed room.
Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record.
The kids foundation, a foundation related to children's hospital, is mailing fundraising information to the families of all the patients who have been treated at children's in the past three years. Based on the facts given:
Children's Hospital must have notified the patients or patients' guardians of this disclosure in the Notice of Privacy Practices
You are a member of the hospital's health information management committee. This committee has created a HIPAA-complaint authorziation form. What items does the privacy rule require for the form:
Identification of the person or entity authorized to receive PHI
What is an identifier under the privacy rule?
Vehicle license plate
The federal law that directed the secretary of health and human services to develop healthcare standards governing electronic data interchange and data security is the:
Health Insurance Portability and Accountability Act
An HIM professional violates privacy protection under the HIPAA privacy rule when he or she releases ______ without specific authoization from teh patients or patient representative.
A list of newborns to the local newspaper for publication in the birth announcements section
The privacy officer is contacted by a patient who is scheduled for elective surgery in three weeks and who is requesting that the information from the scheduled visit be restricted from his primary care provider. Can the privacy officer deny this request?
Yes, if it was determined to be unreasonable because such a request could impact the patient's future treatment by withholding information from the primary care provider
This federal agency is charged with responsibility for the oversight and enforcement of the HIPAA privacy regulations:
The HHS office of civil rights
Employees, volunteers, trainees, and other persons performing functions on behalf of covered entities and business associates, whether paid or not, are considered to be:
The HIPAA methods titled Expert determination and safe harbor are ways in which the following can be achieved legally:
Sometimes federal and state health information privacy laws and regulations are in conflict. When this is the case, one law must take precedence. For health information privacy this is determined as follows:
The law that gives the consumer greater rights with respect to their PHI takes precedence.
Addressable security rule implementation specifications:
Should be implemented unless a healthcare entity determines that the specification is not reasonable and appropriate and documents their reasoning
A breach occurs when unsecured protected health information is accessed or released. The secretary of HHS and local media must be notified when how many records are released?
The workforce security standard has all of the following addressable implementations standards:
Authorization and supervision;
Workforce clearance procedures;
A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?
Submit a certification of destruction in response to the subpoena
Anywhere General Hospital allows all of the ICU nurses to log on with a standard ID and password. This is not allowed by what standard of the security rule?
Access control standard
Although an addressable implementation specification, this reduces or prevents access and viewing of ePHI?
The concept of legal hold requires:
Special tracked handling of patient records involved in litigation to ensure no changes can be made
The security rule leaves the methods for conducting the security risk analysis to discretion of the healthcare entity. The first consideration for a healthcare facility should be:
Its own characteristics and environment
An audit trail is a good tool for which one of the following:
Reconstructing electronic events
Placing locks on computer room doors is considered what type of security control?
Physical access control
A hospital employee destroyed a health record so that its contents--which would be damaging to the employee--could not be used at trial. In legal terms, the employee's action constitutes;
An RFP serves two important purposes; it solidifies the planning information and healthcare entity requirements into a single document, and it:
Provides valuable insights into the vendors operations and products and levels the playing field in terms of asking all the vendors the same questions
A possible justification for building an information system in-house rather than purchasing one from a vendor is that:
the facility has unique information needs
By querying the healthcare entity data, you find that patients admitted on a weekend have a mean length of stay that is 1.3 days longer than patients who are admitted Monday through Friday. This method of finding information is called:
Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total 500 discharges for the same period, including deaths of adults children, and newborns. The hospital's gross death rate for the month of June was:
The researcher's informed consent form stated that the patients' information would be anonymous. Later, in the application form for IRB approval, the researcher described a coding system to track respondents and non-respondents. The IRB returned the application to the researcher with stipulation that the informed consent must be changed. What raised the red flag?
The description of the use of a coding system to track respondents and nonrespondents
you want to graph the average length of stay by sex and service for the month of April. What graphic tool would you use?
In healthcare, one of the primary uses for data warehouses is:
If an anlyst is studying the wait times at a clinic and the only list of patient available is on hand copy, which sampling technique is the easiest to use?
To reduce the effect of a server crash in an EHR environment, it is advisable to:
set up redundant system
What type of data display tool is used to display discrete categories?
In what phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed?
A health information professional is preparing statistical information about the third-party payers that reimburse care in the facility. She finds the following information: Medicate reimburses 46 percent; Medicaid reimburses 13%; blue cross reimburses 21%; workers' compensation reimburses 1%; commercial plans reimburse 15%; and other payers or self-payers reimburse 4%. What is the best graphic tool to use to display this data?
During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30% of the nursing home's population. This rate represents the:
In assessing the quality of care given to patients with diabetes mellitus, the CQI group collects data regarding blood sugar levels on admission and on discharge. This data is called:
What activity is likely to occur in the analysis phase of the systems development life cycle;
examine the current system and identify opportunities for improvement
Assume you are the manager of a 10-physician group pirmary care practice. The Physicians are interested in contracting with an application service provider to develop and manage patient records electronically. What statement is an indication that an ASP may be a good idea for this practice?
The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor
What statement most accurately describes the optimal relationship between strategic planning and strategic IS planning in a healthcare entity?
The two processes are clearly related. It is important for the CIO to be involved in both processes to ensure that IS priorities are congruent with the overall strategic plans of the entity.
This health information exchange consent model requires the patient to give their consent for the inclusion of their data in the HIE
What is true of a PHR
Individuals own and manage their PHR.
It is life-long resource.
Individuals determine rights of access.
After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Registration or patient access
At Medical Center Hospital, the master patient index system is not meeting facility needs. There are duplicate numbers and errors in patient identification information. The IS director replaces the system with a newer system from a different vendor. After several months, the new system is exhibiting many of the same problems as the old system, and the facility staff is frustrated and angry. What is the most likely cause of the problem
Underlying human and proecess problems were not identified and corrected prior to making a system change
A health information exchange entity that has no access to personal health information is an example of this kind of architectural model:
The personal health record model that maintains provider control of content while allowing online access to the authorized patient is the:
EHR extension model
How are hospital compare measures used by CMS
Hospitals that report all measures receive the full payment update.
John Smith, who was treated as a patient at a multi hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:
The technology commonly utilized for automated claims processing (sending bills directly to third party payers) is:
Electronic data interchange
Technology that electronically stores, manages, and distributes distributes documents that are generated in a digital format and whose output data are report-formatted and print-stream originated is called:
Computer output laser disk techology
University Medical Center contracts with the XYZ Corporation for a clinical information system. The hospital pays a fixed monthly fee. XYZ owns the hardware and hosts the application software using the internet. The Medical Center accesses the system through onsite workstations. In this situation, XYZ Corporation is an:
Application Service Provider
What would likely be recorded on an information system issues log?
Betty Reported receiving 25 erroneous messages
What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document?
The application of information science to the management of healthcare data and information through computer technology is referred to as:
The JC and CMS identify core measures that provide an indication of healthcare facility's performance. Some of the core measure data sets include what:
Pneumonia, congestive heart failure, and myocardium infarction
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging and patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data?
It is impossible to have health information interoperability or health information exchange without the following:
Complete, publicly available standards
What kind of data might be displayed on a pie chart?
Percentage of discharges by third-party payer
If an analyst wishes to predict future ancillary charges for hip replacement patients based on the age of the patient, which of the following is a correct statement?
Age is the independent variable: ancillary charges is the dependent variable
Medical identify thefts are situations in which the following occurs:
When demographic and financial information is used to acquire medical services
The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:
A physician query may not be appropriate in what instance
Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
Before Central Hospital is permitted to open and provide medical services in a particular state, the healthcare entity must first go through what process?
You are the coding supervisor and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer". What should have been coded as the patient's diagnosis?
Diagnosis of unknown etiology
For Medicare patients, how often must the home health agency's assessment and care plan be updated?
At least every 60 days or as often as the severity of the patient's condition requires
A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing compnay where the industrial accident occurred. Basic Manufacturing carried workers' compensation insurance. The workers' compensation insurance paid the neurosurgeon fees. What entity is the third-party?
Workers' compensation insurance
The coding manager at Community hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. What will provide the most comprehensive solution to handle this documentation issue?
Place all offending physicians on suspension if the documentation issues continue
The financial manager of the physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group practice receiving?
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients, so he received $4500 from the health plan. What method is the health plan using to reimburse Dr. Tan?
A patient has surgery. The initial service and subsequent recovery lasted 10 months. As a member of an MCO in an integrated delivery system, how should Phil expect that his healthcare billing will be handled?
Bills for each service from each physician, each facility, and each other healthcare provider from every encounter
What conditions would would be most likely to fall into into the category of notifiable diseases as defined by the national notifiable disease surveillance system?
What would generally be found in a query to physician?
Date query initiated and date query must be completed
A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm?
Mental or behavior problems
In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
Query the physician to determine if the condition was present on admission
What payment arrangements is streamlined by the use of charge masters?
The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan make an average of two errors per day. Given this information, what action should the coding supervisor take?
Take no action since not enough information is given to make a judgement.
Once all data has been posted to patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have an internal auditing system that runs each claim through a set of edits. This internal auditing system is known as a:
What health care entities' mission is to reduce Medicare improper payments through detection and collection of over payments, identification of underpayments, and implementation of actions that will prevent future improper payments:
Recovery audit contractor
The practice of under coding can affect a hospital's MS-DRG case mix in what way:
Makes it lower than warranted by the actual service/resource intensity of the facility
A ___________ assists in educating medical staff members on documentation needed for accurate billing.
A healthcare entity plans to implement an EHR project in which nurses will electronically document their observations and treatments. It is thought that handheld personal digital assistants, rather than laptop computers or bedside terminals, will be used for this function. This type of prediction is called a(n):
External change agents have the advantage over internal agents regarding:
Bench-marking the healthcare entity against other entities
What statement is most accurate regarding effective communication:
Monitor others' nonverbal behaviors for cues that they are following or confused
According to the records kept on filing unit performance over the past year, the filing unit has filed an average of 1,000 records per day. You have three FTE record filers in the deapartment who are productive 88% of the day. Based on this information, what is the average number of records filed per productive hour in the file unit as a whole:
143 records per hour
The slightly higher wage paid to an employee who works a less desirable sift is called a:
A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called:
Balanced scorecard methodology
The financial statement that presents a record of operations by showing revenue and expenses over a period of time is called an:
The HIM department records copy fees as revenue. For the year the budgeted fees were $25k, and the actual fees received are $23k. The director may be asked to explain an:
Unfavorable variance of $2000
As an HIM professional, you have to tend to the AHIMA code of ethics and follow the rule that:
Health information management professionals will refuse to participate in or conceal unethical practices or procedures
A director of health information services in a hospital want to implement a computer-based patient record system over the next two years. She gets support from the CIO, who champions the project with the administrative team. The CIO has become the project's:
What would be an indicator of process problems in an HIM department:
18% error rate on abstracting data
Employees covered by the provisions of the Fair Labor Standards Act are called ______________ employees
Strategic thinkers exhibit what skills:
The ability to gain a powerful core of healthcare entity supporters and custoemrs
The form of coaching in which an individual in the beginning stages of a career is matched as a protege with a senior person is known as:
A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called:
What statement is most accurate regarding the relationship between levels of management and managerial skills:
Conceptual skills are greatest at the top level of management
The performance standard to "respond to release of information requests for continuing care in one working day 95% of the time" is an example of a:
The advantage of using internal change agents over external change agents is that the former can usually:
provide a more detailed understanding of healthcare entity's history and issues
What is a true statement about business process reengineering:
it seeks to reevaluate and redesign organizational processes to make dramatic performance improvements
Contracting for staffing to handle a complete function within the HIM department, such as the cancer registry function, would be considered what type of contracting arrangement?
Every y ear, a director of health information services sponsors a series of presentations about the confidentiality of patient information. All facility employees are required to attend a session. This method of educational delivery is called:
What is the best reason for team building:
to quickly move from acquaintanceship to a strong team.
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