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Health Information RHIT Exam

OASIS data are used to assess the ___ of home health services.


A statement or guideline that directs decision making or behavior is called a:


Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except:

Returned Overpayments

Healthcare fraud is all of the following except:

Unnecessary Costs to a program

Corporate compliance programs became common after adoption of which of the following:

Federal Sentencing Guidelines

Which of the following is a legal concern regarding the EHR?

Ability to subpoena audit trails.

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:


A group practice has hired an HIT as its chief compliance officer. The current compliance program includes written standards of conduct and policies and procedures that address specific areas of potential fraud. It also has audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?

A hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?

Nursing Staff

Which of the following organizations within the federal government is responsible for looking at the issues related to the efficiency and effectiveness of the healthcare delivery system, disease protocols, and guidelines for improved disease outcomes?

Agency for Healthcare Research and Quality (AHRQ)

Which of the following issues compliance program guidance?

HHS Office of Inspector General (OIG)

Which of the following is an example of data security?

Automatic logoff after inactivity

A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed?

Retrospective Utilization Review

An EHR system can provide better security than a paper record for protected health information system due to:

Access controls, audit trails, and authentication systems

Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations?

Each physician practice should obtain a business associate agreement with the hospital

Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?

The Joint Commission

Developing, implementing, and revising the organization's policies is the role of:

Middle Managers

Position descriptions, policies and procedures, training checklists, and performance standards are all examples of:

Staffing Tools

This organization has been responsible for accrediting healthcare organizations since the mid 1950's and determines whether the organization is continually monitoring and improving the quality of care they provide.

The Joint Commission

Which of the following is a written description of an organization's formal position?


The Deficit Reduction Act of 2005:

Made compliance programs mandatory

Which of the following statements best defines utilization management?

It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care

Which of the following is not a type of utilization review?

Peer Review

Which of the following is not one of the basic functions of the utilization review process?

Claims Management

The Medical Review Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM Director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude?

Data are insufficient to determine whether the hospital is in compliance

Which of the following is the largest healthcare standards-setting body in the world?

The Joint Commission

Which of the following is the largest healthcare standards-setting body in the world?

The Joint Commission

Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise?

City Hospital should obtain a business associate agreement with Community Hospital

Which of the following facilities do not have to meet standards in the Conditions of Participation?

Physician Offices

An audit trail may be used to detect which of the following:

Unauthorized access to system

Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:

Elements of performance

The creation of the National Practitioner Data Bank was mandated by the:

Health Care Quality Improvement Act

Which of the following dictates how the medical staff operates?

Medical Staff Bylaws

Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team?

Chief Executive Officer

Medical school graduates must pass a test before they can obtain a _____ to practice medicine.


Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:

Can deny access to psychotherapy notes.

In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information?

When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual

Which of the following statements is true in regard to responding to requests from individuals for access to their PHI?

A cost-based fee may be charged for making a copy of the PHI

Which of the following is not an automatic control that helps preserve data confidentiality and integrity in an electronic system?

Security Awareness programs

Within the context of data security, protecting data privacy means defending or safeguarding:

Access to information

The protection measures and tools for safeguarding information and information systems is a definition of:

Data Security

To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide?

Base charges on the cost of labor and supplies for copying and postage if copies are mailed

A risk analysis is useful to:

Identify security threats

Which of the following is required by HIPAA standards?

A written contingency plan

Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?

Administrative safeguards

What is the biggest threat to the security of healthcare data?


To ensure relevancy, an organization's security policies and procedures be reviewed at least:

Once a year

Which of the following is not true of good electronic forms design?

Use radio buttons to select multiple items from a set of options

What committee usually oversees the development and approval of new forms for the health record?

Use radio buttons to select multiple items from a set of options

The process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria is:

Utilization Review

Placing locks on computer room doors is considered what type of security control?

Physical Control

Which of the following is recommended for design of forms for an EDMS?

24 lb. paper for double-sided forms

The HIM Supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has no specific data to support this suspicion. In this case, what should the supervisor do?

Ask the security officer for audit trail data to confirm or disprove the suspicion.

Coding policies should include which of the following elements?

AHIMA Standards of Ethical Coding

The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities?

Payment determinations and audit of cost reports

An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?


A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options here, what is the best course of action?

Allow her to review her record after obtaining authorization from her

St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action?

Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patient

Minors are basically deemed legally incompetent to access, use or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?

State law because HIPAA defers to state laws on matters related to minors

If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing:


What is the general name for Medicare rules affecting healthcare organizations?

Conditions of Participation

The permanent RAC program was completely implemented in the United States by:

January 2010

During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log-on to view laboratory results. One physician suggests having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide?

Single sign-on is less frustrating for the end user and can provide better security

Which of the following are security safeguards that protect equipment, media, and facilities?

Physical Access Controls

What does the term access control mean?

Identifying which data employees should have a right to use

Which of the following is a software program that tracks every access to data in the computer system?

Audit Trail

All of the following are steps in medical necessity and utilization review, except:

Access consideration

Which of the following can be used to discover current hot areas of compliance?

The OIG work plan

In Medicare, the most common forms of fraud and abuse include all of the following, except:

Implementing a clinical documentation improvement program

The one aspect of managed care that has had the greatest impact on healthcare organizations is:

Cost Control

The policies and procedures section of a coding compliance plan should include all of the following except:

Utilization Review

What is the term for an explicit statement that directs clinical decision making?

Evidence-based practice guideline

Gatekeepers determine the appropriateness of all of the following components, except:

Rate of capitation or reimbursement

Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are:

Safe Harbors

How often are healthcare facilities required to practice their emergency preparedness plan annually?


This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.

Commission on Accreditation of Rehabilitation Facilities

What is it called when accrediting bodies such as The Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government?

Deemed Status

Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?

Tracer Methodology

Which of the following services is most likely to be considered medically necessary?

Standard of care for health condition

Case management coordinates an individual's care, especially in complex and high cost cases. Goals of case management include all of the following except:

Information Security

When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n) ____ indicating that Medicare might not pay and that the patient might be responsible for the entire charge.


The number that has been proposed for use as a unique identification number but is controversial because of confidentiality and privacy concerns is the:

Social Security Number

HIM Professionals have been working with a multidisciplinary committee to identify the best solution that will allow hospital physicians coordinated access to all forms of incoming and outgoing messages including voice, fax, e-mail, and video mail. Currently, physicians have to log in to various systems, using different IDs and passwords to retrieve all their messages, reducing effectiveness and efficiency. Which of the following would provide the best solution to the current problem?

Computer-telephone integration (CTI)

The chief information officer is a senior-level executive who is responsible for:

Leading the organization's strategic Information Systems planning process

Which of the following is not a true statement about a hybrid health record system?

Version control is easy to implement

Which of the following would be the best course of action to take to ensure continuous availability of electronic data?

Use mirrored processing on redundant servers

Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?

Electronic document management system

Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy, and radiology information systems?

Clinical data repository

Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?

Controlled Vocabulary

Why does an ideal EHR system require point-of-care charting?

Ensures that appropriate data are collected

Which of the following is a transition strategy to achieve an EHR?

Electronic document management system

To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place?

Pharmacy Information System

Which of the following is the unique identifier in the relational database patient table?

Patient Number

As part of an EHR system selection, due diligence should be done:

Before contracting for an EHR product

Which of the following tasks is not performed in an electronic health record system?


A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:

Implementation Plan

Which of the following is an application that uses standard order sets and other clinical decision support that supports physician order entry into the computer?


Electronic systems used by nurses and physicians to document assessments and findings are called:

Electronic point-of-care charting

In the relational database shown here, the patient table and the visit table are related by:

Patient Number

A key element in effective systems implementation is:

User training

The director of health information services is allowed access to the medical record tracking system when providing the proper log-in and password. Under what access security mechanism is the director allowed access to the system?


A special web page that offers secure access to data is a(n):


When some computers are used primarily to enter data and others to process data the architecture is called:


The ability to electronically send data from one electronic system to a different electronic system and still retain its meaning is called:


To effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standard?


Who are the primary users of the health record for delivery of healthcare services?

Clinical professionals who provide direct patient care

The vision of the EHR is that discrete data would be entered by providers into an EHR via:


The key for linking data about an individual who is seen in a variety of care settings is:

Identity Matching Algorithm

Which statement is true concerning CDR and EHR?

CDR supports management of data for an EHR

The primary user of computerized provider entry is:


One of the advantages of an EDMS is that it can:

Help manage work tasks

Which of the following computer architectures uses a single large computer to process data received from terminals into which data are entered?


A transition technology used by many hospitals is to increase access to medical record content is:

Electronic document management system

When a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications, this is commonly referred to as a ____ strategy.

Dual Core

Which of the following is not true about document imaging?

Uses microfilm to store images

What type of information system would be used for processing patient admissions, employee time cards, and purchase orders?

Transaction processing system

The first phase of the SDLC is the ____ phase.


What basic components make up every electronic network communications system?

Transmitters, receivers, media, and data

The concept of systems integration refers to the healthcare organization's ability to:

Combine information from any system within the organization

The RFP generally includes a detailed description of the system's requirements and provides guidelines for vendors to follow in:

Bidding for the contract

The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the ____ approach.

Direct cutover

In which phase of the systems development life cycle is the primary focus on identifying and assigning priorities to the various upgrades and changes that might be made in an organization's information systems?


In which phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users performed?


Which of the following is considered a consumer-centric informatics application?


Which of the following best describes the function of kiosks?

A computer station that promotes the healthcare organization's services

A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n):


Which of the following systems would the HIM department director use to receive daily reports on the number of new admissions to, and discharges from, the hospital?

Management information system

Which of the following is a snapshot in time and consolidates data from multiple sources to enhance decision making?


Which of the following uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base?

Expert System

Which of the following stores data in predefined tables consisting of rows and columns?

Relational database

Which of the following uniquely identifies each record in a database table?

Primary Key

What is the purpose of computer databases?

Store and retrieve data.

Which of the following is a technique for graphically depicting the structure of a computer database?

Data Model

An organization identifies key people in various functional areas to be trained first, and then asks them to subsequently train other users in this same functional area. What is this approach to user training called?


Which of the following connects computers together in a way that allows for the sharing of information and resources?


Which of the following is considered a two-factor authentication system?

Password and swipe card

Which of the following technologies would reduce the risk that information is not accessible during a server crash?

Server redundancy

A system that enables processing of diagnostic studies results into tables, graphs, or other structure is:

Results retrieval and management technology

Community Hospital's hardware has been placed on back-order; the network team is having trouble getting the network to function properly. This is an example of:

Issues management

Audit logs and alert pop-ups are examples of:


Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?


The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric: field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?

The field type should be changed to Character

Systems testing of a new information system should be conducted using:

Actual Patient Data

Which of the following are used to associate relationships between entities (tables) in a relational database?

Foreign Keys

Which of the following security controls are built into a computer software program?

Application Controls

Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations?

Implement session termination

OASIS data are used to assess the ___ of home health services.


The Deficit Reduction Act of 2005:

Made compliance programs mandatory

Which of the following statements best defines utilization management?

It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care

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