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RHIT Mock Exam ALL sections
Terms in this set (111)
In the past, the Joint Commission standards focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to
use of prohibited or "dangerous" abbreviations
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
The federally mandated resident assessment instrument used in long term care facilities consists of three basic components, including the new care area assessments, utilization guidelines, and the
MDS or minimum data set
As Director of HIT program, your community college has been selected to participate in the workforce develeopment of electronic health specialits as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need regular access to the Web site of this governmental agency.
A qualitative review of a health record reveals that the h and p for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the h and p are true in the situation? Completion and charting of h and p indicates
noncompliance with JC standards. H and P must be completed within 24 hours
The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is
12-0001/00 because in accession number 12 represents the year the patient first entered the database, 0001 represents the first case entered that year, and 00 indicates no previous known neoplasm.
Setting a drop down menu to make sure the registration clerk collects gender as male or female is a method of ensuring data
Validity refers to the accuracy of data, while reliability refers to the consistency of the data. Timeliness refers to the data being available when needed, and precision refers to data values that are just large enough to support the application process.
In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is
The Federal Register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.
In an acute care hospital, a complete history and physical may not be required for a new admission when
A legible copy of a recent h and p performed in the attending physician's ofice is available.
An interval h and p can be used when a patient is readmitted for the same or related problem within the 30 days, and no matter how long the patient stays an h and p is required.
The authors of all entries in a health care record should be
In creating a new form or computer view, the designer should be most driven by
needs of the users
According to the following data, the most serious record delinquecy problem occurred in which month?
Record Delinquency Mo. April May June
% incomplete records 70% 88% 79%
%delinquent records 51% 43% 61%
% delinquent DT minssing H&P 3% 1.4% .05%
April, because JC reccommendation for improvement is indicated if the number of delinquent records is greater than 50% or if the % of delinquent records DT missing H&P exceeds 2% of average monthly discharges. The % of incomplete records is irrelevant
An example of objective entry in the health record supplied by a health care practitioner is the
The medical history, including a review of systems and chief complaint, is information supplied by the patient.
As Chair of the Health Record Committee you have been asked to reccommend a time limited documentation standard for inclusion in medical staff bylaws, rules, and regulations. that must meet standards of both JC and Medicare COP. For H&P you advise the time period for completion should be set at
24 hours after admission or prior to surgery
An example of a primary data source for health care statistics is the
Which of the following is LEAST likely to be identified by a definciency analysis technician
Discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist
In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatinet scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from
R-ADT system also known as the registration-admission, discharge and transfer system
Which method of authorship or authentication of entries would be inappropriate to use in a patient's health record?
Delegated use of a computer hey by radiology secretary.
Use of codes and stamped signatures MUST be confined to the owners and they are never to be used by anyone else.
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of
Which of the four distinct components of the problem oriented record serves to help index documentation throughout the record
Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record
Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011
Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?
Use CPOE for medication orders
Using a template to collect data for key reports may help to prompt caregivers to document all required elements in the patient record. This practice contributes to data
A primary focus of screen format design in a health record computer application should be to ensure that
The user is capturing essential data elements
A quality improvement team is focusing on the unacceptable number of unsigned doctors' orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be
Developing an open record review process
Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders mus be
recorded by persons authorized by hospital regulations and procedures.
For inpatients, the first data item collected of clinical nature is usually
When asked to explain how review of systems differs form a physical exam you explain that the review of systems is used to document
Subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant
Skilled nursing facilities chose to submit MDS data using RAVEN software, or software purchased commercially through a vendor provided the software meets
In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26
What is the chief criterion for determining record inactivity?
Amount of space available for storage of newer records
According to terminal digit filing, what would be the number of the record immediately after record 99-99-30
The function of a ______________ is limited to data retrieval
Clinical data repository
A coder notes that a patient is taking prescrition Pilocarpine. The final Dx is CHF and DM. The coder should query about adding DX of
Which of the following classification systems was designed with the electronic systems in mind and is currently being used for problem lists, ICU monitoring, patient care assessments, data collections, medical research studies, clinical trials, disease surviellance, and image d?
The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type is the
The most common type of registry located in hospitals of all sizes and in every region of the country is the
The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment. The best source is the
Cancer registry abstracts
All of the following items are packaged under the Medicare OPPS except
How many major Dx categories are there in the MS-DRG system?
The standard form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the
Currently which PPS is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient?
HIPAA requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period
The prevention of illness though vaccination occurs due to the formation of
Dr. Z ordered a CEA test for Mr. L, a 67 year old African American male patient. Dr. Z may be considering a dx of
Which of the following cells produces antibodies?
Each of the following conditions fall under the category of COPD EXCEPT
Which of the following is a lethal arrhythmia?
Impetigo can be
Spread through autoinoculation or caused by Streptoccus pyogenes
Which disease is a malignancy of the lymphatic system?
Necrosis extendning down to the underlying fascia is characteristic of a decubitus ulcer in stage
The most common type of vaginitis is
both yeast and protozan
The hypothalalmus, thalamus, and pituitary gland are all part of the
Which of the following BEST summarizes the current treatment of cervical cancer?
A new three-shot vaccinination series that protects against the types of HPV that cause most cervical cancers
Which of the following is a characteristic of Graves' disease?
It is an autoimmune disease
A "pill-rolling"tremor of one hand is a characteristics symptom of
A toxic goiter has what distinguishing characteristic
Which of the following elements of negligence must be present in order to recover damages?
duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
As the director of HIT for Bayshore Hospital you are asked to provide sworn verbal testimony in a suit by a former patient. This testimony is
As the director of HIT for Bayshore Hospital you are asked to provide written answers to questions asked in a suit by a former patient. This is
As the director of HIT for Bayshore Hospital you are asked to provide written answers to questions asked in a suit by a former patient and asked to provide sworn verbal testimony as well. The phase of this lawsuit is
Which of the following claims of negligence fits into the category of res ipsa loqitur?
Leaving a foreign body inside a patient
When a health care facility fails to invesetigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under
Electronically stored information, for example, the EHR, differs from paper-based information in Volume, variety of sources, and confidentitality but not
Under traditional rules of evisence, a medical/health record is considered _______________ and is ____________into evidence.
Elements of a contract are
offer/communication, price/consideration, acceptance
_________ is not an element of a contract
In which of the following circumstances would release of information without the patient's authorization be permissible?
Release to third party payers
When conducting a study, you classify pain levels associated with a specific illness as: 01, none; 02, little or minimal; 3 moderate; 04 heavy; 05, severe. These data are best described as
Which of the following interactions fits the definition of a patient encounter? P daw Dr. H during a scheduled office visit. Dr. H prescribed a new med. J called Dr. H with a question about her med. Dr. H retruned the call and answered J's question. L was seen by Dr. H in the ER adfter having a reaction to his meds. The pharmacy recevied telephone approval from Dr. H for a refil on F's meds.
P and L.
A small portion of the form you are using for a research study is reproduced below. Male 1 Female 2. This data is
MT. hospital has discovered a security breach. Someone hacked into the system and viewed 50 medical records. According to the ARRA, what is the responsibility of the covered entity?
All individuals must be notified within 60 days.
A patient has submitted an authorization to release information to a physician office for continued care. The ROI clerk wants to limit the information provided because of the minimum necessary rule. What should the supervisor tell the clerk?
The patient is an exception to the minimum necessary rule, so process as written.
Pat is processing a request for medical records. The record contains an op. report and a discharge summary from another hospital. The records are going to another physician for patient care. What should Pat do?
Include the documents from the other hospital.
You are writing a policy for ROI. The policy will include requirements for a valid authorization. What would not be included?
A request for an accounting of disclosure.
Your dept is unable to provide the patient with a copy of his record in 30 day time limitation window. What do you do?
Write the patient and tell him you will need a 30 day extension.
Which techniques would a facility employ for access control?
Automatic logoff and Unique user identification
Which is true about the Privacy Act of 1974?
It applies to the Federal Govt.
Mag looked up PHI on her ex-sister-in-law. A routine audit discovered the violation. Which statement is true under ARRA?
Mag cannot be prosecuted as a covered entity.
Which statement is true when a family member can be provided PHI?
The family member is directly involved in the the care of the patient.
Nick is developing an agreement that will be used between the hospital and the health care clearing house. This will require the two parties to protect the privacy of data exchanged and is called
A business associate agreement
You have been given the task of destroying PHI stored on an old server. What method would you use?
Which of the following documents is subject to the HIPAA security rule?
Scanned op report stored on CD (security rule only applies to ePHI)
Which of the following situations would require authorizations before disclosing PHI?
public health activities
A covered entity is
includes health care providers who perform specified actions electronically
You have been asked to create a presentation on intentional and unintentional threats. What would you cite?
a patient SSN being used for a credit card applications.
You will be choosing the type of encryption to be used for the new EHR. What are your choices?
symmetric and asymmetric
Your system just crashed. You have established a site that holds computer processors but not data. This site can be converted to meet needs quickly. This is a
Which of the following is a true statement about symmetric encryption?
Symmetric encryption assigns a secret key to data.
HIPAA workforce security requires
that access to PHI be appropriate.
Richard has asked to view his medical record. The record is stored off-site. How long does the facility have to provide his record to him?
A data use agreement is required when
a limited data set is used
What type of digital signature uses encryption.
You have been assigned the responsibility of performing an audit to confirm that all of the workforce access is appropriate for their role in the organization. This process is called
workforce clearance procedure
Which of the following is subject to the HIPAA security rule?
clinical data repository
You have been asked to establish guidelines for on screen design that will be used in all of our IS projects. Which standard should be included?
The screen should read right to left
You have had a problem with duplicate med record numbers in your facility MPI. Now you are joining a HIE, so you need to clean up the data base and prevent the duplicates from happening again. If you want to find near matches as well as identical matching records in the MPI you should implement a _________ algorithm.
Which of these is found in an ambulatory EHR but not in acute care EHR?
You installed a new computer system and learn the vendor you used does not have a right to part of the system. Another company owns the rights to the information contatined in this part. What clause in your contract would you review to see if you are protected from being sued by the other company?
The most secure model of signatures in IS is
Critique the following statement?
The EHR utilizes existing source systems to supply data
This is true because the EHR uses many source systems to populate the data
The hospital is undergoing the development of an IS strategic plan. The part of the process where changes in the community, legislation, and other factors are monitored is called the
Upon final review of the RFP that is to be sent out to prospective vendors, you notice that there is content that should not be included in the operational requirement section. What should be deleted?
You are interested in performing some data anaylsis on patients with cardiac problems. You have downloaded the data you need from the data warehouse into a smaller database. You are using a
The admin has asked for a patient satisfaction database internally to be used to collect data that can be used to provide improved services. He does not want this to be a long process. Which of the following could speed this process?
In selecting a messaging standard for use in a picture archival communication system (PACS) the best choice would be
DICOM (digital imaging communication in medicine)
Which is an example of EHR functionaltiy?
Why would the database adminstrator add a foreign key to one of the tables?
to indicate that it is a primary key in another table
Which application design is used in computer assisted coding (CAC)
natural language processing (NLP)
You ROI system has part of the computing on the workstation and part on the file server. What type of technology is being used?
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