Upgrade to remove ads
RHIT 2019 Practice Set
Terms in this set (341)
a. Provide uniform data definitions
In healthcare, data sets serve two purposes- The first is to identify data elements to be collected about each patient. The second is to:
A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:
d. Data dictionary
A critical early step in designing an. EHR is to develop a(n) _ in which the characteristics of each data element are defined.
In a long-term care, the resident's care plan is based on data collected in the:
b. They provide a complete and exhaustive list of data elements that must be collected.
Which of the following is not a characteristic of the common healthcare data sets such as UMLDDS and UACDS
What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?
a. Recommend common data elements to be collected in health records
The primary purpose of a minimum data set in healthcare is to:
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry- No insulin reaction She says she is following her diabetic diet," In which part of a problem- oriented health record progress note would this be written?
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data:
c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females
In which of the following examples does the gender of the patient constitute information rather than) a data element?
b. Continuity of care record
11. A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from^ care setting to another is:
12. The home health prospective payment system uses the data set for patient assessments.
13. A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." " In which part of a problem-oriented health record progress note would this be written')
d. Systematized Nomenclature of Medicine Clinical Terminology
14. Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?
15. The data set designed to organize data for public release about the outcomes of care is:
b. Data consistency
16- Mrs. Smith's admitting data indicates that her birth date is March 21,1948. On the discharge summary, Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
c. Operative report
17. 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."
Structure and content
18. What type of standards provide clear descriptors of data- element to be included in computer-based patient record systems?
d. Data accountability
19. Which of the following is not a characteristic of high-quality healthcare data?
b. Data are easy to obtain
20. Which of the following is a primary purpose of the health record?
b. Data are easy to obtain
21. Which of the following best describes data accessibility
c. Invoice for services
22. Which of the following elements is not a component of most patient health records?
a. Laboratory report
23. Identify where the Moving documentation would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB14.8, HCT 43.3, MCV 93."
b. Discharge summary
24. The attending physician is responsible for which of the following types of acute-care documentation?
A numerical measurement carried out to the appropriate decimal place
25. Which of the following represents an example of data granularity?
26. Which of the following is an example of clinical data
c. Data currency
27. Dr. Jones 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?
b. Patient registration
28. In which department or unit is the health record number typically assigned?
d. Social service note
29. The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CpS re: referral. Case manager to meet with patient and family" In which of the following would this documentation appear
c. Data include all required elements.
30. Which of the following best describes data comprehensiveness
b. In numeric order
On the problem list in a problem-oriented health record, problems are organized:
.Which of the following represents documentation of the patient's current and past health status?
Medication administration record
A nurse is responsible for which of the following types of acute-care documentation?
Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
What is the function of a consultation report
A secondary purpose of the health record is to provide support for which of the following?
d. physical examination
The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHBST: Good bilateral chest sounds." In which of the following would this documentation appear?
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block:." In which of the following would this documentation appear?
The HIM department is planning to scan paper-based components of the medical record such as consent forms and lab orders from physician offices. Which of the following methods would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
Two health information professionals are abstracting data for the same case for a registry- When their work is checked, discrepancies are found. Which data quality component is lacking?
patient's complete medical history
Which of the following materials is not documented in an emergency care record?
Which of the following contains the physician's findings based on an examination of the patient?
Which one of the following indexes contains a list maintained in diagnosis code number order for patients who are discharged from a facility during a particular time period?
American College of Surgeons
Cancer registries receive approval as part of the facility cancer program from which of the following agencies?
Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services.
Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient?
Which one of the following indexes contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period?
HIM departments may be the hub of identifying^ mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. 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?
Coding and billing staff
Which of the following is an individual user of the health record?
Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines.
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. Which of the following will provide the most comprehensive solution to handle this documentation issue?
Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?
. OASIS-C data are used to assess the ——— of home health services.
The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:
The Joint Commission
Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided?
Clinical forms committee
What committee usually oversees the development and approval of new forms for the health record?
Uses radio buttons to select multiple items from a set of options
Which of the following is not true of good electronic forms design?
Insurance companies that cover healthcare expenses
Which of the following is not an individual user of the health records
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
How many times each year are healthcare facilities required to practice emergency preparedness plans?
Commission on Accreditation of Rehabilitation Facilities
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.
Multiple users entering data may have different definitions or perceptions about what goes into a data field, thereby confounding the data. For example, one department may use the term "PATIENT" while another department my use the term "CLIENT' to define the same entity. Which of the following would be used to provide standardization?
The Joint Commission
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
Version control is easy to implement.
Which of the following is not a true statement about a hybrid health record system?
The ability to electronically send data from one EHR to another while maintaining the original meaning is called:
Identity matching algorithm
What is the key piece of data needed to link a patient who is seen in a variety of care settings*
Conditions of Participate
What is the general name for Medicare rules affecting healthcare organizations?
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
Ensures that appropriate data are collected timely
Why does an ideal EHR system require point-of-care charting?
When a user keys in 10X01963, the computer displays it as 10/10/1963. What enables this?
Electronic document management system
A transition technology used by many hospitals to increase access to health record content is:
Design a plan
What is the first step an organization should take when developing a data dictionary?
Elements of performance
Specific performance expectations and structures and processes that provide detailed information for each of the Joint Commission standards are called:
When all required data elements are included in the health record, the quality characteristic for data is met.
A record that fails quantitative analysis is missing the quality criterion of:
This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans:
What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice*)
Joan reviewed the health record of Sally Williams and found the physician stated on her post—op note, "examined after surgery." This review process would be an example of:
Document name, media type, source system electronic storage start date, stop printing start date
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
Establishment of its baseline trustworthiness
Authentication of a record refers to:
Establish minimum quality standards for hospitals
The primary goal of the Hospital Standardization Program, established in 191 8 by the American College of Surgeons, was to:
The field type should be changed to Character.
The following descriptors about the data element PATIENTLAST_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 Joint Commission
Which of the following is the healthcare industry's leading standards-setting body in the country?
All categories of health records
General documentation guidelines apply to:
Behavioral health records
What type of health records may contain family and caregiver input?
The content may contain outdated information
Why should the copy and paste function not be used in the electronic health records
. An RAI/MDS and care plan are found in records of patients in what setting
The evaluation of data collected based on business needs and strategy is part of
A patient's birth date and gender documented in the health record are examples of a data
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?
George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of:
Is the number assigned to each case as it is entered into a cancer registry
In a cancer registry, the accession number:
Bob Smith is a 56-year-old white male. This is an example of what type of data?
Master patient index
Which of the following indexes is an important source of patient health record numbers
What are the patient data such as name, age, and address called?
What type of registry maintains a database on patients injured by an external physical force
Which of the following are data that have been filtered and put into context?
Which of the following describe criteria with specific objectives and measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care?
Which of the following systems is the key to identifying a patient's multiple hospitalizations?
Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an organization's data assets?
. Embedded metadata
Which of the following would be used to track data movement from one system to another?
The statement, "the unique patient identifier must be numeric," is an example of which of the following business rule categories?
. Linking an older version of a code set to a newer version
Which of the following is the best definition of a forward map in data mapping?
Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area?
The patient's address is the same in the master patient index, electronic health record, laboratory information system, and other systems. This means that the data values are consist". consistent and therefore indicative of which of the following?
The term used to describe controlling information is
a. Evaluate the performance of employees
How do patient care managers use the data documented in the health record?
Which of the following data quality characteristics means all data items are included within the information collected?
Assuring documentation that is being changed is permanently deleted from the record
Which of the following is not a recommended guideline for maintaining integrity in the health record?
The documentation needs based on accrediting bodies
When creating requirements of documentation for the hospital bylaws, which of the? following should be evaluated?
The use of the health record by a clinician to facilitate quality patient care is considered:
The use of the health record by a clinician to facilitate quality patient care is considered:
. Which group focuses on accreditation of rehabilitation programs and service^
What is it called when accrediting bodies, such as the Joint Commission, rather than the government can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals?
Mary Jones's hemoglobin of 13 is within normal range
Which of the following statements represents knowledge?
Data silos and fragmented data inhibit data integration
Which of the following is the best example of a data governance business case?
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
. Assess the legal environment, system limitations, and HIE agreements
A healthcare provider organization, when defining its legal health record must.
Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, ru]es, and regulations
Which of the following is considered a clinical documentation best practice?
The H&P must be documented within 30 days before admission with an update within 24 hours after admission
Dr. Hall is an orthopedic surgeon performing a knee replacement on Mary- Mary was seen in Hall's office 2 months before the surgery and Dr. Hall documented her history and physical (H&P) at that point. Does his H& P meet documentation requirements for the surgery?
At the time a hospital implemented an electronic health record, the the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two the active filing area. These patient records are considered from. the active filing area,
How long should the MPI be retained?
a patient's registration forms, personal property list, RAL care plan, and discharge or transfer documentation would be found most frequently in which type of health record1)
Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?
Electronic point-of-care charting
Electronic systems used by nurses and physicians to document assessments and findings are called:
Promoting the sale of enterprise data
Which of the following is not part of data governance
To determine whether standards are being met
How do accreditation organizations use the health record*)
This is an example of reverse mapping
A healthcare system wants to map ICD-10-CM to ICD-9'CM. Which of the following would be true about this effort?
Reduce documentation variability
What is the primary puipose of structured data entry
Which of the following is considered a secondary data source?
Date of birth
Which of the following would be a discriminating attribute used to disqualify two or more similar records?
When one entity has different unique identifiers in different databases
In data matching which of the following best describes an overlap?
Authoritative source for data about an entity
Which of the following is the best definition of system of record (SOR)?
The average length of stay is the sum of inpatient days for a period divided by the Member of discharges for a period
Which of the following would be considered a derivation business rule?
Describes a real or conceptual structure that organizes a system or concept
Which of the following is the best definition of a data governance framework;?
Including original and revised dates
Which of the following should be taken into consideration when designing a health record form?
Automatic logoff after inactivity
Which of the following is an example of data security?
Which of the following is not an automatic control that helps preserve data confidentiality and integrity in an electronic system?
Which of the following is not an automatic control that helps preserve data confidentiality and integrity in an electronic system?
The function used to provide access controls, authentication, and audit logging in an HIE is:
American Recovery and Reinvestment Act
. Which of the following laws created the HITECH act?
Unauthorized access to a system
An audit trail may be used to detect which of the following
A contingency" plan
Which of the following administrative safeguards includes policies and procedures for responding to emergencies or failures in systems that contain e-PHl?
A cost-based fee may be charged for making a copy of the PHI.
Which of the following statements is true in regard to responding to requests from individuals for access to their protected health information (PHI)?
Can deny access to psychotherapy notes
Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:
When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual
In which of the following situation must a covered entity provide an appeals; process for denials to requests from individuals to see their own health information?
Access to information
Within the context of electronic health records, protecting data privacy means defending or safeguarding:
Once a year
, To ensure relevancy, an organization's security policies and procedures should be reviewed at least
Identify security threats
An electronic health record risk analysis is useful to:
An individual designated as an inpatient coder may have access to an electronic health record to code the record. Under what access security mechanism is the coder allowed access to the systems
Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?
What is the biggest threat to the security of healthcare data?
The protection measures and tools for safeguarding information and information systems is a definition of:
Ask the security officer for audit trail data to confirm or disprove the suspicion.
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?
Placing locks on computer room doors is considered what type of security control?
a. Allow her to review her record after obtaining authorization from her.
151. A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the HIM department and requests to review her health record. Of the options here, what is the best course of action?
c. Allow the patient to access his record if, after contacting his physician, his physician does not it will be harmful to the patient.
152. 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 pr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for last two months. These records are not psychotherapy notes. Of the options here, what is. the best course of action?
Single sign-on is less frustrating for the end user and can provide better security-
153. During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all the system modules. For example, they have to use one Jog-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 EH|R system components. However, the hospital. administrator thinks that one log-on would be a security issue. information should the HIM director provide?
154. Which of the following are security safeguards that protect equipment, media, and facilities?
Identifying which data employees should have a right to use
155. What does the term access control mean?
a. Age IS
156. Which of the following is not an identifier under the Privacy Rule?
c. State law because HIPAA defers to state laws on matters related to minors
157 ■ What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?
a(n): Patient portal
158. A secure method of communication between the healthcare provider and the patient is
d. Use redundant servers.
159. Which of the following would be the best course of action to take to ensure continuous availability of electronic data?
160. The director of health information services is allowed access to the health record tracking system len providing the proper log-in and password. What is this access security mechanism called'/
161. A special web page that offers secure access to data is an
a. It must report the breach to HHS within 60 days after the end of the calendar year in which the breach occurred
162. Mary's PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the- physician office's required action1)
c. Password and swipe card
'163. Which of the following is considered a two-factor authentication system?
c. A computer station that facilitates integrated communications within the healthcare organization
164. Which of the following best describes the function of kiosks?
c. Server redundancy
165. Which of the following technologies would reduce the risk that informationkimot accessible during a server crash?
A authorization must contain an expiration date or event.
166. Under the HIPAA Privacy rule, which of the following statements istrue?
c. Application safeguards
167. Which of the following security controls are built into a computer software program?
168- An audit log is an example of:
d. Access controls
169. An HIT using her password can access and change data in the hospital's master patient index A billing clerk, using his password, cannot perform the same function. Limiting the class of information and functions that can be performed by these two employees is managed by:
170. Which of the following is an organization's planned response to protect its information in the case of a natural disaster?
d. Outsourced transcription company
171. Under HIPAA, which of the following is not named as a covered entity?
d. Sets a minimum (floor) of privacy requirements
172. The HIPAA Privacy Ruie;
b. General rules
173. Which of the following provide the objective and scope for the HIPAA Security Rule as a whole*)
c. Contained within a personnel file
174. Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule?
b. Audit trail
175. Which of the following is a software program that tracks every access to data in the computer system?
c. The Privacy Rule's minimum necessary requirement does not apply-
176. Centra] Ci# Clinic has requested that Ghent Hospital send its hospital records for Susan Hall's most recent admission to the clinic for her follow-up appointment Which of the following statements is true*)
d. Workforce member
177. Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n):
Not a business associate because it does not use or disclose individually identifiable health information
178. Lane Hospital has a contract with Ready /-Clean, a local company, to come into the hospital to pick up all of the facility's linens for off-site laundering. Ready-Clean is:
c. The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment.
179. For HIPAA implementation specifications that are addressable* of the following statements is true
a, Disaster recovery plan
180. The HIPAA Security Awareness and Training administrative safeguard requires all of the following addressable implementation programs for an entity's workforce except
d. Right to consent to treatment and the right to access his or her own PHI
181. A competent individual has the following rights concerning his or her healthcare:
c. Establish a contingency plan
182. Covered entities must do which of the following to comply with HIPAA security provisions')
d. Business records exception
183- The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition- "The plaintiff's attorney wishes .to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the:
b. Not protected by the Privacy Rule because it is part of a personnel record
184. Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San- Fernando Hospital. Jeremy's medical information is:
b. Destruction of paper-based health records
185. Burning, shredding, pulping, and pulverizing are all acceptable methods in which process
a. Minimum necessary
186. The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this example of?
b. Notice of Privacy Practices
187. To comply with HIPAA regulations, a hospital would make its membership in an HIE known to its
b. It allows the business associate to maintain PHI indefinitely.
188. Which of the following statements is not true about a business associate agreement?
a. Make an amendment request in writing and provide a rationale for the amendment.
189If a patient wants to amend his or her health record, the covered entity may require the individual to:
d. Testifying regarding the care of the patient
190.The "custodian of health records" refers to the indMduahwithin an organization who is responsible for all except which of the following actions?
b. Must comply with it
191.When served with a court order directing the release of health records, an individual:
192- The process of releasing health record documentation originally created by a different provider called:
c. Must contain content that may not be changed
c. Must contain content that may not be changed
194.To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request
b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment
195. Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to the physician office visits because she often forgets to tell the physician vital information. xJnder the Privacy Rule, the release of her mother's PHI to Jennifer is:
c. An authorization must be obtained for uses and disclosures for treatment, payment, and operations.
196. Which of the following statements is false with regard to the HIPAA Privacy Rule?
b. Provider who generated the information
197Who owns the health record
198. What is the legal term used to define the protection of health information in a patient-provider relationship?
a. HITs must ensure that patient-identifiable information is not released to unauthorized parties.
199. Which of the following statements represents an example of nonmaleficence
c. 60 days
200. Under HIPAA regulations, how many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHI is stored off-site?
c. Any outside company that handles electronic PHI
201. Written business associate agreements are required with:
a. Contract coder
202. Which of the following is an example of a business associate?
c. Retention policies
203. What type of health record policy dictates how long individual health records must remain available for authorized use?
c. Subpoena duces tecum
204. Which document directs an individual to bring originals or copies of records to courts
a. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory-
205. Which of the following statements about the directory of patients maintained by covered entity is true?
a. It must include at least two examples of how information is used for both treatment and operations.
206. Which of the following is not true about the Notice of Privacy Practices?
a. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information
207. The legal health record (LHR) is a(n):
208. The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:
c. Public health department for disease reporting purposes
209. Which of the following has access to personally identifiable data without authorization or subpoena?
c. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role.
210. Community Hospital is discussing restricting the access that physicians have to electronic health records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available, whereas others maintain that HIPAA director advise the committee? Which of the following should the director advise the committee?
d. Is protected by the Privacy Act
211. When a patient revokes authorization for release of information after a healthcare facility has already released the information, the facility in this case:
b. Noncompliant and hostile toward staff
212. Mrs. Bolton is an angry patient who resents her physicians "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is:
a. This information could be rejected because the physician dictated the procedure note after the malpractice suit was filed.
213. As the corporate director of HIM services and enterprisepri privacy officer, yoirare asked to review a patient's health record in preparation for a legal proceeding for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longsta' longstanding history of being lackadaisical with record completion practices. Previous concerns regarding this physician's record maintenance practices had been reported to the facility's Credentialing Committee. Is this information admissible in court?
c. Refuse the request.
214. The sister of a patient requests the HIM department to release copies of her brother's health record to her. She states that because the doctor documented her name as her brother's caregiver that HIPAA regulations apply and that she may receive copies of her brother's health record. In this case, how should the HIM department proceed?
215. Given the numbers 47,20,11, 33,30,30,35, and 50, what is the mode?
d. Whether all access by hospital employees was appropriate
216. Recently, a state senator was admitted to your facility for a serious medical condition. The facility privacy officer has been tasked with reviewing access logs daily to determine which of the following?
217. Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of The hospital had a total of 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:
d. Request a new data chart be presented that accurately reflects the trend of infection rate
218. The HIM data analytics professional is reviewing a chart (shown here) on nosocomial infections presented by the hospital's infection control committee. The committee is reporting that the decrease in infection rate has accelerated during the past 10 years. What comments should the data analytics professional make? (See graph)
b. Annualized revenue for YR-7 is more than the costs.
219. City Hospital's HIM department made a decision to discontinue outsourcing its release of (ROI) function and perform the function in house. Because of HIPAA implementation, the department wanted better control over tracking release of information. Given the graph sfciown here, how would you evaluate the ROI revenue growth? See graph
220. After the types of cases to be included in a trauma registry have been determined, what is the next step in data acquisition?
b. Case finding
221Review of disease indexes, pathology reports, and radiation therapy reports are parts of which function in the cancer registry?
'B. Predictive analytics
222. The business office at Community Hospital is looking at software that can help them with decreasing their fraud and abuse cases. The software claims to be able to flag those patients that would most likely be involved in fraud by examining many databases at the same time and finding those patients with demographic discrepancies. This is an example of
c. 8 days
223. Community Hospital discharged nine patients on April 1. The' length of stay for each of the patients was as follows: for patient A, 1 day; for patient B, 5 days; for patient C, 3 days; for patient p, 3 days; for patient E, 8 days; for patient F, 8 days; for patient G, 8 days; for patient H, 9 days; patient I, 9 days. What was the median length of stay?
a. Contains data about a patient and has been documented by the professionals who provided care the patient
224. A record is considered a primar—y data source when it:
d. Employee D
225. At Community Hospital, each M-time employee is required to work 2,080 hours annually. The table below shows the amount of time that four employees were absent from work over the past year. See graph
226. The following data were derived from a comparative dischargedatabase for hip and femur procedures: see table
These data can best be described as:
227. In a frequency distribution, the lowest value is 5, and the highest value is 20. What is the range?
228. What is the mean for the following frequency distribution: 10,15,20,25,25?
b. Whether the person viewed, created, updated, or deleted information belonging to a patient with the same last name
229. The HIM manager at Community Hospital is responsible for reviewing audit trails detailing potential access issues within the EHR. Which one of the following would be a type of activity that.t the manager would want to review?
c. There are "blank cells.
230. What is (are) the format problem(s) with the following table? See table
c. ll days
231. Mr. Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay for Mr. Jones?
d. Benchmarking with other facilities
232. Which of the following is an example of how an internal user utilizes secondary data?
233. Community Hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed five autopsies for the same period. What was the gross autopsy rate for the hospital for June?
d. Pie chart
234. If you want to display the parts of A whole in graphic form, what graphic technique wouldyooiznse?
d. Daily inpatient census
235. Which term is used to describe the number of inpatients present at the census-taking time each day plus the number of inpatients who were both admitted and discharged after the census-taking time the previous day?
a. Average length of STAY
236. Suppose that five patients stayed in the hospital for a total of 27 days. Which term would used to describe the result of the calculation 27 divided by 5?
c. Gross hospital death rate
237. Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges?
b. Length of stay
238. Which term is used to describe the number of calendar days that a patient is hospitalized
a. Inpatient service day
239. Which unit of measure is used to indicate the services received by one inpatient in a 24-hour period?
240. What term is used for the number of inpatients present at any one time in a healthcare facility?
241. Which rate describes the probability or risk of illness in a population over a period of time?
b. External data
242. A statewide data base is used by your performance improvement department each month to compare other facilities' readmission rates to your facility's rates. This is an example of
b. It only contains Medicare patients.
243. Why is the MEDPAR file limited in terms of being used for research purposes?
244. At Community Hospital, each full-time employee is required to work 2,080 hours annually. The table below shows the amount of time that five employees were absent from work over the past year, see table
a. In each MS-DRG, the geometric mean is lower than the arithmetic mean.
245. Given the information here, which of the following statements is correct? See table
246. Given the following information, in which city is the GPCI the highest for practice expense? See table
247. One of the pediatricians at Community Physician's Clinic worked with a software vendor to get a display of the patients she currently has in the hospital on her smart phone that lets hern know current information such as lab results, vital signs, medications given. This is called
d. Patient number
248. Which of the following is the unique identifier in the relational database patient table? See table
d. Primary key
249. Which of the following uniquely identifies each record in a database table?
a. Data model
250. Which of the following is a technique for graphically depicting the structure of a computer database?
a, Ad hoc or demand
251. The Medical Staff Executive Committee has requested a report that identifies all medical staff members who have been suspended in the last six months due to delinquent health records. Thi-as is an example of what type of report?
c. Suggest that the data be adjusted for possible differences in type and volume of patients treated.
252. Hospital A discharges 10,000 patients per year. Hospital B is located in the same town and discharges 5,000 patients per year. At Hospital B's medical staff committee meeting, a physician reports that lie is concerned about the quality of care at Hospital B because the hospital has double the number of deaths per year than Hospital A. The HIM director is attending the meeting in a staff position. Which of the following actions should the director take?
253.Community Hospital has compared its admission-type patient-profile data for two consecutive years. From a performance improvement standpoint, which admission types should the hospital examine for possible changes in capacity handling? See graph
c. Recommended for staff reappointment
254. A report that lists the ICD-10-CM codes associated with each physician in a healthcare faciltiy canbe used to assess the quality of the physician's services before he or she is:
c. Family practice
255. The following table compares Community Hospital's pneumonia length of stay (observed LOS to the pneumonia LOS of similar hospitals (expected LOS). Given this data, where might Community Hospital want to focus attention on its pneumonia LOS? See table
b. Full-time coders are more productive than part-time coders.
256. The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data? See table
c. Cost comparison reflects a net reduction in overall expenses on a monthly basis for the e-WebCoding system.
257. Community Hospital performed a cost-savings analysis between its current paper-based, on-site processes and an e-WebCoding telecommuting model. Given the graph here, what does the cost analysis show? See graph
258. Given the following information, from which payer does the hospital proportionately receive the least amount of payment' see table
259. Which of the following is made up of claims data from Medicare claims submitted by acute-care hospitals and skilled nursing facilities?
260. Which autopsy rate compares the number of autopsies performed on hospital inpatients to the total
261. What do the wedges or divisions in a pie graph represent?
a. The sum of all relative weights divided by the total number of discharges
^262. Within the context of the inpatient prospective payment system, how is the case-mix index calculated?
263. Using the information in the table below, calculate the C-section rate at University Hospital for the semiannual period. See table
a. Descriptive analytics
264. Your administrator has asked you to generate a report that gives the number of hypertension patients last year. This is an example of
d. Real-time analysis
265. Community Hospital is using a system that will help them detect when intracranial pressure becomes high in patients with a recent CVA that will quickly send an "alert to the physician. This is an example of
266. Which of the following types of data does not have a natural order?
267. In the community clinic Dr. Simpson, an interventional cardiologist, saw 270 patients last quarterOf those, he performed stent procedures on 1 patients and angioplasty procedures on 88 patents. What is the proportion of Dr. Simpson's patients who have had stent procedures?
268. Which of the following reportable diseases usually requires telephone reporting as opposed to other methods of reporting'!
b. Inferential statistics
269. The type of statistics that makes a best guess about a larger group of data by drawing: conclusions
from a smaller group of data is called:
b. Predictive modeling
270. A managed care organization is using a system that examines the past healthcare behaviors of their patients to determine their future costs for their healthcare. This is an example
c. The physician's index
271. A secondary data source includes
b. Evidence-based medicine
272. Large population-based studies are used to identify the care processes or interventions that achieve the best healthcare outcomes in different types of medical practice. This research concept is called?
a. Have some consistency
273. To be reliable, statistical data must:
c, Daily inpatient census
274. What is the official count of inpatients taken at midnight called'?
c. Patient number
275. In the relational database shown here, the patient table and the visit table are related by: see table
a. Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry
276. Case finding is a method used to:
277. pata found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. This data collection is called?
a. National Center for Health Statistics
278.Certificates, such as those for births and fetal-deaths, are reported by hospitals to the individual state registrars and maintained permanently. State vital statistics registrars then compile the data and report them to which of the following:
279. The HIM professional reported to the qualify improvement committee at Community Hospital that there were 58 patients with influenza discharged from the hospital in January. Of those, 3 died. What is the case fatality rate for influenza for January7
: c. Abstracted
280. Information that has been taken from the health records of injured patients and entered into the trauma registry database has been
c. $5.43 per record
281. The HIM department at Community Hospital has three full time coders. One is considered the lead coder and his salary is $20.35 per hour. One coder is a new graduate who makes $15.50 per hour and the third coder is an experienced employee who earns $ 18.90 per hour. The lead coder codes four records per hour; the new coder codes three records per hour and their experienced coder codes six records per hour. Using a 7.5-hour productive what is the unit cost for the lead coder?
Analyze the following report of physician deficiency rates and determine which physician has the lowest deficiency rate / for H&P complete within 24 hrs of admission
283. Suppose that 6 males and 14 females are in a class of 20 students with the data reported as 3/1. What term could be used to describe the comparison
284. One of the questions on the patient satisfaction survey that is sent to the patient after discharge asts for the number of times the nurses checked the patient's vital signs in a day. This is an example of which type of data?
c, personal mobile device
285. The Information Services Department has requested information about the electronic signature system being used in your facility. They would like to kniow locations where physicians are accessing the system. Review the information in the table below and determine which site has the highest percentage of use. See table
d. Review audit trail information to determine which employees have accessed this patient's information
286. A celebrity injured while on vacation was admitted to the local community hospital for treatment of a fracture. On day two of the admission, the hospital was contacted by several media agencies stating that they were a ware the patient was at at the facility and requesting information about the current medical condition of this high profile celebrity patieni patient. The CEO is concerned that an has shared information to the media regarding this patient. The facility privacy officer was tasked with determining if a facility employee leaked this information to the press. How would the privacy officer begin this analysis?
287. A family practitioner in your looal physician's clinic saw 150 adults in one week for their annual physical examinations. Sixty- y-seven received the flu vaccine and three patients received the pneumococcal pneumonia vaccine. What is the rate of the flu vaccine administration for this physician?
d. Scatter diagram
288. Which of the following is used to plot the points for two variables that maybe related to each other in some way?
c. Worker's Compensation
289. The coding department at Community Physician's s Clinic developed the following report for the denials committee at the clinic. The billing report shows the following information. Using the information below, identify which payment source has the highest denial rate.
290. Using the information in the table below, calculate the vaginal delivery fate at University Hospital for the semiannual period, see table
d. Which employees viewed, created, updated, or deleted information
291. The facility privacy officer is visited at the hospital by a recent patient that is concerned that her nosy neighbor, who happens to be=s a hospital employee, accessed her electronic health record inappropriately in order to tell othier neighbors about the patient's health conditions. In order to determine this occurred the privacy officer requests an audit log of activity within the p^atient's health record. What part of the audit log would the privacy officer need to first analyze to determine if this patient complaint is valid?
b. 264 hours
292. The coding department at Community Physician's Clinic developed the following report for the denials committee at the clinic. The billing report shows the following information. How many hours will it take to reconcile these denials if each denial takes 1.5 hours to review and resubmit the bill? See table
293. On October 1st, a hurricane hit a small coastal community, which has a community hospital licensed for 50 beds. Hospital staff set up 10 additional beds around the facility and used three labor room beds and two treatment room beds in order to help take care of patients. Which of the following would be the denominator used to determine the percentage of occupancy for October 1st?
294. The number of inpatients present in a healthcare facility at any given time is called
295. The Information Services Department has requested information about the electronic signature system being used in your facility. They would like to know the locations where physicians are accessing the system. Review the information in the table below. What is the percentage of pnysicians not using the electronic signature system? See table
a. Core measures
296. The Joint Commission and CMS have identified sets of patient care characteristics that they have determined reflect the quality of care an organization can provide for important diagnosis These sets are called
B. I&d of pilonidal cyst, simple
297 Given the following information, which of the following has the lowest work RVU?
d. $5.51 per record
298. The HIM department at Community Hospital has three full time coders. One is considered the lead coder and his salary is $20.35 per hour. One coder is a new graduate who makes $15.50 per hour and - 'the third cciJ^coder is an experienced employee who earns $ 18.90 per hour. The lead coder codes four records per hour; the new coder codes three records per hour and their experienced coder codes six records per hour. Using a 7.5-hour productive day, what is the unit cost for the new graduate coder?
c. Prescriptive analytics
299. This type of analytics allows users to prescribe a number of different possible actions:
d. MS-DRG triples, pairs, and singles
300. In analyzing the reason for changes in a hospital's Medicare case-mix index over time, time analyst should start wilwHhich of the following levels of detail?
d. Utilization review
301. What is the term that means evaluating the appropriateness of the setting for the healthcare service and the level of service?
a. Identify all records for a period having these indicators for these conditions and determine whether these conditions are the only secondary diagnoses present on the claim that will lead to higher payment
302. Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement?
303. A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a comorbid condition?
c. Counsel the coder and stop the practice immediately
304. A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
c. Major diagnostic categories
305. Diagnosis-related groups are org -anized into:
d. Incorrect code combinations are on the claim.
306. NCCI edits prevent improper payments in which of the following cases?
B. MS-DRG calculated for the encounter
307. Medicare inpatient reimbursement levels are based on:
308. Dr. Green discharged 30 patients from Medicine Service during the month of August. The table above presents the number of patients discharged by MS-DRG. Calculate the CMI for Green.
c. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis
309. A physician query may not be appropriate in which of the following instances
310. A coder might find which of the following on a patient's problem list if the medication list contains the drug Procardia?
d. Diameter of the lesion as well as the margins excised as described in the operative report
311.Ifa patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?
a. Inpatient Medicare claims submitted by hospitals
312. The present on admission indicator is a requirement for:
d. Acute cholecystitis
313. The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal paim of the following would be the correct coding and sequencing for this case?
b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina
314. A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case1)
c. Query the physician to ask if the patient has septicemia because of the symptomatology
315. An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of coli per cc of urine Hie attending physician documents "urosepsis." How should this case be coded?
316. 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:
c. Metastatic carcinoma of the brain
317. A 65-year-old patient with a history of lung cancer is admitted to a healthcare fs^.cility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a *closed reduction of the fracture in theewnergency department as well as a complete workup for metastatic carcinoma of the brain The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case?
318. According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
c. Metastatic carcinoma of the brain; history of carcinoma of the prostate
319. A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay*>
a. Either the pancreatitis or noncalculus cholecystitis sequenced as principal diagnosis
320. A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be:
321. When coding a benign neoplasm of skin of the vermilion border of the lip, which of the following codes should be used? See table
c. Asthma with status asthmaticus
322. A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
323. The ICD-10-CM utilizes a placeholder character at certain codes to allow for future expansion of the classification system. What letter is used to represent this placeholder character?
b. Fever, cough, shortness of breath
324. A physician orders a chest x-ray for an office patient who presents with fever, productive cough, and shortness of breath. The physician indicates in the progress notes: "Rule out pneumonia." What should the coder report for the visit when the results have not yet been received?
325A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?
b. Healthcare Common Procedure Coding System
326. Which of the following promotes uniform reporting and statistical data collection for medical procedures, supprlies, products, and services?
a. Case-mix index
327. The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on:
b. A41.01, K57.32
328. A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methiciZlin-susceptible Staphylococci aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? See table
329. Given the information here, how much of the APC payment would the facility receive the status T procedure? See table
330. Patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the code assignment? See table
331. When coding a hydrocystoma of the right eyelid, which of the following codes should be used? See table
d, -55, Postoperative management only
^32. Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient but another physician performed the surgical procedure.
d. 33222, Relocation of skin pocket for pacemaker
333. Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket.
a. Principal diagnosis
334. In the inpatient prospective payment system, the calculation of the DRG begins with the:
b. 37609, Ligation or biopsy, temporal artery
335. Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center.
336In ICD-10-PCS, foe root operation defined as taking or letting out fluids and/or gases from a body part is
b. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status
337. When reporting an encounter for a patient whois HTV positive but has never had any symptoms, the following code is assigned:
d. Utilization review
338what is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified?
d. paying for value
339. What type of value-based purchasing
program is the Hospital-Acquired Conditions Reduction Program?
340. Under outpatient prospective payment system, decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Mr. Smith had a minor procedure performed in the hospital
MS-DRGs may be split into a maximum of payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC, or no CC
THIS SET IS OFTEN IN FOLDERS WITH...
RHIT 2019 Reviewer Domain 3
RHIT Study Guide 2019
RHIT 2019 Reviewer Domain 6
RHIT 2019 Reviewer Domain 1
YOU MIGHT ALSO LIKE...
RHIT - ALL DOMAINs
RHIT Exam Prep 2017 Domain 1: Data Content, Struct…
OTHER SETS BY THIS CREATOR
CCS Exam 2020
ICD-10-PCS - Root Operations