2016 RHIT LATEST EXAM QUESTIONS AND
100% CORRECT ANSWERS
The minimum length of time for retaining original medical records is primarily governed
by
readmission rates.
Joint Commission.
medical staff.
state law.
state law.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals
are now required to use a preoperative verification process to confirm the patient's true
identity, and to confirm that necessary documents such as x-rays or medical records are
available. They must also develop and use a process for
including the primary caregiver in surgery consults.
including the surgeon in the preanesthesia assessment.
marking the surgical site.
apprising the patient of all complications that might occur.
marking the surgical site.
The new electronic system recently purchased at your physician practice allows for e-
prescribing, exchange of data to a centralized immunization registry, and it allows your
physicians to report on key clinical quality measures. In all likelihood, your practice has
succeeded in choosing a (an)
AMA-approved product
Certified EHR
Joint Commission-approved system
Functional EMR
Certified EHR
In preparation for an upcoming site visit by Joint Commission, you discover that the
number of delinquent records for the preceding month exceeded 50% of discharged
patients. Even more alarming was the pattern you noticed in the type of delinquencies.
Which of the following represents the most serious pattern of delinquencies? Fifteen
percent of delinquent records show
missing discharge summaries.
missing operative reports.
, absence of SOAP format in progress notes.
missing signatures on progress notes.
missing operative reports.
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 must be
recorded by persons authorized by hospital regulations and procedures.
written within 24 hours of the patient's admission.
accepted by charge nurses only.
cosigned by the attending physician within 4 hours of giving the order.
recorded by persons authorized by hospital regulations and procedures.
Joint Commission standards require that a complete history and physical be documented
on the health records of operative patients. Does this report carry a time requirement?
Yes, prior to surgery
Yes, within 24 hours postsurgery
No, as long as it is done ASAP
Yes, within 8 hours postsurgery
Yes, prior to surgery
As the Chair of a Forms Review Committee, you need to track the field name of a
particular data field and the security levels applicable to that field. Your best source for
this information would be the
glossary of health care terms.
MDS.
UHDDS.
facility's data dictionary.
facility's data dictionary.
An example of a primary data source for health care statistics is the
transfer record.
interdisciplinary patient care plan.
discharge summary.
problem list
problem list
The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with
colon cancer with no known history of previous malignancies. The accession number
assigned to this patient is
100% CORRECT ANSWERS
The minimum length of time for retaining original medical records is primarily governed
by
readmission rates.
Joint Commission.
medical staff.
state law.
state law.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals
are now required to use a preoperative verification process to confirm the patient's true
identity, and to confirm that necessary documents such as x-rays or medical records are
available. They must also develop and use a process for
including the primary caregiver in surgery consults.
including the surgeon in the preanesthesia assessment.
marking the surgical site.
apprising the patient of all complications that might occur.
marking the surgical site.
The new electronic system recently purchased at your physician practice allows for e-
prescribing, exchange of data to a centralized immunization registry, and it allows your
physicians to report on key clinical quality measures. In all likelihood, your practice has
succeeded in choosing a (an)
AMA-approved product
Certified EHR
Joint Commission-approved system
Functional EMR
Certified EHR
In preparation for an upcoming site visit by Joint Commission, you discover that the
number of delinquent records for the preceding month exceeded 50% of discharged
patients. Even more alarming was the pattern you noticed in the type of delinquencies.
Which of the following represents the most serious pattern of delinquencies? Fifteen
percent of delinquent records show
missing discharge summaries.
missing operative reports.
, absence of SOAP format in progress notes.
missing signatures on progress notes.
missing operative reports.
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 must be
recorded by persons authorized by hospital regulations and procedures.
written within 24 hours of the patient's admission.
accepted by charge nurses only.
cosigned by the attending physician within 4 hours of giving the order.
recorded by persons authorized by hospital regulations and procedures.
Joint Commission standards require that a complete history and physical be documented
on the health records of operative patients. Does this report carry a time requirement?
Yes, prior to surgery
Yes, within 24 hours postsurgery
No, as long as it is done ASAP
Yes, within 8 hours postsurgery
Yes, prior to surgery
As the Chair of a Forms Review Committee, you need to track the field name of a
particular data field and the security levels applicable to that field. Your best source for
this information would be the
glossary of health care terms.
MDS.
UHDDS.
facility's data dictionary.
facility's data dictionary.
An example of a primary data source for health care statistics is the
transfer record.
interdisciplinary patient care plan.
discharge summary.
problem list
problem list
The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with
colon cancer with no known history of previous malignancies. The accession number
assigned to this patient is
