RED BOOK RHIT EXAM PREP -
ALL DOMAINS
H.I.M has been recognized as an allied Health profession since:-1928
The hospital standardization movement was inaugurated by the :-American College of Surgeons
The new model of H.I.M practice is:-Information based
What evolving role oversees the process that begins at the time of documentation through billing?-Revenue cycle
management
The organization that accredits H.I.M programs is:-C.A.H.I.I.M
What evolving role assesses quality in health record banking?-Health record reviewer
The primary focus of AHIMA is to:-Foster professional development of its members
I am a patient. My medical history including information from myself and my physicians in stored on the Internet. This
is an example of which of the following:-P.H.R: Personal Health Record
Which of the following is an example of a primary purpose of the medical record?-Patient care management
what is an example of patient care delivery usage in the medical record?-Communication of practice guidelines
Are The P.H.R and E.H.R synonyms?-no, the P.H.R is controlled by the patient and the E.H.R is controlled by the
care providers
Give an example of an institutional user for a health record-Third-party payer
institutional user-middle - man between insurance companies and facilities; they help collect the money
Which of the following users would utilize aggregate data?-Patient care managers and support staff
what type of organization utilizes health record data to prove or disprove hypotheses related to diseases?-Research
organizations
Critique the following statement: A user of health records includes only care providers who document in the health
record of refer to it for patient care.-This is a false statement as the information is used for other purposes such as
analysis
how does C.M.S use the health record?-decisions on healthcare reimbursement; medicare
,A physician just received notification from an E.H.R system that a patient's lab test had a dangerously high value.
This is an example of what kind of clinical tool?-Clinical decision support
I just told my physician something embarrassing about myself. I told him because I expect him to use the information
for my care only. This concept is called:-Confidentiality
Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic
would be the justification for not collecting this information?-Relevancy
It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic
would be the justification for not doing this, but rather sharing information between the systems?-Consistency
what is the term that is used to describe how data is translated into information?-Data analysis
Which two major types of data are contained inn the health record?-Administrative and clinical
Which of the following terms refers to state or county regulation that healthcare facilities must meet to be permitted to
provide care?-Licensure
Which of the following would not be found in a medical history?-Vital signs
An attending physician requests the advice of a second physician who than reviews the health record and examines
the patient. The second physician records impressions in what type of report?-Consultation
Which specialized type of progress note provides healthcare professionals impressions of patient problems with
detailed treatment action steps?-Care plan
Written or spoken permission to proceed with care is classified as:-Expressed consent
Which of the following reports provides information on tissue removed during a procedure?-Pathology report
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are
recorded in which of the following records?-Newborn
Which of the following is not considered patient demographic information?-Admitting diagnosis
Which of the following administrative documents name the patient's choice of legal representative for healthcare
purposes?-Advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting and
documentation of care provided to stabilize the patient-Emergency care
patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found
in which type of record?-Ambulatory care
The ambulatory surgery record contains information most similar to:-Hospital operative records
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?-Patient assessment instrument,
P.A.I
Interdisciplinary care plans are an important part of which type of health record?-Hospice care
Portions of a treatment record may be maintained in a patient's home in which two types of settings?-Home health
and end-stage renal disease
A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be
found most frequently in which type of health record?-Rehabilitative care
Paper records may require thinning in which two settings?-Long-term care and correctional services
A growth and development record may be found in what type of record?-Pediatric
, The document that indicates current and past medical conditions is :-Problem list
Which of the following is an accrediting organization?-D.N.V., Det Norske Veritas
An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation
under its guidelines do not need to:-Undergo Medicare certification surveys
Which group focuses on accreditation of managed care and preferred provider organizations?-National Committee for
Quality assurance
Which of the following regulations would most likely contain information on who is authorized to enter documentation
in a patient's record?-Facility rules and regulations
Which of the following groups has instituted a health record-prohibited abbreviation list?-Joint Commission on
Accreditation of Healthcare Organizations
Which type of health record includes both paper and computerized components?-Hybrid
Which of the following is a disadvantage of an E.H.R over a paper-based record?-Requires privacy and security
measures
In an integrated health record, documentation by health professionals is organized:-Intermixed in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?-
Subjective
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in
another state?-Image processing
Which of the following is true of paper-based records?-They are susceptible to damage from fire or floods
A definition of what constitutes a record, recording where each component is located, and noting dates of format
changes are particularly important in:-Hybrid records
In a problem-oriented health record, problems are organized by:-number
Health Level Seven has developed guidelines that address which aspect of the electronic record?-Definition of
function
Which type of data input mechanism is commonly used in both paper and electronic environments?-transcription
A transition technology used by many hospitals to increase access to medical record content is?-E.D.M.S. electronic
document management system
Systems used by nurses & physicians to document assessments & findings are called?-Patient care charting
A clinical data repository is?-Database to manage data from multiple sources
Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some
patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered?-
standard order set
A system that provides alerts & reminders to clinicians is?-Clinical decision support systems
What does the Electronic Medication Administration Record or E.M.A.R. utilize and support?-It utilizes bar codes or
Radio Frequency Identification; R.F.I.D. technology to support the medications "five rights".
medications five rights-because of bar codes nurses identify the right patient, the right drug, the right time, the right
does, and the right route.
How many physician practices in 2010 had an E.H.R.?-less than half
ALL DOMAINS
H.I.M has been recognized as an allied Health profession since:-1928
The hospital standardization movement was inaugurated by the :-American College of Surgeons
The new model of H.I.M practice is:-Information based
What evolving role oversees the process that begins at the time of documentation through billing?-Revenue cycle
management
The organization that accredits H.I.M programs is:-C.A.H.I.I.M
What evolving role assesses quality in health record banking?-Health record reviewer
The primary focus of AHIMA is to:-Foster professional development of its members
I am a patient. My medical history including information from myself and my physicians in stored on the Internet. This
is an example of which of the following:-P.H.R: Personal Health Record
Which of the following is an example of a primary purpose of the medical record?-Patient care management
what is an example of patient care delivery usage in the medical record?-Communication of practice guidelines
Are The P.H.R and E.H.R synonyms?-no, the P.H.R is controlled by the patient and the E.H.R is controlled by the
care providers
Give an example of an institutional user for a health record-Third-party payer
institutional user-middle - man between insurance companies and facilities; they help collect the money
Which of the following users would utilize aggregate data?-Patient care managers and support staff
what type of organization utilizes health record data to prove or disprove hypotheses related to diseases?-Research
organizations
Critique the following statement: A user of health records includes only care providers who document in the health
record of refer to it for patient care.-This is a false statement as the information is used for other purposes such as
analysis
how does C.M.S use the health record?-decisions on healthcare reimbursement; medicare
,A physician just received notification from an E.H.R system that a patient's lab test had a dangerously high value.
This is an example of what kind of clinical tool?-Clinical decision support
I just told my physician something embarrassing about myself. I told him because I expect him to use the information
for my care only. This concept is called:-Confidentiality
Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic
would be the justification for not collecting this information?-Relevancy
It was suggested that we enter the patient's age manually in all of our information systems. What quality characteristic
would be the justification for not doing this, but rather sharing information between the systems?-Consistency
what is the term that is used to describe how data is translated into information?-Data analysis
Which two major types of data are contained inn the health record?-Administrative and clinical
Which of the following terms refers to state or county regulation that healthcare facilities must meet to be permitted to
provide care?-Licensure
Which of the following would not be found in a medical history?-Vital signs
An attending physician requests the advice of a second physician who than reviews the health record and examines
the patient. The second physician records impressions in what type of report?-Consultation
Which specialized type of progress note provides healthcare professionals impressions of patient problems with
detailed treatment action steps?-Care plan
Written or spoken permission to proceed with care is classified as:-Expressed consent
Which of the following reports provides information on tissue removed during a procedure?-Pathology report
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are
recorded in which of the following records?-Newborn
Which of the following is not considered patient demographic information?-Admitting diagnosis
Which of the following administrative documents name the patient's choice of legal representative for healthcare
purposes?-Advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting and
documentation of care provided to stabilize the patient-Emergency care
patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found
in which type of record?-Ambulatory care
The ambulatory surgery record contains information most similar to:-Hospital operative records
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?-Patient assessment instrument,
P.A.I
Interdisciplinary care plans are an important part of which type of health record?-Hospice care
Portions of a treatment record may be maintained in a patient's home in which two types of settings?-Home health
and end-stage renal disease
A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be
found most frequently in which type of health record?-Rehabilitative care
Paper records may require thinning in which two settings?-Long-term care and correctional services
A growth and development record may be found in what type of record?-Pediatric
, The document that indicates current and past medical conditions is :-Problem list
Which of the following is an accrediting organization?-D.N.V., Det Norske Veritas
An accrediting organization is awarded deemed status by Medicare. This means that facilities receiving accreditation
under its guidelines do not need to:-Undergo Medicare certification surveys
Which group focuses on accreditation of managed care and preferred provider organizations?-National Committee for
Quality assurance
Which of the following regulations would most likely contain information on who is authorized to enter documentation
in a patient's record?-Facility rules and regulations
Which of the following groups has instituted a health record-prohibited abbreviation list?-Joint Commission on
Accreditation of Healthcare Organizations
Which type of health record includes both paper and computerized components?-Hybrid
Which of the following is a disadvantage of an E.H.R over a paper-based record?-Requires privacy and security
measures
In an integrated health record, documentation by health professionals is organized:-Intermixed in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?-
Subjective
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in
another state?-Image processing
Which of the following is true of paper-based records?-They are susceptible to damage from fire or floods
A definition of what constitutes a record, recording where each component is located, and noting dates of format
changes are particularly important in:-Hybrid records
In a problem-oriented health record, problems are organized by:-number
Health Level Seven has developed guidelines that address which aspect of the electronic record?-Definition of
function
Which type of data input mechanism is commonly used in both paper and electronic environments?-transcription
A transition technology used by many hospitals to increase access to medical record content is?-E.D.M.S. electronic
document management system
Systems used by nurses & physicians to document assessments & findings are called?-Patient care charting
A clinical data repository is?-Database to manage data from multiple sources
Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some
patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered?-
standard order set
A system that provides alerts & reminders to clinicians is?-Clinical decision support systems
What does the Electronic Medication Administration Record or E.M.A.R. utilize and support?-It utilizes bar codes or
Radio Frequency Identification; R.F.I.D. technology to support the medications "five rights".
medications five rights-because of bar codes nurses identify the right patient, the right drug, the right time, the right
does, and the right route.
How many physician practices in 2010 had an E.H.R.?-less than half
