(Solved) RHIT EXAM Health Data Content and Standards
Final Quiz 1.1
Discharge summary documentation must include
Significant findings during hospitalization
In preparation for an EHR, you are conducting a total facility inventory of all forms
currently used. You must name each form for bar coding and indexing into a document
management system. The unnamed document in front of you includes a microscopic
description of tissue excised during surgery. The document type you are most likely to
give to this form is
pathology report
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
The health record states that the patient is a female, but the registration record has the
patient listed as male. Which of the following characteristics of data quality has been
compromised in this case?
data accuracy
Joint Commission does not approve auto authentication of entries in a health record.
The primary objection to this practice is that
evidence cannot be provided that the physician actually reviewed and approved each
report
In the past, Joint Commission standards have 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 the
use of prohibited or "dangerous" abbreviations
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that
health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure
surgery. In order to accomplish this, which of the following would NOT be considered
part of a preoperative verification process?
Follow the daily surgical patient listing for the surgery suite if the patient has been
sedated.
During a retrospective review of Rose Hunter's inpatient health record, the health
information clerk notes that on day 4 of hospitalization, there was one missed dose of
insulin. What type of review is this clerk performing?
qualitative review
As part of a quality improvement study, you have been asked to provide information on
the menstrual history, number of pregnancies, and number of living children on each OB
patient from a stack of old obstetrical records. The best place in the record to locate this
information is the
prenatal record.
, Improving the specificity of clinical reports through the use of a physician query is a
documentation goal that may be shared by the coding staff and this specialist:
CDIP
You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted
for disc surgery, but the progress notes indicate that due to some heart irregularities, he
may not be a good surgical risk. Because of your knowledge of COP regulations, you
expect that a(n) _________ will be added to his health record
consultation report
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor
vehicle accident. According to her sister, Gerda has had a recent medical history taken
at the public health department. The physician on call is grateful that she can access
this patient information using the area's
RHIO.
As a working HIM professional, you are investigating the workforce development
projections of electronic health record specialists as outlined by ARRA and HITECH. In
order to keep abreast of changes in this program, you will need to regularly access the
website of this governmental agency.
ONC
Engaging patients and their families in health care decisions is one of the core
objectives for
achieving meaningful use of EHRs
Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
attending physician.
As a trauma registrar working in an emergency department, you want to begin
comparing your trauma care services to other hospital-based emergency departments.
To ensure that your facility is collecting the same data as other facilities, you review
elements from which data set?
DEEDS
Under which of the following conditions can an original paper-based patient health
record be physically removed from the hospital?
when the director of health records is acting in response to a subpoena duces tecum
and takes the health record to court
The best example of point-of-care service and documentation is
nurses using bedside terminals to record vital signs
A clinical documentation specialist performs many duties. These include reviewing the
data and looking for trends or patterns over time, as well as noting any variances that
require further investigation. In this role, the CDS professional is acting as a(n)
analyst
Which of the following services is LEAST likely to be provided by a facility accredited by
CARF?
palliative care
In an acute care hospital, a complete history and physical may not be required for a new
admission when
a legible copy of a current H&P performed in the attending physician's office is available
Accreditation by Joint Commission is a voluntary activity for a facility, and it is
Final Quiz 1.1
Discharge summary documentation must include
Significant findings during hospitalization
In preparation for an EHR, you are conducting a total facility inventory of all forms
currently used. You must name each form for bar coding and indexing into a document
management system. The unnamed document in front of you includes a microscopic
description of tissue excised during surgery. The document type you are most likely to
give to this form is
pathology report
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
The health record states that the patient is a female, but the registration record has the
patient listed as male. Which of the following characteristics of data quality has been
compromised in this case?
data accuracy
Joint Commission does not approve auto authentication of entries in a health record.
The primary objection to this practice is that
evidence cannot be provided that the physician actually reviewed and approved each
report
In the past, Joint Commission standards have 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 the
use of prohibited or "dangerous" abbreviations
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that
health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure
surgery. In order to accomplish this, which of the following would NOT be considered
part of a preoperative verification process?
Follow the daily surgical patient listing for the surgery suite if the patient has been
sedated.
During a retrospective review of Rose Hunter's inpatient health record, the health
information clerk notes that on day 4 of hospitalization, there was one missed dose of
insulin. What type of review is this clerk performing?
qualitative review
As part of a quality improvement study, you have been asked to provide information on
the menstrual history, number of pregnancies, and number of living children on each OB
patient from a stack of old obstetrical records. The best place in the record to locate this
information is the
prenatal record.
, Improving the specificity of clinical reports through the use of a physician query is a
documentation goal that may be shared by the coding staff and this specialist:
CDIP
You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted
for disc surgery, but the progress notes indicate that due to some heart irregularities, he
may not be a good surgical risk. Because of your knowledge of COP regulations, you
expect that a(n) _________ will be added to his health record
consultation report
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor
vehicle accident. According to her sister, Gerda has had a recent medical history taken
at the public health department. The physician on call is grateful that she can access
this patient information using the area's
RHIO.
As a working HIM professional, you are investigating the workforce development
projections of electronic health record specialists as outlined by ARRA and HITECH. In
order to keep abreast of changes in this program, you will need to regularly access the
website of this governmental agency.
ONC
Engaging patients and their families in health care decisions is one of the core
objectives for
achieving meaningful use of EHRs
Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
attending physician.
As a trauma registrar working in an emergency department, you want to begin
comparing your trauma care services to other hospital-based emergency departments.
To ensure that your facility is collecting the same data as other facilities, you review
elements from which data set?
DEEDS
Under which of the following conditions can an original paper-based patient health
record be physically removed from the hospital?
when the director of health records is acting in response to a subpoena duces tecum
and takes the health record to court
The best example of point-of-care service and documentation is
nurses using bedside terminals to record vital signs
A clinical documentation specialist performs many duties. These include reviewing the
data and looking for trends or patterns over time, as well as noting any variances that
require further investigation. In this role, the CDS professional is acting as a(n)
analyst
Which of the following services is LEAST likely to be provided by a facility accredited by
CARF?
palliative care
In an acute care hospital, a complete history and physical may not be required for a new
admission when
a legible copy of a current H&P performed in the attending physician's office is available
Accreditation by Joint Commission is a voluntary activity for a facility, and it is
