(solved) RHIA Exam - Health Data Content & Standards
(Chapter 3)
In preparation for an EHR, you are conducting a total facility inventory of inventory of all
forms currently used. You must name each 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:
A. recovery room record
B. pathology report
C. operative report
D. discharge summary
B (C and D) Although a gross description of tissue removed may be mentioned on the
operative note or discharge summary, only the pathology report will contain a
microscopic description.
Patient data collection requirements vary according to health care setting. A data
element you would expect to be collected in the MDS, but NOT in the UHDDS would be:
A. personal identification.
B. cognitive patterns.
C. procedures and dates.
D. principal diagnosis.
B Answers A, C, and D represent items collected on Medicare inpatients according to
UHDDS requirements. Only B represents a data item collected more typically in long-
term care settings
and required in the MDS.
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:
A. prohibited use of any abbreviations.
B. flagrant use of specialty-specific abbreviations.
C. use of prohibited or "dangerous" abbreviations.
D. use of abbreviations used in the final diagnosis.
C The Joint Commission requires hospitals to prohibit abbreviations that have caused
confusion or problems in their handwritten form, such as "U" for unit, which can be
mistaken for "O" or the number "4". Spelling out the unit is preferred.
In the number "10-0001" listed in a tumor registry accession register, what does the
prefix "10" represent?
A. The number of primary cancers reported for that patient
B. The year the case was entered into the database of the registry
C. The sequence number of the case
D. The stage of the tumor based upon the TNM system of staging
,B Every case entered into the registry is assigned a unique accession number preceded
by the accession year, or the year the case is entered into the database.
A risk manager needs to locate a full report of a patient's fall from his bed, including
witness reports and probable reasons for the fall. She would most likely find this
information in the:
A. doctors' progress notes.
B. integrated progress notes.
C. incident report.
D. nurses' notes
C Factual summaries investigating unexpected facility events should not be treated as
part of
the patient's health information and therefore would not be recorded in the health
record.
For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the
A. interdisciplinary patient care plan.
B. discharge summary.
C. transfer record.
D. problem list.
D (A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are
likely to be found on the records of long-term care patients.
Joint Commission does not approve of auto authentication of entries in a health record.
The primary objection to this practice is that:
A. it is too easy to delegate use of computer passwords.
B. evidence cannot be provided that the physician actually reviewed and approved each
report.
C. electronic signatures are not acceptable in every state.
D. tampering too often occurs with this method of authentication.
B Auto authentication is a policy adopted by some facilities that allows physicians to
state in advance that transcribed reports should automatically be considered approved
and signed
(or authenticated) when the physician fails to make corrections within a preestablished
time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another
version of this practice is when physicians authorize the HIM department to send weekly
lists of unsigned documents. The physician then signs the list in lieu of signing each
individual report. Neither practice ensures that the physician has reviewed and
approved each report individually.
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:
A. prenatal record.
, B. labor and delivery record.
C. postpartum record.
D. discharge summary.
The antepartum record should include a comprehensive history and physical exam on
each OB patient visit, with particular attention to menstrual and reproductive history.
As a concurrent record reviewer for an acute care facility, you have asked Dr.
Crossman to provide an updated history and physical for one of her recent admissions.
Dr. Crossman pages through the medical record to a copy of an H&P performed in her
office a week before admission. You tell Dr. Crossman:
Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's
office in lieu of an admission H&P as long as interval changes are documented in the
record upon admission. In addition, when the patient is readmitted within 30 days for the
same or a related problem, an interval history and physical exam may be completed if
the original H&P
is readily available.
You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's:
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments.
Joint Commission requires the attending physician to countersign health record
documentation that is entered by: interns or medical students.
Those who make entries in the medical record are given that privilege by the medical
staff.
Only house staff members who are under the supervision of active staff members
require countersignatures once the privilege has been granted.
The minimum length of time for retaining original medical records is primarily governed
by: state law.
The statute of limitations for each state is information that is crucial in determining
record retention schedules.
The use of personal signature stamps for authentication of entries in a paper-based
record requires special measures to guard against delegated use of the stamp. In a
completely computerized patient record system, similar measures might be utilized to
govern the use of: electronic signatures
Authentication by signature stamps requires a written agreement with the facility not to
delegate the use of the stamps. Similarly, in a computer-based system, it is important to
ensure that personal identification codes used to authenticate entries are used only by
the persons to whom they are assigned. A. Fingerprint signatures are individualized
automatically
Discharge summary documentation must include:
A. a detailed history of the patient.
B. a note from social services or discharge planning.
C. significant findings during hospitalization.
D. correct codes for significant procedures.
(Chapter 3)
In preparation for an EHR, you are conducting a total facility inventory of inventory of all
forms currently used. You must name each 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:
A. recovery room record
B. pathology report
C. operative report
D. discharge summary
B (C and D) Although a gross description of tissue removed may be mentioned on the
operative note or discharge summary, only the pathology report will contain a
microscopic description.
Patient data collection requirements vary according to health care setting. A data
element you would expect to be collected in the MDS, but NOT in the UHDDS would be:
A. personal identification.
B. cognitive patterns.
C. procedures and dates.
D. principal diagnosis.
B Answers A, C, and D represent items collected on Medicare inpatients according to
UHDDS requirements. Only B represents a data item collected more typically in long-
term care settings
and required in the MDS.
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:
A. prohibited use of any abbreviations.
B. flagrant use of specialty-specific abbreviations.
C. use of prohibited or "dangerous" abbreviations.
D. use of abbreviations used in the final diagnosis.
C The Joint Commission requires hospitals to prohibit abbreviations that have caused
confusion or problems in their handwritten form, such as "U" for unit, which can be
mistaken for "O" or the number "4". Spelling out the unit is preferred.
In the number "10-0001" listed in a tumor registry accession register, what does the
prefix "10" represent?
A. The number of primary cancers reported for that patient
B. The year the case was entered into the database of the registry
C. The sequence number of the case
D. The stage of the tumor based upon the TNM system of staging
,B Every case entered into the registry is assigned a unique accession number preceded
by the accession year, or the year the case is entered into the database.
A risk manager needs to locate a full report of a patient's fall from his bed, including
witness reports and probable reasons for the fall. She would most likely find this
information in the:
A. doctors' progress notes.
B. integrated progress notes.
C. incident report.
D. nurses' notes
C Factual summaries investigating unexpected facility events should not be treated as
part of
the patient's health information and therefore would not be recorded in the health
record.
For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the
A. interdisciplinary patient care plan.
B. discharge summary.
C. transfer record.
D. problem list.
D (A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are
likely to be found on the records of long-term care patients.
Joint Commission does not approve of auto authentication of entries in a health record.
The primary objection to this practice is that:
A. it is too easy to delegate use of computer passwords.
B. evidence cannot be provided that the physician actually reviewed and approved each
report.
C. electronic signatures are not acceptable in every state.
D. tampering too often occurs with this method of authentication.
B Auto authentication is a policy adopted by some facilities that allows physicians to
state in advance that transcribed reports should automatically be considered approved
and signed
(or authenticated) when the physician fails to make corrections within a preestablished
time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another
version of this practice is when physicians authorize the HIM department to send weekly
lists of unsigned documents. The physician then signs the list in lieu of signing each
individual report. Neither practice ensures that the physician has reviewed and
approved each report individually.
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:
A. prenatal record.
, B. labor and delivery record.
C. postpartum record.
D. discharge summary.
The antepartum record should include a comprehensive history and physical exam on
each OB patient visit, with particular attention to menstrual and reproductive history.
As a concurrent record reviewer for an acute care facility, you have asked Dr.
Crossman to provide an updated history and physical for one of her recent admissions.
Dr. Crossman pages through the medical record to a copy of an H&P performed in her
office a week before admission. You tell Dr. Crossman:
Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's
office in lieu of an admission H&P as long as interval changes are documented in the
record upon admission. In addition, when the patient is readmitted within 30 days for the
same or a related problem, an interval history and physical exam may be completed if
the original H&P
is readily available.
You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's:
The major sources of case findings for cancer registry programs are the pathology
department, the disease index, and the logs of patients treated in radiology and other
outpatient departments.
Joint Commission requires the attending physician to countersign health record
documentation that is entered by: interns or medical students.
Those who make entries in the medical record are given that privilege by the medical
staff.
Only house staff members who are under the supervision of active staff members
require countersignatures once the privilege has been granted.
The minimum length of time for retaining original medical records is primarily governed
by: state law.
The statute of limitations for each state is information that is crucial in determining
record retention schedules.
The use of personal signature stamps for authentication of entries in a paper-based
record requires special measures to guard against delegated use of the stamp. In a
completely computerized patient record system, similar measures might be utilized to
govern the use of: electronic signatures
Authentication by signature stamps requires a written agreement with the facility not to
delegate the use of the stamps. Similarly, in a computer-based system, it is important to
ensure that personal identification codes used to authenticate entries are used only by
the persons to whom they are assigned. A. Fingerprint signatures are individualized
automatically
Discharge summary documentation must include:
A. a detailed history of the patient.
B. a note from social services or discharge planning.
C. significant findings during hospitalization.
D. correct codes for significant procedures.
