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.
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?
utilization review
quantitative review
legal review
qualitative review
qualitative review
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
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.
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?
utilization review
quantitative review
legal review
qualitative review
qualitative review
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
