RHIT practice part 2 Questions and Answers 2024
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
A. including the primary caregiver in surgery consults.
B. marking the surgical site.
C. including the surgeon in the preanesthesia assessment.
D. apprising the patient of all complications that might occur. *** marking the surgical
site.
The health care providers at your hospital do a very thorough job of periodic open
record review to ensure the completeness of record documentation. A qualitative review
of surgical records would likely include checking for documentation regarding
A. whether the severity of illness and/or intensity of service warranted acute level care.
B. the presence or absence of such items as preoperative and postoperative diagnosis,
description of findings, and specimens removed.
C. whether a postoperative infection occurred and how it was treated.
D. the quality of follow-up care. *** the presence or absence of such items as
preoperative and postoperative diagnosis, description of findings, and specimens
removed.
The Quality Payment Program includes:
A. Diagnosis-related groups
B. Merit-Based Incentive Payment System
C. Advanced Alternative Payment Models
D. Advanced Alternative Payment Models and Merit-Based Incentive Payment System
*** Advanced Alternative Payment Models and Merit-Based Incentive Payment System
While data governance focuses primarily on managing data as it is being created within
a healthcare system, information governance focuses instead on managing
A. data currency.
B. the granularity of health care systems.
C. data accuracy.
D. the output of those systems. *** the output of those systems.
An effective information governance system should include all of the following principles
EXCEPT the principle of
A. interoperability.
B. disposition.
,C. retention.
D. availability. *** interoperability.
Which of the four distinct components of the problem-oriented record serves to help
index documentation throughout the record?
A. initial plan
B. problem list
C. progress notes
D. database *** problem list
Documentation found in acute care health records should include core measure quality
indicators required for compliance with Medicare's Health Care Quality Improvement
Program (HCQIP). A typical quality indicator for patients with pneumonia might be
A. early administration of aspirin.
B. beta blocker at discharge.
C. blood culture before first antibiotic received.
D. discharged on antithrombotic. *** blood culture before first antibiotic received.
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. discharge summary.
B. transfer record.
C. problem list.
D. interdisciplinary patient care plan. *** problem list.
A patient has presented to the ER in a coma with injuries sustained in a motor vehicle
accident. According to her sister, the patient 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
A. CPOE.
B. RHIO.
C. expert system.
D. EDMS system. *** RHIO.
Which of the following is a form or view that is typically seen in the health record of a
long-term care patient but is rarely seen in records of acute care patients?
A. medical consultation
B. physical exam
C. pharmacy consultation
D. emergency record *** pharmacy consultation
,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. use of abbreviations in the final diagnosis.
B. use of prohibited or "dangerous" abbreviations.
C. prohibited use of any abbreviations.
D. flagrant use of specialty-specific abbreviations. *** use of prohibited or "dangerous"
abbreviations.
The best example of point-of-care service and documentation is
A. nurses using bedside terminals to record vital signs.
B. using an automated tracking system to locate a record.
C. using occurrence screens to identify adverse events.
D. using occurrence screens to identify adverse events. *** nurses using bedside
terminals to record vital signs.
In addition to diagnostic and therapeutic orders from the attending physician, you would
expect every completed inpatient health record to contain
A. standing orders.
B. telephone orders.
C. discharge order.
D. stop orders. *** discharge order.
The minimum length of time for retaining original medical records is primarily governed
by
A. state law.
B. readmission rates.
C. medical staff.
D. Joint Commission. *** state law.
You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's
A. patient index.
B. disease index.
C. physicians' index.
D. number control index. *** disease index.
Reviewing a medical record to ensure that all diagnoses are justified by documentation
throughout the chart is an example of
A. qualitative review
, B. quantitative review.
C. legal analysis.
D. peer review. *** qualitative review
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
A. missing signatures on progress notes.
B. missing discharge summaries.
C. absence of SOAP format in progress notes.
D. missing operative reports. *** missing operative reports.
Select the appropriate situation for which a final progress note may legitimately be
substituted for a discharge summary in an inpatient medical record.
A. Baby Boy Hiltz, born 1/5/2022, maintained normal status, discharged 1/7/2022.
B. Baby Boy Hiltz's mother admitted 1/5/2022, C-section delivery, and discharged
1/7/2022.
C. Patient admitted with COPD 1/4/2022 and discharged 1/7/2022.
D. Baby Boy Doe admitted 1/3/2022, died 1/4/2022. *** Baby Boy Hiltz, born 1/5/2022,
maintained normal status, discharged 1/7/2022.
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result,
core assessment data elements are collected on each SNF resident as defined in the
A. Uniform Clinical Data Set.
B. MDS.
C. Uniform Ambulatory Core Data.
D. UHDDS. *** MDS.
Based on the following documentation in an acute care record, where would you expect
this excerpt to appear? The patient is alert and in no acute distress. Initial vital signs: T
98, P 102 and regular, R 20 and BP 120/69...
A. past medical history
B. social history
C. physical exam
D. chief complaint *** physical exam
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, determine which of the following would NOT be
considered part of a preoperative verification process?
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
A. including the primary caregiver in surgery consults.
B. marking the surgical site.
C. including the surgeon in the preanesthesia assessment.
D. apprising the patient of all complications that might occur. *** marking the surgical
site.
The health care providers at your hospital do a very thorough job of periodic open
record review to ensure the completeness of record documentation. A qualitative review
of surgical records would likely include checking for documentation regarding
A. whether the severity of illness and/or intensity of service warranted acute level care.
B. the presence or absence of such items as preoperative and postoperative diagnosis,
description of findings, and specimens removed.
C. whether a postoperative infection occurred and how it was treated.
D. the quality of follow-up care. *** the presence or absence of such items as
preoperative and postoperative diagnosis, description of findings, and specimens
removed.
The Quality Payment Program includes:
A. Diagnosis-related groups
B. Merit-Based Incentive Payment System
C. Advanced Alternative Payment Models
D. Advanced Alternative Payment Models and Merit-Based Incentive Payment System
*** Advanced Alternative Payment Models and Merit-Based Incentive Payment System
While data governance focuses primarily on managing data as it is being created within
a healthcare system, information governance focuses instead on managing
A. data currency.
B. the granularity of health care systems.
C. data accuracy.
D. the output of those systems. *** the output of those systems.
An effective information governance system should include all of the following principles
EXCEPT the principle of
A. interoperability.
B. disposition.
,C. retention.
D. availability. *** interoperability.
Which of the four distinct components of the problem-oriented record serves to help
index documentation throughout the record?
A. initial plan
B. problem list
C. progress notes
D. database *** problem list
Documentation found in acute care health records should include core measure quality
indicators required for compliance with Medicare's Health Care Quality Improvement
Program (HCQIP). A typical quality indicator for patients with pneumonia might be
A. early administration of aspirin.
B. beta blocker at discharge.
C. blood culture before first antibiotic received.
D. discharged on antithrombotic. *** blood culture before first antibiotic received.
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. discharge summary.
B. transfer record.
C. problem list.
D. interdisciplinary patient care plan. *** problem list.
A patient has presented to the ER in a coma with injuries sustained in a motor vehicle
accident. According to her sister, the patient 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
A. CPOE.
B. RHIO.
C. expert system.
D. EDMS system. *** RHIO.
Which of the following is a form or view that is typically seen in the health record of a
long-term care patient but is rarely seen in records of acute care patients?
A. medical consultation
B. physical exam
C. pharmacy consultation
D. emergency record *** pharmacy consultation
,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. use of abbreviations in the final diagnosis.
B. use of prohibited or "dangerous" abbreviations.
C. prohibited use of any abbreviations.
D. flagrant use of specialty-specific abbreviations. *** use of prohibited or "dangerous"
abbreviations.
The best example of point-of-care service and documentation is
A. nurses using bedside terminals to record vital signs.
B. using an automated tracking system to locate a record.
C. using occurrence screens to identify adverse events.
D. using occurrence screens to identify adverse events. *** nurses using bedside
terminals to record vital signs.
In addition to diagnostic and therapeutic orders from the attending physician, you would
expect every completed inpatient health record to contain
A. standing orders.
B. telephone orders.
C. discharge order.
D. stop orders. *** discharge order.
The minimum length of time for retaining original medical records is primarily governed
by
A. state law.
B. readmission rates.
C. medical staff.
D. Joint Commission. *** state law.
You have been asked to identify every reportable case of cancer from the previous
year. A key resource will be the facility's
A. patient index.
B. disease index.
C. physicians' index.
D. number control index. *** disease index.
Reviewing a medical record to ensure that all diagnoses are justified by documentation
throughout the chart is an example of
A. qualitative review
, B. quantitative review.
C. legal analysis.
D. peer review. *** qualitative review
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
A. missing signatures on progress notes.
B. missing discharge summaries.
C. absence of SOAP format in progress notes.
D. missing operative reports. *** missing operative reports.
Select the appropriate situation for which a final progress note may legitimately be
substituted for a discharge summary in an inpatient medical record.
A. Baby Boy Hiltz, born 1/5/2022, maintained normal status, discharged 1/7/2022.
B. Baby Boy Hiltz's mother admitted 1/5/2022, C-section delivery, and discharged
1/7/2022.
C. Patient admitted with COPD 1/4/2022 and discharged 1/7/2022.
D. Baby Boy Doe admitted 1/3/2022, died 1/4/2022. *** Baby Boy Hiltz, born 1/5/2022,
maintained normal status, discharged 1/7/2022.
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result,
core assessment data elements are collected on each SNF resident as defined in the
A. Uniform Clinical Data Set.
B. MDS.
C. Uniform Ambulatory Core Data.
D. UHDDS. *** MDS.
Based on the following documentation in an acute care record, where would you expect
this excerpt to appear? The patient is alert and in no acute distress. Initial vital signs: T
98, P 102 and regular, R 20 and BP 120/69...
A. past medical history
B. social history
C. physical exam
D. chief complaint *** physical exam
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, determine which of the following would NOT be
considered part of a preoperative verification process?
