RHIA Exam Questions with Verified
Solutions
A discharge summary must be completed within____days after discharge for most
patients but within ___for patients transferred to other facilities. Discharge summaries
are not always required for patients who were hospitalized for less than ___ - ANS-30
days/24 hours/48 hours
systematic random sample - ANS-a simple random sample that may be generated by
selecting every fifth or every tenth member of the sampling frame. In order to ensure
that a systematic random sample is truly random, the sample frame should not be
sorted in an order that might bias the sample. Example: If an analyst is studying the wait
times at a clinic and the only list of patients available is on hard copy, which sampling
technique is the easiest to use. Systematic sampling
Entity relationship modeling - ANS-is a type of conceptual modeling. Conceptual models
are abstract and encourage high-level problem structing; they help establish a common
ground for communication between users and developers. The entity-relationship
diagram was developed to depict relational database structures.
The emergency health record should include - ANS-time and means of arrival,
treatment rendered, and instruction at discharge. Facilities are required to do a pertinent
history, including the chief complaint and onset of illness or injury but not a complete
medical history of the patient
Minimum Data set - ANS-a component of the resident assessment instrument (RAI) and
is used to collect information about the resident's risk factors and to plan the ongoing
care and treatment of the resident in the long-term care facility.
many-to-many relationship - ANS-occurs only in a data model developed at the
conceptual level. In this case, the relationship between patients and consulting
physicians is a many-to-many. For each instance of patient, there could be many
instances of consulting physician because patients can be seen by more than one
consulting physicians. For each instance of consulting physician, there could be many
patients because the physician sees many patients.
metadata - ANS-data about data. metadata are structured information used to increase
the effective use of data. One of the most familiar types of metadata is used to describe
data in databases. Data element name, data type, and field length are examples of this
kind of metadata.
,Health Record Matrix - ANS-Identifies and tracks the physical location of each paper
document and the source of each electronic document that constitutes the LHR. The
documentation of the LHR may physically exist in separate and multiple paper-based or
electronic systems. This complicates the process of pulling the entire legal record
together in response to authorized requests to produce the complete patient record.
The legal health record for disclosure consists of: - ANS-the data, documents, reports
and information that comprise the formal business records of any healthcare entity that
are to be utilized during legal proceedings. Understanding legal health records requires
knowledge of not only what comprises business records used as legal health records,
but also the processes as well as the physical and electronic systems used to manage
these records.
privileged communication - ANS-information held confidential within a protected
relationship as delineated by state law. Example: Mary goes to her doctor to discuss her
current medical conditions.
Firewall - ANS-a part of a computer system or network that is designed to block
unauthorized access while permitting outward communication.
A firewall can limit internal users from accessing various portions of the internet
The most common place to find a firewall is between the healthcare entity's internal
network and the internet
It supports access control policy between two networks.
It cannot prevent all types of attacks
How long does the privacy rule use for the period of time which privacy rule-related
documents must be retained? - ANS-Six years. The six-year time frame refers to the
date the document was created or the last effective date of the document. Such
documents include policies and procedures, the notice of privacy practices, complaint
dispositions, and other actions, activites, and designations that must be documented
per privacy rule requirements.
corporate negligence - ANS-a legal doctrine that was established by a judicial decision
handed down in the 1965 court case Darling v Charleston Community hospital. The
court in this case ruled specifically that hospital governing boards have a duty to institue
a means to evaluate and council medical staff who personally perform services on a
patient that results in harm due to unreasonable risk. Hospitals may be held liable when
a member of the medical staff fails to meet established standards of patient care.
the privacy rule requires covered entities to - ANS-arrange a convenient time and place
for the individual to inspect his or her record. However, the covered entity also has an
obligation to protect the records integrity. Therefore, it is within the covered entitiys right
,to provide an authorized HIM staff member to be present when the individual reviews
the record.
fundraising activities - ANS-Those that benefit the CE, the covered entity may use or
disclose to a BA or an institutionally related foundation without authorization,
demographic information and dates of healthcare provided to the individual.
Must have an option to Opt Out from receiving the material.
If a fundraising activity targets individuals based on their diagnosis, prior authorization is
required
The privacy rule - ANS-establishes a patients right to receive an accounting of
disclosures of their PHI made by a covered entity.
first step in conducting the security risk analysis - ANS-consider their own
characteristics and environment and implement reasonable and appropriate measures
to protect against reasonably anticipated threats and hazards to the security of PHI. The
security risk analysis process provides covered entities and business associates with
the structural framework up on which to bulid their securty plan
Addressable Implementation Specifications - ANS-Addressable specifications allow a
covered entity flexibility when:
(1) it is determined that the specification is not reasonable or appropriate for the
covered entity's environment
(2) the covered entity documents why the specification is not reasonable or appropriate
and implements an equivalent alternative measure as appropriate.
(3) Implementing "security measures to reduce risks and vulnerabilities to a reasonable
and appropriate level" is a required specification, while encryption of electronic PHI is an
addressable specification
The breach notification rule requires - ANS-covered entities and business associates to
establish policies and procedures to investigate an authorized use or disclosure of PHI
to determine if a breach occured to
Record locator service (RLS) - ANS-A process that seeks information about where a
patient, once identified, may have a health record available to the HIO. It manages the
pointers to the information on the servers of the HIE participants. The pointers in a RLS
can include a person identification number and metadata. The RLS does NOT provide
information about the record, it merely points to where it might be found. Data are not
stored in a centralized database and records are only provided when queried.
, Qualitative standards - ANS-specify the level of service from a function such as
accuracy rate, error rate, turnaround time and response time. In this case, timely
response to release of information requests can indirectly impact patient care. To
properly communicate performance standards, managers need to make the distinction
between quantitative and qualitative standards and identify examples of each for the
health information systems functions.
A possible justification for building an information system in-house rather than
purchasing one from a vendor - ANS-the facility has development teams that they do
not want to give up
gross death rate - ANS-the proportion of all hospital discharges that ended in death. It is
the basic indicator of mortality in a healthcare facility. It is calculated by dividing the total
number of deaths occurring in a given time period by the total number of discharges,
including deaths, for the same time period. 25/500=0.05x100=5%
work distribution chart - ANS-A matrix that depicts the work being done in a particular
workgroup in terms of specific tasks and activities, time spent on tasks, and the
employees performing the tasks
is initially completed by each employee and includes all responsible task content. Can
help when problems have been identified with work proceses such as too much time
spent on unimportant tasks.
pie chart - ANS-a chart that shows the relationship of a part to a whole.
pie charts can be used to show the component parts of a single group or variable.
incidence rate - ANS-a computation that compares the number of new cases of a
specific disease for a given time period to the population at risk for the disease during
the same period.
a hospital is looking to cut cost on a vendors proposal for health IT should consider -
ANS-acquiring it's own hardware
Boolean Search - ANS-A Boolean operator is a computer-programming term for
conjunctions like, AND, OR, and NOT which can be used to construct more complex
search conditions. Usually found under the advanced options.
Structured Query Language (SQL) - ANS-A language used to create and manipulate
databases.
Truncation - ANS-In metric verse, the omission of an unaccented syllable at either end
of a line
Solutions
A discharge summary must be completed within____days after discharge for most
patients but within ___for patients transferred to other facilities. Discharge summaries
are not always required for patients who were hospitalized for less than ___ - ANS-30
days/24 hours/48 hours
systematic random sample - ANS-a simple random sample that may be generated by
selecting every fifth or every tenth member of the sampling frame. In order to ensure
that a systematic random sample is truly random, the sample frame should not be
sorted in an order that might bias the sample. Example: If an analyst is studying the wait
times at a clinic and the only list of patients available is on hard copy, which sampling
technique is the easiest to use. Systematic sampling
Entity relationship modeling - ANS-is a type of conceptual modeling. Conceptual models
are abstract and encourage high-level problem structing; they help establish a common
ground for communication between users and developers. The entity-relationship
diagram was developed to depict relational database structures.
The emergency health record should include - ANS-time and means of arrival,
treatment rendered, and instruction at discharge. Facilities are required to do a pertinent
history, including the chief complaint and onset of illness or injury but not a complete
medical history of the patient
Minimum Data set - ANS-a component of the resident assessment instrument (RAI) and
is used to collect information about the resident's risk factors and to plan the ongoing
care and treatment of the resident in the long-term care facility.
many-to-many relationship - ANS-occurs only in a data model developed at the
conceptual level. In this case, the relationship between patients and consulting
physicians is a many-to-many. For each instance of patient, there could be many
instances of consulting physician because patients can be seen by more than one
consulting physicians. For each instance of consulting physician, there could be many
patients because the physician sees many patients.
metadata - ANS-data about data. metadata are structured information used to increase
the effective use of data. One of the most familiar types of metadata is used to describe
data in databases. Data element name, data type, and field length are examples of this
kind of metadata.
,Health Record Matrix - ANS-Identifies and tracks the physical location of each paper
document and the source of each electronic document that constitutes the LHR. The
documentation of the LHR may physically exist in separate and multiple paper-based or
electronic systems. This complicates the process of pulling the entire legal record
together in response to authorized requests to produce the complete patient record.
The legal health record for disclosure consists of: - ANS-the data, documents, reports
and information that comprise the formal business records of any healthcare entity that
are to be utilized during legal proceedings. Understanding legal health records requires
knowledge of not only what comprises business records used as legal health records,
but also the processes as well as the physical and electronic systems used to manage
these records.
privileged communication - ANS-information held confidential within a protected
relationship as delineated by state law. Example: Mary goes to her doctor to discuss her
current medical conditions.
Firewall - ANS-a part of a computer system or network that is designed to block
unauthorized access while permitting outward communication.
A firewall can limit internal users from accessing various portions of the internet
The most common place to find a firewall is between the healthcare entity's internal
network and the internet
It supports access control policy between two networks.
It cannot prevent all types of attacks
How long does the privacy rule use for the period of time which privacy rule-related
documents must be retained? - ANS-Six years. The six-year time frame refers to the
date the document was created or the last effective date of the document. Such
documents include policies and procedures, the notice of privacy practices, complaint
dispositions, and other actions, activites, and designations that must be documented
per privacy rule requirements.
corporate negligence - ANS-a legal doctrine that was established by a judicial decision
handed down in the 1965 court case Darling v Charleston Community hospital. The
court in this case ruled specifically that hospital governing boards have a duty to institue
a means to evaluate and council medical staff who personally perform services on a
patient that results in harm due to unreasonable risk. Hospitals may be held liable when
a member of the medical staff fails to meet established standards of patient care.
the privacy rule requires covered entities to - ANS-arrange a convenient time and place
for the individual to inspect his or her record. However, the covered entity also has an
obligation to protect the records integrity. Therefore, it is within the covered entitiys right
,to provide an authorized HIM staff member to be present when the individual reviews
the record.
fundraising activities - ANS-Those that benefit the CE, the covered entity may use or
disclose to a BA or an institutionally related foundation without authorization,
demographic information and dates of healthcare provided to the individual.
Must have an option to Opt Out from receiving the material.
If a fundraising activity targets individuals based on their diagnosis, prior authorization is
required
The privacy rule - ANS-establishes a patients right to receive an accounting of
disclosures of their PHI made by a covered entity.
first step in conducting the security risk analysis - ANS-consider their own
characteristics and environment and implement reasonable and appropriate measures
to protect against reasonably anticipated threats and hazards to the security of PHI. The
security risk analysis process provides covered entities and business associates with
the structural framework up on which to bulid their securty plan
Addressable Implementation Specifications - ANS-Addressable specifications allow a
covered entity flexibility when:
(1) it is determined that the specification is not reasonable or appropriate for the
covered entity's environment
(2) the covered entity documents why the specification is not reasonable or appropriate
and implements an equivalent alternative measure as appropriate.
(3) Implementing "security measures to reduce risks and vulnerabilities to a reasonable
and appropriate level" is a required specification, while encryption of electronic PHI is an
addressable specification
The breach notification rule requires - ANS-covered entities and business associates to
establish policies and procedures to investigate an authorized use or disclosure of PHI
to determine if a breach occured to
Record locator service (RLS) - ANS-A process that seeks information about where a
patient, once identified, may have a health record available to the HIO. It manages the
pointers to the information on the servers of the HIE participants. The pointers in a RLS
can include a person identification number and metadata. The RLS does NOT provide
information about the record, it merely points to where it might be found. Data are not
stored in a centralized database and records are only provided when queried.
, Qualitative standards - ANS-specify the level of service from a function such as
accuracy rate, error rate, turnaround time and response time. In this case, timely
response to release of information requests can indirectly impact patient care. To
properly communicate performance standards, managers need to make the distinction
between quantitative and qualitative standards and identify examples of each for the
health information systems functions.
A possible justification for building an information system in-house rather than
purchasing one from a vendor - ANS-the facility has development teams that they do
not want to give up
gross death rate - ANS-the proportion of all hospital discharges that ended in death. It is
the basic indicator of mortality in a healthcare facility. It is calculated by dividing the total
number of deaths occurring in a given time period by the total number of discharges,
including deaths, for the same time period. 25/500=0.05x100=5%
work distribution chart - ANS-A matrix that depicts the work being done in a particular
workgroup in terms of specific tasks and activities, time spent on tasks, and the
employees performing the tasks
is initially completed by each employee and includes all responsible task content. Can
help when problems have been identified with work proceses such as too much time
spent on unimportant tasks.
pie chart - ANS-a chart that shows the relationship of a part to a whole.
pie charts can be used to show the component parts of a single group or variable.
incidence rate - ANS-a computation that compares the number of new cases of a
specific disease for a given time period to the population at risk for the disease during
the same period.
a hospital is looking to cut cost on a vendors proposal for health IT should consider -
ANS-acquiring it's own hardware
Boolean Search - ANS-A Boolean operator is a computer-programming term for
conjunctions like, AND, OR, and NOT which can be used to construct more complex
search conditions. Usually found under the advanced options.
Structured Query Language (SQL) - ANS-A language used to create and manipulate
databases.
Truncation - ANS-In metric verse, the omission of an unaccented syllable at either end
of a line
