RHIA Exam Set I with Accurate
Solutions
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 - ANSWER-B. Cognitive Patterns: Is data generally collected for
long-term care settings and required in MDS. All other choices are collected on
Medicare inpatients according to UHDDS requirements.
Engaging patients and their families in health care decisions is one of the core
objectives for:
A. achieving meaningful use of EHRs
B. The JC's National Patient Safety goals
C. HIPAA 5010 regulations
D. Establishing flexible clinical pathways. - ANSWER-A. Achieving meaningful use of
EHRs: It is one of the core objectives of achieving meaningful use.
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 - ANSWER-D. problem list - All other choices are more likely to be found
on the records of long-term care patients.
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 he
office a week before admission. You tell Dr. Crossman:
A. A new H&P is required for every IP admission
B. that you apologize for not noticing the H&P she provided
C. the H&P copy is acceptable as long as she documents any interval changes
D. TJC standards do not allow copies of any kind in the original record - ANSWER-C.
TJC 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. Additionally, when the patient is readmitted within 30 days for the same of a
related problem, an interval H&P and physical exam may be completed if the original
H&P is readily available.
,Improving clinical outcomes and optimal continuity of care for patients are common
goals of CDI programs in acute care hospitals. Additionally, CDI programs may work
together with UM programs to:
A. reduce clinical denials for medical necessity
B. decrease medication errors through CPOE systems
C. Increase patient engagement through patient portals
D. report sentinel events to TJC - ANSWER-A. B and D are related to patient safety
goals. C is related to HITECH goals for physician practices.
Discharge summary documentation must include:
A. detailed history of the patient
B. a note from social services or discharge planning
C. significant finding during hospitalization
D. correct codes for significant procedures - ANSWER-C. Reference to the patient's
history may be found in the discharge summary but not detailed. The attending
physician records the discharge summary. Codes are generally recorded on a different
form in the record.
A HI manager develops a formal plan or record retention schedule for the automatic
transfer of records to inactive storage and potential destruction based on of the the
following factors:
A. statue of limitations
B. volume of research
C. readmission rate
D. department staffing - ANSWER-D. Oachs & Watters p62-63, 129, 133-134
Unless state or federal laws require longer time periods, AHIMA recommends hat
patient health information for minors be retained for at least how long?
A. age of majority plus statue of limitation
B. 10 years after the most recent encounter
C. 20 years after the age of majority
D. permanently - ANSWER-A. age of majority plus statue of limitation
A surgeon request the name of a patient he admitted on January 11, 2017. Which of the
following would be used to retrieve this information?
A. physician index
B. number index
C. R-ADT system
D. operation index - ANSWER-C. R-ADT system
Admissions, discharge, transfer (R-ADT) system
- Administrative application that connects to the EHR system.
Oachs & Watters, p. 369
,When evaluating an outside contract microfilm company, all but which of the following
are important factors to rate?
A. cost
B. emergency returns
C. storage after filming
D. cache memory - ANSWER-D. cache memory
Sayles and Gordon, p. 62
Case finding methods for patients with diabetes include a review of all but which one of
the following?
A. health plans
B. CPT diagnostic codes
C. billing data
D. medication lists - ANSWER-B. CPT diagnostic codes
Case finding includes methods to ID patient who have been seen and treated fora
particular disease or condition of interest to the registry in a facility.
Purpose of registries is to collect data from the patient health recored and make them
available to users. Other registries take an additional step to enter information into the
database for routine follow-up of patients at specified intervals including rate and
duration of survival and quality-of-life issues over time.
All other choices are included in the review. Demographics data, , laboratory values
such as HbA1c, ICD diagnostic codes, and physician identification are also included.
Oachs & Watters, p. 173
Sayles and Gordon, p 175
A quality control measure that should be established for the filing, storage, and retrieval
of health records includes criteria for the
A. accuracy of analyzing records
B. number of incomplete records
C. inclusion of late reports
D. tracking of release of information requests - ANSWER-C. inclusion of late reports
Sayles and Gordon, p. 68
How many years does the Food and Drug Administration require research records
pertaining to cancer patients be maintained?
A. 5
B. 7
C. 30
D. permanently - ANSWER-C. 30
AHIMA practice brief
What data cannot be retrieved fro the MEDPAR?
, A. ICD-10-CM diagnosis codes
B. Charges broken down by specific types of services
C. Non-Medicare patient data
D. Data on the provider - ANSWER-C. Non-Medicare patient data
All other choices are included. Other types of data include:
demographic data on patient
information on Medicare coverage for the claim
total charges
ICD-10CM diagnosis and procedure codes
DRGs
The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care
hospital and skilled nursing facility (SNF) claims data for all Medicare claims.
The MEDPAR files is frequently used for research on topics such as charges for
particular types of care and analysis by DRG. Limitation for the data for research
purposes is that it only contains data for Medicare patients.
Oachs & Watters, p 185-186
The HIM practitioner's duty to retain health information via the archiving and storage of
health data includes all but which of the following:
A. strategies that consider accessibility, natural disasters, and innovations in storage
technology
B. strategies ensuring that inactive records are as secure as active records
C. a retention plan for multiple volumes of records
D. a retention plan for financial data - ANSWER-D. a retention plan for financial data
University Hospital has the messaging technology to securely route an alert for a
patient's possible drug interaction or abnormal lab result to the appropriate physician's
pager number. Which one of the following is the medical staff using?
A. intranet
B. extranet
C. internet
D. clinical information systems - ANSWER-D. clinical information systems
Intranet - private network, typically contained within an enterprise
extranet - private network that utilizes internet technology and public telecommunication
system to share business information with suppliers, vendors, customers, etc
internet - global system of interconnected computer networks that uses the internet
protocol suite to link devices worldwide
Solutions
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 - ANSWER-B. Cognitive Patterns: Is data generally collected for
long-term care settings and required in MDS. All other choices are collected on
Medicare inpatients according to UHDDS requirements.
Engaging patients and their families in health care decisions is one of the core
objectives for:
A. achieving meaningful use of EHRs
B. The JC's National Patient Safety goals
C. HIPAA 5010 regulations
D. Establishing flexible clinical pathways. - ANSWER-A. Achieving meaningful use of
EHRs: It is one of the core objectives of achieving meaningful use.
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 - ANSWER-D. problem list - All other choices are more likely to be found
on the records of long-term care patients.
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 he
office a week before admission. You tell Dr. Crossman:
A. A new H&P is required for every IP admission
B. that you apologize for not noticing the H&P she provided
C. the H&P copy is acceptable as long as she documents any interval changes
D. TJC standards do not allow copies of any kind in the original record - ANSWER-C.
TJC 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. Additionally, when the patient is readmitted within 30 days for the same of a
related problem, an interval H&P and physical exam may be completed if the original
H&P is readily available.
,Improving clinical outcomes and optimal continuity of care for patients are common
goals of CDI programs in acute care hospitals. Additionally, CDI programs may work
together with UM programs to:
A. reduce clinical denials for medical necessity
B. decrease medication errors through CPOE systems
C. Increase patient engagement through patient portals
D. report sentinel events to TJC - ANSWER-A. B and D are related to patient safety
goals. C is related to HITECH goals for physician practices.
Discharge summary documentation must include:
A. detailed history of the patient
B. a note from social services or discharge planning
C. significant finding during hospitalization
D. correct codes for significant procedures - ANSWER-C. Reference to the patient's
history may be found in the discharge summary but not detailed. The attending
physician records the discharge summary. Codes are generally recorded on a different
form in the record.
A HI manager develops a formal plan or record retention schedule for the automatic
transfer of records to inactive storage and potential destruction based on of the the
following factors:
A. statue of limitations
B. volume of research
C. readmission rate
D. department staffing - ANSWER-D. Oachs & Watters p62-63, 129, 133-134
Unless state or federal laws require longer time periods, AHIMA recommends hat
patient health information for minors be retained for at least how long?
A. age of majority plus statue of limitation
B. 10 years after the most recent encounter
C. 20 years after the age of majority
D. permanently - ANSWER-A. age of majority plus statue of limitation
A surgeon request the name of a patient he admitted on January 11, 2017. Which of the
following would be used to retrieve this information?
A. physician index
B. number index
C. R-ADT system
D. operation index - ANSWER-C. R-ADT system
Admissions, discharge, transfer (R-ADT) system
- Administrative application that connects to the EHR system.
Oachs & Watters, p. 369
,When evaluating an outside contract microfilm company, all but which of the following
are important factors to rate?
A. cost
B. emergency returns
C. storage after filming
D. cache memory - ANSWER-D. cache memory
Sayles and Gordon, p. 62
Case finding methods for patients with diabetes include a review of all but which one of
the following?
A. health plans
B. CPT diagnostic codes
C. billing data
D. medication lists - ANSWER-B. CPT diagnostic codes
Case finding includes methods to ID patient who have been seen and treated fora
particular disease or condition of interest to the registry in a facility.
Purpose of registries is to collect data from the patient health recored and make them
available to users. Other registries take an additional step to enter information into the
database for routine follow-up of patients at specified intervals including rate and
duration of survival and quality-of-life issues over time.
All other choices are included in the review. Demographics data, , laboratory values
such as HbA1c, ICD diagnostic codes, and physician identification are also included.
Oachs & Watters, p. 173
Sayles and Gordon, p 175
A quality control measure that should be established for the filing, storage, and retrieval
of health records includes criteria for the
A. accuracy of analyzing records
B. number of incomplete records
C. inclusion of late reports
D. tracking of release of information requests - ANSWER-C. inclusion of late reports
Sayles and Gordon, p. 68
How many years does the Food and Drug Administration require research records
pertaining to cancer patients be maintained?
A. 5
B. 7
C. 30
D. permanently - ANSWER-C. 30
AHIMA practice brief
What data cannot be retrieved fro the MEDPAR?
, A. ICD-10-CM diagnosis codes
B. Charges broken down by specific types of services
C. Non-Medicare patient data
D. Data on the provider - ANSWER-C. Non-Medicare patient data
All other choices are included. Other types of data include:
demographic data on patient
information on Medicare coverage for the claim
total charges
ICD-10CM diagnosis and procedure codes
DRGs
The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care
hospital and skilled nursing facility (SNF) claims data for all Medicare claims.
The MEDPAR files is frequently used for research on topics such as charges for
particular types of care and analysis by DRG. Limitation for the data for research
purposes is that it only contains data for Medicare patients.
Oachs & Watters, p 185-186
The HIM practitioner's duty to retain health information via the archiving and storage of
health data includes all but which of the following:
A. strategies that consider accessibility, natural disasters, and innovations in storage
technology
B. strategies ensuring that inactive records are as secure as active records
C. a retention plan for multiple volumes of records
D. a retention plan for financial data - ANSWER-D. a retention plan for financial data
University Hospital has the messaging technology to securely route an alert for a
patient's possible drug interaction or abnormal lab result to the appropriate physician's
pager number. Which one of the following is the medical staff using?
A. intranet
B. extranet
C. internet
D. clinical information systems - ANSWER-D. clinical information systems
Intranet - private network, typically contained within an enterprise
extranet - private network that utilizes internet technology and public telecommunication
system to share business information with suppliers, vendors, customers, etc
internet - global system of interconnected computer networks that uses the internet
protocol suite to link devices worldwide
