RHIA Part 3 Exam with Complete
Solutions
As the corporate director of HIM Services and enterprise privacy officer, you are asked
to review a patient's health record in preparation for a legal proceeding for a malpractice
case. The lawsuit was brought by the patient 72 days after the procedure. Health
information contains a summary of two procedures that were dictated 95 days after the
procedure. The physician in question has a longstanding history of being lackadaisical
with record completion practices. Previous concerns regarding this physician's record
maintenance practices had been reported to the facility's Credentialing Committee. Are
the summaries of the two procedures admissible in court? - ANS-This information could
be rejected since the physician dictated the procedure note after the malpractice suit
was filed.
In a recent coding audit, the coding manager discovered the following issue: A skin
lesion was removed from a patient's cheek in the dermatologist's office. The
dermatologist documented skin lesion, probable basal cell carcinoma. Which of the
following actions should the coding professional take in order to correctly code this
encounter? - ANS-Code skin lesion
Which of the following statements is true regarding HIPAA security? - ANS-A security
risk assessment must be performed every year.
Which of the following is an example of a 1:M relationship? - ANS-Patients to hospital
admissions
What information might be displayed on a histogram? - ANS-Discharges by age
The Joint Commission requires a varying number of safety functions and plans
depending on the license or services provided by an organization. The standards
require the assessment of safety features for patients, staff, and visitors. Which of the
following lists are required safety standard plans for the environment of care? - ANS-
Medical equipment management, life safety management, and emergency management
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia,
oliguria, and elevated WBC. The patient has more than 100,000 organisms of
Escherichia coli per cc of urine. The attending physician documents "urosepsis." How
should the coder proceed to code this case? - ANS-Query the physician to ask if the
patient has septicemia because of the symptomatology.
, A database rule that states "patient gender must be recorded as M=male, F=female,
and U= unknown" is referred to as: - ANS-Integrity constraint
A medical staff committee wants to compare long-term survival rates for breast cancer
by comparing outcomes for the mastectomy versus lumpectomy approaches. The best
source of this information is the: - ANS-Cancer registry
Which RFP component would fit the following description?
Describe the EHR product's data architecture, analytical processes supported,
necessary interfaces, reliability and security features, system capacity, expansion
capabilities, response time, downtime, and other issues associated with system
maintenance. - ANS-Operational requirements
If a patient is readmitted to a facility after a recent admission, Joint Commission allows
the facility to use the existing history and physical from the first admission if it is for a
related condition and was completed within _____ of the second admission and if an
interval note updating any changes to the patient's condition has been documented. -
ANS-30 days
The IT department of an academic medical center has created a project management
office (PMO) in order to help manage the many projects relating to implementing an
EHR that have been underway for a few years already. After a few months, the chief
information officer is concerned that many tasks the PMO was expected to perform
have not been accomplished. In addition, the chairs of the domain teams continue to
work independently and directly with the vendor. The project management mistake
illustrated in this scenario is: - ANS-Lack of ownership
What information does not have to be included in a covered entity's notice of privacy
practice?
A. A description with one example of disclosures made for treatment, payment, and
healthcare operations
B. A description of all the other purposes for which a covered entity is permitted or
required to disclose PHI without consent or authorization
C. A statement of individual's rights with respect to PHI and how the individual can
exercise these rights
D. The signature of the patient and date the notice was given to the patient - ANS-The
signature of the patient and date the notice was given to the patient
The director of Health Information Services is allowed access to the health record
tracking system when providing the proper login and password. Under what kind of
access security mechanism is the director allowed access to the system? - ANS-User-
based
The final judgment of a competent court is conclusive - ANS-res judicata
Solutions
As the corporate director of HIM Services and enterprise privacy officer, you are asked
to review a patient's health record in preparation for a legal proceeding for a malpractice
case. The lawsuit was brought by the patient 72 days after the procedure. Health
information contains a summary of two procedures that were dictated 95 days after the
procedure. The physician in question has a longstanding history of being lackadaisical
with record completion practices. Previous concerns regarding this physician's record
maintenance practices had been reported to the facility's Credentialing Committee. Are
the summaries of the two procedures admissible in court? - ANS-This information could
be rejected since the physician dictated the procedure note after the malpractice suit
was filed.
In a recent coding audit, the coding manager discovered the following issue: A skin
lesion was removed from a patient's cheek in the dermatologist's office. The
dermatologist documented skin lesion, probable basal cell carcinoma. Which of the
following actions should the coding professional take in order to correctly code this
encounter? - ANS-Code skin lesion
Which of the following statements is true regarding HIPAA security? - ANS-A security
risk assessment must be performed every year.
Which of the following is an example of a 1:M relationship? - ANS-Patients to hospital
admissions
What information might be displayed on a histogram? - ANS-Discharges by age
The Joint Commission requires a varying number of safety functions and plans
depending on the license or services provided by an organization. The standards
require the assessment of safety features for patients, staff, and visitors. Which of the
following lists are required safety standard plans for the environment of care? - ANS-
Medical equipment management, life safety management, and emergency management
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia,
oliguria, and elevated WBC. The patient has more than 100,000 organisms of
Escherichia coli per cc of urine. The attending physician documents "urosepsis." How
should the coder proceed to code this case? - ANS-Query the physician to ask if the
patient has septicemia because of the symptomatology.
, A database rule that states "patient gender must be recorded as M=male, F=female,
and U= unknown" is referred to as: - ANS-Integrity constraint
A medical staff committee wants to compare long-term survival rates for breast cancer
by comparing outcomes for the mastectomy versus lumpectomy approaches. The best
source of this information is the: - ANS-Cancer registry
Which RFP component would fit the following description?
Describe the EHR product's data architecture, analytical processes supported,
necessary interfaces, reliability and security features, system capacity, expansion
capabilities, response time, downtime, and other issues associated with system
maintenance. - ANS-Operational requirements
If a patient is readmitted to a facility after a recent admission, Joint Commission allows
the facility to use the existing history and physical from the first admission if it is for a
related condition and was completed within _____ of the second admission and if an
interval note updating any changes to the patient's condition has been documented. -
ANS-30 days
The IT department of an academic medical center has created a project management
office (PMO) in order to help manage the many projects relating to implementing an
EHR that have been underway for a few years already. After a few months, the chief
information officer is concerned that many tasks the PMO was expected to perform
have not been accomplished. In addition, the chairs of the domain teams continue to
work independently and directly with the vendor. The project management mistake
illustrated in this scenario is: - ANS-Lack of ownership
What information does not have to be included in a covered entity's notice of privacy
practice?
A. A description with one example of disclosures made for treatment, payment, and
healthcare operations
B. A description of all the other purposes for which a covered entity is permitted or
required to disclose PHI without consent or authorization
C. A statement of individual's rights with respect to PHI and how the individual can
exercise these rights
D. The signature of the patient and date the notice was given to the patient - ANS-The
signature of the patient and date the notice was given to the patient
The director of Health Information Services is allowed access to the health record
tracking system when providing the proper login and password. Under what kind of
access security mechanism is the director allowed access to the system? - ANS-User-
based
The final judgment of a competent court is conclusive - ANS-res judicata
