Pass4Sure RHIA practice test

Exam Code: RHIA Vendor: IBM Exam Name: Registered Health Information Administrator Cert Name: Registered Health Information Administrator/

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AHIMA RHIA

Exam Name: Registered Health Information Administrator

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Question: 1 In preparation for an HER, 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 A. recovery room record.

B. pathology report.

C. operative report.

D. discharge summary.

Answer: B Question: 2 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 Question: 3 A good first step toward protecting the security of data contained in a health information computer system would be to A. establish a good record tracking system.

B. define levels of security for different types of information, depending on sensitivity.

C. provide remote terminals for improved access to the record.

D. provide internet access to facility records.

Answer: B Question: 4 In the number “99-0001” listed in a tumor registry accession register, what does the prefix “99” represent?

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A. the number of primary cancers reported for that patient B. the year the case was entered into the database of the registry C. the sequence number of the case D. the stage of the tumor based upon the TNM system of staging

Answer: B Question: 5 A risk manager needs to locate a full report of a patient’s fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A. doctors’ progress notes.

B. integrated progress notes.

C. incident report.

D. nurses’ notes.

Answer: C Question: 6 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 Question: 7 Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that A. it is too easy to delegate use of computer passwords.

B. evidence cannot be provided that the physician actually reviewed and approved each report.

C. electronic signatures are not acceptable in every state.

D. tampering too often occurs with this method of authentication.

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Question: 8 As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the A. prenatal record.

B. labor and delivery record.

C. postpartum record.

D. discharge summary.

Answer: A Question: 9 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 her office a week before admission. You tell Dr. Crossman.

A. a new H&P is required for every inpatient admissions.

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. Joint Commission standards do not allow copies of any kind in the original record.

Answer: C Question: 10 As a new CTR, you are interested in identifying every reportable case of cancer from the previous year.

A key resource will be the facility’s A. disease index.

B. number control index.

C. physicians’ index.

D. patient index.

Answer: A Question: 11

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Joint Comission requires the attending physician to countersign health record documentation that is entered by A. interns or medical students.

B. midwives.

C. consulting physicians.

D. physician partners.

Answer: A Question: 12 The minimum length of time for retaining original medical records is primarily governed by A. Joint Commission.

B. medical staff.

C. state law.

D. readmission rates.

Answer: C Question: 13 The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar rmeasures might be utilized to govern the use of A. fingerprint signatures.

B. voice recognition systems.

C. expert systems.

D. electronic signatures.

Answer: D Question: 14 Discharge summary documentation must include A. a detailed history of the patient.

B. a note from social services or discharge planning.

C. significant findings during hospitalization.

D. correct codes for significant procedures

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Answer: C Question: 15 The performance of ongoing record reviews is an important tool is ensuring data quality through accurate health records. These reviews evaluate A. quality of care through the use of pre-established criteria.

B. adverse effects and contraindications of drugs utilized during hospitalization.

C. potentially compensable events.

D. completeness, adequacy, and quality of documentation.

Answer: D Question: 16 Ultimate responsibility for the quality and completion of entries in patient health records belongs to the A. chief of staff.

B. attending physician.

C. HIM director.

D. risk manager.

Answer: B Question: 17 Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of A. retrospective deficiency analysis.

B. special study audits.

C. concurrent chart review.

D. occurrence screening.

Answer: C Question: 18 The foundation for communicating all patient care goals in long-term care settings is the Page |6 Page |6

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A. legal assessment.

B. labor and delivery record.

C. interdisciplinary patient care plan.

D. Uniform Hospital Discharge Data Set.

Answer: C Question: 19 Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?

A. Health Record Committee.

B. Utilization Review Committee.

C. Risk Management Committee.

D. Joint Conference Committee.

Answer: A Question: 20 A health record analyst needs to quickly compare all lab values during one hospitalization. The paperbased health record format best suited for this purpose is A. problem-oriented.

B. source-oriented.

C. reverse chronological.

D. integrated.

Answer: B Question: 21 In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of Him department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards your first recommended change is to A. have more frequent committee meetings.

B. have the committee report to the Executive Committee.

C. have a physician perform all the reviews.

D. provide for record reviews to be performed by an interdisciplinary team of care providers.

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Answer: D Question: 22 As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it. Another step you will need to take is to A. authorize access to information collected based on level of data sensitivity.

B. prevent all nonclinicians’ access to any confidential information in the system.

C. establish firewalls to protect aggregate data collected within your facility.

D. establish passwords for all customers, both internal and external, who request access to the information in your system.

Answer: A Question: 23 A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statement regarding the history and physical is ture in this situation? Completion and charting of the H&P indicates.

A. noncompliance with Joint Commission standards.

B. compliance with Joint Commission standards.

C. compliance with Medicare regulations.

D. compliance with Joint Commission standards for nonsurgical patients.

Answer: A Question: 24 As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that willc ontribnute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for decision support regarding drug dosages and contraindications. You think they are ready for a A. computer-output-to-laser-disk system.

B. electronic medication administration record system.

C. electronic document management system.

D. computerized provider order-entry system.

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Answer: D Question: 25 You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

A. disease index.

B. physician index.

C. master patient index.

D. operation index.

Answer: D Question: 26 The best example of point-of-care service and documentation is A. using an automated tracking system to locate a record.

B. using occurrence screens to identify adverse events.

C. doctors using voice recognition systems to dictate radiology reports.

D. nurses using bedside terminals to record vital signs.

Answer: D Question: 27 Many of the principles of forms designa pply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computerbased system must give careful consideration to A. placement of hospital logo.

B. signature line for authentication.

C. use of box design.

D. bar code placement.

Answer: D Question: 28

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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 a acute care patients?

A. pharmacy consultation.

B. medical consultation.

C. physical exam.

D. emergency record.

Answer: A Question: 29 One distinct advantage of the HER over paper-based health records is the A. ease of developing screen designs over from designs.

B. accessibility of the record by multiple data users.

C. standardized format.

D. ease of data collection

Answer: B Question: 30 The first cancer patient seen in your facility on January 1, 2008, was diagnosed with colon cancer, with no known history of previous malignancies. Th eaccession number assigned to this patient is A. 2008-0000/00.

B. 2008-0000/01.

C. 2008-0001/00.

D. 2008-0001/01.

Answer: C Question: 31 As the Data Security Officer for your institution, you plan to implement a log-on process for electronic signing that is LEAST susceptible to improper delegation of use. The method you will recommend is A. password assigned by system administrator.

B. password assigned by user.

C. biometrics-based identifier.

D. encryption.

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Answer: C Question: 32 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 A. CARF manual.

B. hospital bylaws.

C. Joint Commission accreditation manual.

D. Federal Register.

Answer: D Question: 33 In an acute care hospital, a complete history and physical may not be dictated for a new admission when A. the patient is readmitted for a similar problem within 1 year.

B. the patient’s stay is less than 24 hours.

C. the patient has an uneventful course in the hospital.

D. a legible copy of a recent H&P performed in the attending physician’s office is available.

Answer: D Question: 34 You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

A. Minimum Data Set B. Uniform Hospital Discharge Data Set C. Conditions of Participation D. Federal Register

Answer: B

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