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RHIA EXAM QUESTIONS AND ANSWERS
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RHIA EXAM QUESTIONS AND ANSWERS
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RHIA EXAM QUESTIONS AND ANSWERSWhat are the common types of random samplying?
Simple, Stratified, Systemic, Cluster
What is Simple random sampling?
Every member of the population has an equal probability of being selected for the
sample
What is stratified random sampling?
Selected by first dividing the population into subsets or strata, then a simple random
sample is selected from each strata from the sample.
What is cluster random sampling?
The population is divided into subsets, called 'clusters'. The clusters are then randomly
selected. All units within the randomly selected clusters are included in the sample /
Process of selecting subjects for a sample from each cluster within a population.
Example: A family, school, or community.
What is systemic random sampling?
Method used to determine a simple random sample. In systemic random sampling
every N/nth record is selected from the population. N is the number of units in the
population and n is the sample size.
What is Qualitative Analysis and why is it conducted?
HIM personnel carefully review the quality and adequacy of record documentation and
ensure that it is in accordance with the policies, rules, and regulations established by
the facility, the standards of licensing and accrediting bodies, and government
requirements. Can be done concurrently or retrospectively. Qualitative Analysis is a
more in-depth review of health records than quantitative analysis though there may be
some overlap depending on the facility, This review process looks at requirements such
presence of the H&P examination prior to surgery, completion of the postoperative note,
and many other aspects of the care process as documented in the health record.
What is Structured Data?
Data that is organized and easily retrievable and interpreted by traditional database and
database models.
What does CDI stand for?
Clinical Documentation Improvement
What is CDI used for?
,Clinical documentation improvement is a process to facilitate the accurate
representation of a patient's clinical status in the patient health record. It is then
transformed into coded data. This information and coded data is then utilized for many
purposes in health care. Used to improve clinical specificity and documentation that will
allow coders to assign more concise disease classification codes.
What are examples and elements of structured data?
- Patients automated laboratory order
- Laboratory results
Structured data is coded and alphanumeric. Their fields are predefined and
limited
Is the health record a primary or secondary data source?
Primary data source
Registries, reports, and incidences are examples of a primary or secondary data
source?
Secondary data source
Structured data is has many benefits including:
Completeness, quality of data, and accessibility. It is highly recommended for data
entry. Structured data may further be broken down into levels of measurement.
Structured data is comprised of:
Values that can be stored as either numbers or an infinite number of categories. It is
organized and easily retrievable by traditional databases and data models.
Examples of structured data include:
Height, Weight, Age, Gender, date of birth, MS-DRG.
Unstructured data UNLIKE structured
Cannot be expressed as numbers or categories.
Examples of unstructured data include:
Clinician notes recorded into the EHR. Clinician notes are recorded as freeform text and
therefore difficult to use in analyses.
Yes or No questions are examples of what kind of data?
Nominal data
Nominal data is expressed as:
,Categories that represent names of items but do not have a natural order or quantitative
value. Label variables. Examples include: gender(male/female), yes/no questions,
names of people, nationalities, hair color, MS-DRG, Cpt codes, and ICD codes.
Weight is an example of what kind of data?
Ratio/Scale data. It is a defined unit of measure.
APGAP Scores are an example of what kind of data?
Ordinal data. Because the order of the numbers in APGAP scores are meaningful.
What are distribution curves used for?
Used to show variable relationships.
What is Skewness?
The horizontal stretching of the frequency of the distribution curve to one side or the
other.
What is a template used for?
It is used to capture data in a structured manner. Capturing data in a template helps to
ensure data integrity upon data entry.
What are the different data sets used for?
Different data sets are used to encourage uniform data collection and reporting.
Datasets list the recommended data elements with uniform definitions that are relevant
for particular use.
What is an advanced directive?
Special types of consent that communicates an individual's wishes to be treated or not
be treated should the individual become unable to communicate on his or her own
behalf.
What are source systems?
Information systems that capture and feed data into the EHR. This information can
come from various 'sources' such as laboratory, radiology, and hospital/nursing
information systems.
What is the most secure EHR signature form?
A digital signature is the most secure to ensure authentication of data entries. Digital
signatures are similar to the electronic signatures EXCEPT digital signatures use
encryption to provide nonrepudiation to prove the authenticators identity.
What is a Dashboard?
, A method that has been developed for presenting data on a single display in an easy-to-
read format. It is used to create reports of process measures to help leaders follow
progress to assist with strategic planning.
What is an Ancillary (secondary) function of the healthcare record?
Bio-medical research.
What is ERD?
Entity Relationship Diagram. Used to describe how the tables in a database work
together. Graphic representation of entities, attributes, and relationships. A specific type
of data modeling used in conceptual data modeling and the logical-level modeling of
relational databases. Illustrates the logical structure of a database.
Post Operative Progress notes are required when
There are delays in dictation or transcription.
Who are the only ones allowed to document in the patient's health record?
Only healthcare providers can document in the patient's record. HIM professionals
monitor documentation, guidelines, and train healthcare providers in documentation
techniques. HIM professionals also audit patient records.
What is charting by exception?
Method of documenting only abnormal or unusual findings or deviations from the
prescribed plan of care. Notes should focus on that particular event and include the
data, assessment, intervention, and response. Also called focus charting.
Should facilities maintain all information related to a patient's diagnosis and treatment
methods in the patient's record?
Yes. This information could be in an email between the patient and the health care
provider. HOWEVER, information regarding appointment times, insurance, and billing
should NOT be made part of the record.
What is Aggregate data and what is it used for?
Data on groups of people/patients without identifying anyone individually.
- Used to Develop information about groups of patient's without identifying a particular
patient individually. Data is based on performance or utilization.
What is abstracting?
The compilation of pertinent information extracted from the patient record. The purpose
of abstracting is to make information from the patient record readily available for internal
and external reporting needs.
What are examples of administrative information/demographic information?
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