RHIA Domain 1 Exam 1 Study Set Questions With Complete Solutions

Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the: a.) Admitting physical evaluation record b.) Patient's rights acknowledgement form c.) Release of Information form d.) Transfer Record correct answer: D. Transfer Record For further explanation look at page 160 A 65 y/o white male was admitted to the hospital on a 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and a laboratory evaluation of CBC and UA. The X-ray revealed possible cholelithiasis and the UA showed an increase in white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered. The chief complaint was: a. Abdominal pain b. Cholelithiasis c. Exploratory laparoscopy d. Ruptured appendix correct answer: A. Abdominal Pain For further explanation look at page 160. Mrs. Smith's admitting data indicates that her birthdate is 3-21-1948. On the discharge summary, Mrs. Smith's birthdate is recorded as 7-21-1948. Which quality element is missing