RHIA EXAM STUDY GUIDE QUESTIONS AND ANSWERS 100% SOLVED

In preparation for EHR, 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 managment system. THe unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you most likely to give to this form is A. recovery room record B. pathology report C. operative report D. discharge summary - B. pathology report (C and D) although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic descriptio 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 - B. cognitive patterns Answers A, C, And D represent items collected on Medicare inpatients according to UHDDS requirements. Only B represents a data item collected more typically in long-term care settings and required in the MDS. In the past, Joint Commission standards have focused on promoting the use of facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the A. prohibited use of any abbreviations B. flagrant use of specialty-specific abbreviations C. use of prohibited or "dangerous" abbreviations D. use of abbreviations in the final diagnosis - Use of prohibited or "dangerous" abbreviations The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4". Spelling out the unit is preferred. In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent? A. the number of primary cancers reported for the 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 - The year the case was entered into the database of the registry Every case entered into the registry is assigned a unique accession number preceeded by the accession year, or the year the case is entered into the database. 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. doctor's progress notes B. integrated progress notes C. incident reports D. nurses' notes - Incident reports Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record. 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. discharges summary C. transfer record D. problem list - D. problem list (A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients. 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 passwordsB. evidence cannot be provided that the physician accurately reviewed and approved each report C. electronic signatures are not acceptable in every state D. tampering too often occurs with this method of authentication - B. evidence cannot be provided that the physician actually reviewed and approved each report Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians