RHIT exam prep questions & answers 2023

RHIT exam prepExample of Point-of-Service care & documentation - correct answer RN using a terminal to record vital signs. There's a difference between computer application in health care and clinical application of computers What do I find in Medical Staff Rules & Regulations? - correct answer Doc requirements for pts' records, time frame for completion of MRs, penalties for failure to comply C these requirements Auto authentication. Why doesn't TJC approve it? - correct answer No guarantee that MD actually reviewed the MR & did sign it electronically. Some facilities do use auto athentication In what setting Interdisciplinary plan of care is used? - correct answer LTC TJC compliance rate for Delinquent records is - correct answer Under 50% Who is responsible for accurateness & completeness of pts MRs? - correct answer MDs (not HIM director, RNs or other administrative positions) Dictated Operative report is due - correct answer Immediately after surgery. If transcription service is down, the surgeon has to write a detailed OP note One of Utilization Review functions - correct answer Compare severity of illness & Intensity of service warrant acute care level One of Clinical Care Eval processes - correct answer Quality of follow-up care Tumor registry cases accession numbers - correct answer Each case in Tumor registry is assigned a unique accession number. Ex: 10-001 (10- year the case was entered in a database, 001 - case #1) What is accession register? - correct answer Permanent log of all cases entered in a database (used in Tumor registry) What is R-ADT system? - correct answer Registration-Admission, DC & Transfer system. Best to use for tracking pts who have been transferred to a specialty unit Difference between ROS & H&P - correct answer 1) Review of Systems - record of subjective Sx that a pt may have forgotten to mention 2) H&P - record of Objective Sx MD is observing & other info (social Hx, Hx of present illness) Recommendation for improvement from TJC - correct answer # of delinquent records is 50% AND Delinquent records missing H&P 2% of the Average monthly DCs Integrated vs Separated Progress notes - correct answer Integrated - all providers from every discipline record progress notes sequentially on the same form vs Separated - every discipline has its own designated form to record their Progress notes LTC pt care plans rely on documentation found in - correct answer 1) Interdisciplinary pt care plan 2) DC summary 3) Transfer records Ambulatory care providers rely on documentation found in - correct answer Problem list Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality Improvement Program) - correct answer MI - pt is DC'd on ASA, beta blockers or other heart Rxs Stroke - pt is DC'd on an anti-thrombotic Pneumonia - pt had blood culture before 1st Abx started Regional health information organizations - correct answer Support health information exchange within a geographic region