RHIT 11 Exam Questions with Correct Answers
When developing a data collection system, the most effective approach first considers - Answer-the end user's needs
A key data item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record is the - Answer...
RHIT 11 Exam Questions with Correct
Answers
When developing a data collection system, the most effective approach first considers -
Answer-the end user's needs
A key data item you would expect to find recorded on an ER record, but would probably
NOT see in an acute care record is the - Answer-time and means of arrival
A data item to include on a qualitative review checklist of infant and children inpatient
health records which need not be included on adult records would be - Answer-growth
and development record
For each report of care rendered to a patient, the health record entry should include the
date plus the provider's name and - Answer-discipline
In creating a new form or computer view, the designer should be most driven by -
Answer-needs of the users
Under which of the following conditions can an original patient health record he
physically removed from the hospital? - Answer-when the director of health records is
acting in response to a subpoena duces tecum and takes the health record to court
According to the following table, the most serious record delinquency problem occurred
in which of the following months?
April May June
% incomplete records 70% 88% 79%
% delinquent records 51% 43% 61%
% delinquent due to missing H&P 3% 1.4% 0.5% - Answer-April
Using the SOAP style of documenting progress notes, choose the "subjective"
statement from the
following. - Answer-patient states low back pain is as severe as it was on admission
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result,
core assessment data elements are collected on each resident as defined in the -
Answer-MDS.
As the chair of a Forms Review Committee, you need to track the origin of data in a
particular field and the security levels applicable to that field. Your best source for this
information would be the - Answer-facility's data dictionary
, You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted
for disc surgery, but the progress notes indicate that due to some heart irregularities, he
may not be a good surgical risk. Because of your knowledge of COP regulations, you
expect that a(n) ___________ will be added to his health record. - Answer-consultation
report
An example of objective entry in the health record supplied by a health care practitioner
is the - Answer-physical assessment
You have been appointed as chair of the Health Record Committee at a new hospital.
Your committee has been asked to recommend time-limited documentation standards
for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee
documentation standards must meet the standards of both the Joint Commission and
the Medicare Conditions of Participation. The standards for the history and physical
exam documentation are discussed first. You advise them that the time period for
completion of this report be should be set at - Answer-24 hours after admission or prior
to surgery
Based upon the following documentation in an acute care record, where would you
expect this excerpt to appear? "With the patient in the supine position, the right side of
the neck was appropriately prepped with betadine solution and draped. I was able to
pass the central line which was taped to skin and used for administration of d rugs
during resuscitation." - Answer-Operative record
A surgeon on the Health Record Committee voices a concern that, although he has
been told that the operative report is to be dictated immediately after surgery; he has
often had to deal with the problem of transcription backlog which prevented the report
from getting on the health record in a timely manner. Your advice to this doctor is that
when a known backlog exists, he should - Answer-write a detailed operative note in the
record
Discharge summary documentation must include - Answer-significant findings during
hospitalization
The performance of qualitative analysis is an important tool in ensuring data quality.
These reviews evaluate - Answer-completeness, adequacy, and quality of
documentation
Quantitative and qualitative reviews performed on patient records by medical record
personnel in either a skilled nursing facility or inpatient psychiatric facility are generally
in the form of - Answer-concurrent chart review
The foundation for communicating all patient care goals in long-term care settings is the
- Answer-individualized patient care plan.
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