Mock RHIA part 1 Questions and Answers (100% Pass)
Community Hospital is implementing a hybrid record. Some documentation will be paper-based
and digitally scanned after discharge. Other parts of the record will be totally electronic. The
Medical Record Committee is discussing how interim reports in the health record should be
handled. Some on the committee think that all interim reports should be discarded and only the
final reports retained in the scanned record. Others take the opposite position. Which of the
following is a best practice that the health information management (HIM) director should
suggest to the committee? - ✔️✔️Maintaining all interim reports provides the greatest measure of
security.
Maintaining all interim reports provides the greatest measure of security. Managing health
information in a hybrid record environment is challenging, but by maintaining the reports the
facility will reduce some potential problems.
The four major issues that have an impact on the record retention policy of a healthcare facility
are patient care, research, space, and: - ✔️✔️Legal and statutory requirements
Hospitals and other healthcare facilities develop health record retention policies to ensure that
health records comply with all applicable state and federal regulations and accreditation
standards.
Highland Hospital requires all dates be recorded in its clinical information system as
MM/DD/YYYY. This required data definition and format should be part of the________. -
✔️✔️data dictionary
A data dictionary is like a map of the database. Whenever a set of data is created, it should have
an accompanying data dictionary. A data dictionary can ensure consistency by standardizing
definitions. A typical data dictionary allows for the format of each attribute such as
MM/DD/YYYY for the date.
Facility-based cancer registries receive approval as part of the facility cancer program from
which of the following agencies? - ✔️✔️American College of Surgeons
The American College of Surgeons (ACS) Commission on Cancer has an approval process for
cancer programs. One of the requirements of this process is the existence of a cancer registry as
part of the program. When the ACS surveys the cancer program, part of the survey process is a
review of cancer registry activities.
When an Entity Relationship Diagram (ERD) is implemented as a relational database, an
attribute will become a(n): - ✔️✔️field
Attributes are the characteristics or data elements to be collected about each entity. They can be
depicted in an ERD as oval shapes coming off an entity. Attributes become the fields or column
headings within the data tables of a relational database.
A database rule that states "patient gender must be recorded as M=male, F=female, and U=
unknown" is referred to as: - ✔️✔️Application control
Databases contain rules known as application controls that must be satisfied by the stored data.
Data integrity happens when all of the data in the database conform to all rules. Certain fields,
such as dates, must be entered in a certain format, such as MM/DD/YYYY. Application controls
such as edit checks help ensure that the originally-entered data and changes to these data follow
certain rules.
Which of the following clinicians would use the DSM-V system to assist with establishing a
diagnosis? - ✔️✔️Practicing psychiatrists
DSM-V is a multiaxial coding system with five axes. Axis I includes the mental disorders or
illnesses comparable to general medical illnesses. Axis II includes personality disorders. Axis III
includes general medical illnesses. Axis IV covers life events or social problems that affect the
patient. Axis V is the overall level of the patient's functioning, usually as determined by the
Global Assessment of Functioning (GAF). The American Psychiatric Association (APA) states
two general uses for DSM: as a source of diagnostic information that enhances clinical practice,
research, and education.
What data set provides the underpinning of the home health prospective payment system (HH
PPS)? - ✔️✔️OASIS
The HHPPS is based on a predetermined rate for a 60-day episode of home health care. OASIS
data are essential to home health agency's reimbursement under the HHPPS. OASIS data drive
the determination of the case-based adjustment. There are three components in the structure of
payment under the HHPPS: the national standardized episode rate, the HHA case-mix group, and
adjustments.
The primary purpose of a Minimum Data Set in healthcare is to: - ✔️✔️Recommend common data
elements to be collected in health records
The need for standardized data definitions was recognized in the 1960s, and the National
Committee on Vital and Health Statistics took the lead developing uniform Minimum Data Sets
for various sites of care. As technology has driven the development of the data or information
systems, the early data sets have been supplemented with healthcare information standards that
focus on EHR systems. A number of standards-setting organizations are involved in developing
uniform definitions, data fields, and views for health record content and structure.
All states have a health department with a division required to track and record communicable
diseases. When a patient is diagnosed with one of the diseases from the health department's
communicable disease list, the public health department must be notified. Which of the following
diseases would be reportable to the public health department? - ✔️✔️Hepatitis B
Hepatitis B is caused by the hepatitis B virus and is considered a communicable disease that is
reportable to the public health department. This reporting process may be in writing, by
telephone, or by total number of cases.
A medical staff committee wants to compare long-term survival rates for breast cancer by
comparing outcomes for the mastectomy versus lumpectomy approaches. The best source of this
information is the: - ✔️✔️Cancer registry
A cancer registry collects demographic information (such as name, health record number,
address), type and site of the cancer, diagnostic methodologies, treatment methodologies, and
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