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RHIA Domain 1 Exam with Questions and 100% Correct Answers
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hich of the following represent the most serious pattern of delinquencies? Fifteen percent of delinquent records show - Answer missing operative reports A primary focus of screen format design in a health record computer application should be to ensure that - Answer the user is capturing essenti...

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  • August 18, 2024
  • 35
  • 2024/2025
  • Exam (elaborations)
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  • rhia domain 1 exam with questions

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RHIA Domain 1 Exam with Questions and
100% Correct Answers
Which of the following represent the most serious pattern of delinquencies? Fifteen
percent of delinquent records show - Answer missing operative reports


A primary focus of screen format design in a health record computer application should
be to ensure that - Answer the user is capturing essential data elements


A qualitative analysis of OB records reveals a pattern of inconsistent data entries when
comparing documentation of the same data elements captures on both the prenatal
form and labor and delivery form. The characteristic of data quality that is being
compromised in this case is data - Answer reliability


Medicare rules state that the use of verbal orders should be infrequent and used only
when the orders cannot be written or given electronically. In addition, verbal orders
must be - Answer recorded by persons authorized by hospital regulations and
procedures


The lack of a discharge order may indicate that the patient left against medical advice. If
this situation occurs, you would expect to see the circumstances of the leave - Answer
documented in both the progress notes and the discharge summary


Your committee is charged with developing procedures for the Health Information
Services staff of a new home health agency. You recommend that the staff routinely
check to verify that a summary on each patient is provided to the attending physician so
that he or she can review, update, and re-certify the patient as appropriate. The time
frame for requiring this summary is at least every - Answer 60 days


You want to review one document in your facility that will spell out the documentation
requirements for patient records, designate the time frame for completion by the active

,medical staff, and indicate the penalties for failure to comply with these record
standards. Your best resource will be - Answer medical staff bylaws


A quarterly review reveals the following data for Spring field Hospital:
Springfield Hospital Quarterly Statistics
Average monthly discharges 1,820
Average monthly operative procedures 458
Number of incomplete records 1,002
Number of delinquent records 590


What is the percentage of incomplete records during this quarter? - Answer 55%


Referring to the data in the previous question, determine the delinquent record rate for
Springfield Hospital - Answer 32%


Still referring to the information in the table related to Springfield Hospital, would the
facility be out of compliance with Joint Commission standards? - Answer No


In an acute care facility, the responsibility for educating physicians and other health care
providers regarding proper documentation policies belongs to the - Answer health
information manager


For inpatients, the first data item collected of a clinical nature is usually - Answer
admitting diagnosis


Documentation found in acute care health records should include core measure quality
indicators required for compliance with Medicare's Health Care Quality Improvement
Program (HCQIP). A typical indicator for patients with pneumonia is - Answer blood
culture before first antibiotic received

,One record documentation requirement shared by BOTH acute care and emergency
departments is - Answer patient's condition on discharge


In addition to diagnostic and therapeutic orders from the attending physician, you
would expect every completed inpatient health record to contain - Answer discharge
order


As the Chair of the Forms Committee at your hospital, you are helping to design a
template for house staff members to use while collecting information for the history
and physical. When asked to explain how "review of systems" differs from "physical
exam," you explain that the review of systems is used to document - Answer subjective
symptoms that the patient may have forgotten to mention or that may have seemed
unimportant


Based on the following documentation in an acute care record, where would you expect
this excerpt to appear:


"The patient is alert and in no acute distress, Initial vital signs: T98, P102, and regular, R
20 and BP 120/69..." - Answer physical exam


Which one of the following is NOT a step in developing a health record retention
schedule? - Answer assigning all records the same retention period


Information found in which of the following would not be considered secondary data? -
Answer health record


Under the Patient Self-Determination Act of 1990, evidence of advance directives -
Answer are required to be documented in the health record

, A 200-bed acute care hospital currently has 15 years of paper health records and filing
space is limited. What action should be take? - Answer Destroy inactive records that
exceed the statute of limitations


What is the chief criterion for determining record inactivity? - Answer amount of space
available for storage of newer records


How many years does the CMS require that health records be maintained? Medicare
Conditions of Participation for Hospitals requires that patient health records be retained
for at least _____ years unless a longer period is required by state or local laws. -
Answer 5


Your state regulations require health records to be kept for a statute of limitations
period of 7 years. Federal law requires records to be retained for 5 years. The minimum
retention period for health records in your facility should be - Answer 7 years


A research request has been received by the HIM Department from the Quality
Improvement Committee. The Committee plans to review the records of all patients
who were admitted with CHF in the month of January. Which of the following indices
would be the best source in locating the needed records? - Answer disease index


Which of the following should not be included in the documentation of record
destruction? - Answer dates not covered in the destruction


Which of the following is NOT a consideration when implementing a disaster plan? -
Answer test the disaster plan only once


Dr. Gray has applied for medical staff privileges at your hospital. What database would
you research to determine if he has been denied medical staff privileges at another
hospital? - Answer National Practitioner Data Bank

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