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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Domain 1 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
Which of the following is least likely to be identified by a deficiency analysis technician? - the
discrepancy between post up diagnosis by the surgeon and pathology diagnosis by the pathologist
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk
notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this
clerk performing? - Qualitative Review
The Conditions of Participation require that the medical staff bylaws, rules, and regulations address the
status of consultants. Which of the following reports would normally be considered consultation? -
impressions of a cardiologist asked to determine whether the patient is a good surgical risk
The health care providers at your hospital do a very thorough job of periodic open record reviews to
ensure the completeness of record documentation. A qualitative review of surgical records would likely
include checking for documentation regarding - The presence or absence of such items as preoperative
and postoperative diagnosis, description of findings, and specimens removed
In your facility, the health care providers from every discipline document progress note sequentially on
the same form. Your facility is utilizing? - integrated progress notes
Which of the following services is LEAST likely to be provided by a facility accredited by CARF? - palliative
care
Which method of identification of authorship or authentication of entries would be inappropriate to use
in a patient's health record? - delegated use of computer key by radiology secretary
As a trauma registrar working in an emergency department, you want to begin comparing your trauma
care services to other hospital-based emergency departments. To ensure that your facility is collecting
the same data as other facilities, you review elements from which data set? - DEEDS
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a
physicians verbal orders in accordance with Joint Commission standards and state law. Your first area of
,concern is the qualifications of those individuals in your facility who have been authorized to record
verbal orders. For this information, you will consult the - Hospital Bylaws, Rules, and Regulations
Reviewing a medical record to ensure that all diagnosis are justified by documentation throughout the
chart is an example of - qualitative review
Accreditation by Joint Commission is a voluntary activity for a facility and it is - required for
reimbursement of certain patient groups
Which of the four distinct components of the problem-oriented record serves to help index
documentation throughout the record - problem list
As a supervisor of the cancer registry, you report the registry's annual caseload to administration. The
most efficient way to retrieve this information would be to use - accession register
Select the appropriate situation for which a final progress note may legitimately be substituted for a
discharge summary in an inpatient medical record - Baby Boy Hiltz, born 1/5/2016, maintained normal
status, discharged 1/7/2016
Based on the following Documentation in an acute care record, where would you expect this excerpt to
appear?
" Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was
started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and
remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath
resolved. EKG's remained unchanged. Patient will be discharged and followed as an outpatient." -
discharge summary
The information security officer is revising the policies at your rehabilitation facility for handling all
patient clinical information. The best resource for checking our specific voluntary accreditation
standards and guidelines is the - CARF manual
Which of the following is a secondary data source that would be used to quickly gather the health
record of all juvenile patients treated for diabetes within the past 6 months. - disease index
, As the Coding Supervisor, your job description includes working with agents who have been charged
with detecting and correcting over payments made to your hospital in the Medicare Fee for Service
program. You will need to develop a professional relationship with - recovery audit contractors
Using a template to collect data for key reports may help to prompt caregivers to document all required
data elements in the patient record. This practice contributes to data - comprehensiveness
In preparation for an upcoming site visit by Joint Commission, you discover that the number of
delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming
was the pattern you noticed in the type of delinquencies. Which of the following represent the most
serious pattern of delinquencies? Fifteen percent of delinquent records show - missing operative reports
A primary focus of screen format design in a health record computer application should be to ensure
that - 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 - 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 - 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 - 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 - 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
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