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According to the Joint commission accreditation standards, which document must be placed in patient's record before a surgical procedure may be performed? - ️️report of history and physicial examination In assessing the quality of care given to patients with diabetes mellitus, the quality te...

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  • October 2, 2024
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  • 2024/2025
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RHIA Exam
According to the Joint commission accreditation standards, which document must be
placed in patient's record before a surgical procedure may be performed? - ✔️✔️report
of history and physicial examination

In assessing the quality of care given to patients with diabetes mellitus, the quality team
collects data regarding blood sugar levels on admission and on discharge. These data
are called a (n): - ✔️✔️Indicator


The discharge summary must be completed within _________ after discharge for most
patients but within ________ for patients transferred to other facilities. Discharge
summaries are not always required for patients who were hospitalized for fewer than
_______ hours. - ✔️✔️30 days, 24 hours, 48 hours

If an analyst is studying the wait times at a clinic and the only list of patients available is
on hard copy, which sampling technique is the easiest to use? - ✔️✔️Systematic
sampling

In a long term care setting, these are problem oriented frameworks for additional patient
assessment based on problem identification items (triggered conditions) -
✔️✔️Resident Assessment Protocols (RAPs)

What data model is most widely used to illustrate a relational database structure? -
✔️✔️Entity-relationship diagram (ERD)

Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to
ensure that all documents are complete and signatures are present. This is an example
of a: - ✔️✔️Concurrent Review


Which of the following is used by a long term care facility to gather information about
specific health status factors and includes information about specific risk factors in the
resident's care? - ✔️✔️Minimum Data Set

A method of documenting nurses' progress notes by recording only abnormal or
unusual findings or deviations from the prescribed plan of care is called: -
✔️✔️Charting by exception

Dr. Collins admitted Mr. Smith to the University Hospital, Blue Cross Insurance will pay
Mr. Smith's hospital bill. Upon discharge from the hospital, who owns the health record
of Mr. Smith? - ✔️✔️University Hospital

,In a relational database, which of the following is an example of a many to many
relationship? - ✔️✔️Patients to consulting physicians

Anywhere Hospital has mandated that the Social Security number will be displayed in
the XXX-XX-XXX format for their patients. This is an example of the use of a: -
✔️✔️Mask

Sue is updating the data dictionary for her organization. In this dat dictionary, the data
element name is considered which of the following? - ✔️✔️Metadata

Why could it be difficult for a healthcare entity to respond to pulling an entire, legal
health record together for an authorized request for information? - ✔️✔️It can exist in
seperate and multiple paper-based or electronic systems.


When defining the legal health record in a healthcare entity, it is best practice to
establish a policy statement of the legal health record as well as: - ✔️✔️Health Record
Matrix

A subpoena duces tecum compels the recipient to: - ✔️✔️Bring records to a legal
proceeding


What is the implication regarding the confidentiality of incident reports in a legal
proceeding when a staff member documents in the health record that an incident report
was completed about a specific incident - ✔️✔️The data, documents, reports and
information that comprise the formal business records of any healthcare entity that are
to be utilized during legal proceedings

Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure
that they are complying with the HIPAA security rule. What type of network uses a
private tunnel through the internet as a transport medium that will allow the transmission
of ePHI to occur between the coder and the facility securely? - ✔️✔️Virtual private
network

An individual designated as an inpatient coder may have access to an electronic
medical record in order to code the record. Under what access security mechanism is
the3 coder allowed access to the system? - ✔️✔️Role-based

The privacy rule generally requires documentation related to its requirements to be
retained: - ✔️✔️6 Years

Which legal doctrine was established by the Darling v. Charleston Community Hospital
case of 1965? - ✔️✔️Corporate Negligence

, Linda Wallace is being admitted to the hospital. She is presented with a "Notice of
Privacy Practices" In the Notice, it is explained to her that PHI will be used and
disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she
doesn't want her PHI used for those purposes. Of the options listed here, what is the
best course of action? - ✔️✔️The hospital is not required to honor her wishes in this
situation, as the Notice of Privacy Practices is informational only.

St Joseph Hospital has a psychiatric service on the sixth floor. A 31 year old male came
to the HIM department and requested to see a copy of his health record. he told the3
clerk he was a patient of Dr. Schmidt, as psychiatrist, and had been on the sixth floor of
St. Joseph's for the last two months. These records are not psychotherapy notes. The
best course of action for you to take as the HIM director is: - ✔️✔️Allow the patient to
access his record if, after contacting his physician, his physician does not feel it will be
harmful to the patient.

You are a member of the hospital's health information management committee. The
committee has created a HIPAA compliant authorization form. Which of the following
items does the privacy rule require for the form? - ✔️✔️Identification of the person or
entity authorized to receive PHI

What is the implication regarding the confidentiality of incident reports in legal
proceedings when a staff member documents in the health record that an incident
report was completed about a specific incident? - ✔️✔️The incident report cannot be
discovered even though it is mentioned in a discoverable document.

The security rule leaves the methods for conducting the security risk analysis to
discretion of the healthcare entity. The first consideration for a healthcare facility should
be: - ✔️✔️Its own characteristics and environment

Addressable security rule implementation specifications: - ✔️✔️Should be implemented
unless a healthcare entity determines that the specification is not reasonable and
appropriate and documents their reasoning.

In order for health information exchange participants to search for health records on
each of the other systems using patient indexing and identification software, the
systems must be linked by an - ✔️✔️Record Locator Service (RLS)

A possible justification for building an information system in house rather than
purchasing one from a vendor is that: - ✔️✔️The facility has development teams they
do not want to give up

Community Memorial Hospital had 25 inpatient deaths, including newborns, during the
month of June. The hospital had a total of 500 discharges for the same period, including
deaths of adults, children, and newborns. The hospital's gross death rate for the month
of June was: - ✔️✔️5%

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