RHIA & RHIT

Master or Enterprise patient index - Answer is critical to identifying patients and ensuring proper record linkage The health record consist of - Answer handwritten notes, transcribed reports, electronic data, digital images Continuity of care - Answer is improved by the sharing of patient information between providers Standards and regulations - Answer have a great impact on what is documented in the health record The American College of Surgeons (ACS) - Answer developed t...

Primary responsibility of coder - Answer Ensure quality of coded data Responsible for quality and completion of discharge summary - Answer Attending Physician Data set for px that does not require an overnight stay - Answer Uniform Ambulatory Care Data Set Records not completed within designated timeframe - Answer Delinquent Records Provide information not easily determined from looking at records - Answer Secondary Data Sources Decision-making and authority over data-re...

Legal Health Record - Answer Formal business record to be utilized during legal procedings If privacy issues emerge... - Answer Determine source of problem and issue HIPAA training If patient is unable to sign... - Answer Implied Consent Psychiatric patients may view records if physician determines... - Answer Seeing record is not harmful to their condition or treatment Facility Directory - Answer General Condition Acknowledgement of admission HIPAA's Expert Deter...

Coded Data - Answer Data that has been translated into standard nonmenclature of classification so that it may be aggregated, analyzed & compared Research Data - Answer Data used for the purpose of answering a proposed question or testing a hypothesis. Reference Data - Answer Information that interacts with the care of the individual or with teh healthcare delivery system, such as a formulary, protocol, care plan, clinical alert or reminder Demographic Data - Answer Info used to...

Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the: a.) Admitting physical evaluation record b.) Patient's rights acknowledgement form c.) Release of Information form d.) Transfer Record - Answer D. Transfer Record For further explanation look at page 160...

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Fragmentation d. Release - Answer b. Extirpation ***Taking or cutting out solid matter from a body part Which type of data consists of *factual details* a *aggregated or summarized* from a group of health records that provides *no means to identify...

Lack of Priority - Answer In a project when dependencies aren't set out because of a lack of priority on the tasks Security Risk Analysis - Answer Provides covered entities and business associates with the structural frame work in which to build their HIPPA security plan State Licensure Agencies - Answer Organization that works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals Income Statement - Answer Summarizes the organizati...

A discharge summary must be completed within____days 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 less than ___ - Answer 30 days/24 hours/48 hours systematic random sample - Answer a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly rando...

This committee makes recommendations to the governing board for appoints to the medical staff - Answer executive physicians who deliver most of the medical care in hospitals and who site on committees are - Answer active staff accreditation organization which accredits health information educational programs is - Answer CAHIIM which component, group has ultimate authority and is responsible for providing quality care to patients? - Answer governing board

Authorizations are always required for the use or disclosure of psychotherapy notes except in which of the following situations: - employee and employment-related activities - health insurance carrier -media-related activities -carry out payment, treatment and operations - Answer carry out payment, treatment and operations Steve has submitted a written authorization to request a copy of his medical chart. However, Steve's psychiatrist has determined that access to his PHI might...