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RHIA domain 1
Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and: (no 113) - ✔CMS A patient born with a neural tube defect would be included in which type of registry? (no.
✔Birth Defects Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: (no. 152) - ✔Hybrid health records Verbal orders by telephone or in person are discouraged. For cases in which verbal orders are necessary, which of the following is the most effective method for lessening the risk of miscommunication? (no. 71) - ✔The person receiving the order should read it back to ensure the order is correct. 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? (no. 27) - ✔Extirpation A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n): (no. 154) - ✔Immunization registry Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called: (no. 147) - ✔Delinquent records When an entity relational diagram is implemented as a relational database, an entity will become a(n): (no. 73) - ✔Table 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 a: (no. 11) - ✔Health record matrix Which of the following processes is an ancillary function of the health record? (no. 95) - ✔Biomedical research The inpatient data set incorporated into federal law and required for Medicare reporting is the: (no. 98) - ✔Uniform Hospital Discharge Data Set The insured party's member identification number is an example of this type of data: (no. 20) - ✔Financial data It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. (no. 133) - ✔Policies and Procedures A computer software program that supports a coder in assigning correct codes is called a(n): (no. 114) -
✔Encoder This functionality can result in confusion from incessant repetition of irrelevant clinical data. (no. 186) - ✔Copy and Paste A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: (1 in order) - ✔Charting by exception A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: - ✔Abdominal pain Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith's health record? - ✔Data Consistency Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data: - ✔Coded Which of the following is an acceptable means of authenticating a record entry? - ✔The physician personally signs the entry All documentation entered in the health record relating to the patient's diagnosis and treatment are considered this type of data: - ✔Clinical 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) Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a: - ✔Retention program What is the principal function of health records? - ✔Serve as the repository of clinical documentation relevant to the care of individual patients What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records? - ✔Uniform data sets Which of the following materials are required elements in an emergency care record? - ✔Time and means of the patient's arrival, treatment rendered, and instructions at discharge In ICD-10-PCS, what value is used if there is a character that does not apply to a given code? - ✔Z Which of the following is the unique identifier in the relational database patient table? - ✔Patient number
Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this: - ✔Certificate of destruction Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a: - ✔Mask Decision making and authority over data-related matters is known as - ✔Data Governance Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following? - ✔Metadata The data elements in a patient's automated laboratory result are examples of: - ✔Structured data Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication. Abbreviations in the health record: - ✔Should only have one meaning 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 separate and multiple paper-based or electronic systems. Data mapping is used to harmonize data sets or code sets. The code or data set from which the map originates is the: - ✔Source Data that are collected on large populations of individuals and stored in a database without identifying any particular patient individually are referred to as: - ✔Aggregate data Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: - ✔Unstructured clinical information A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? - ✔Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? - ✔Report of history and physical examination Mary Smith, RHIA, has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry? - ✔Data Elements for Emergency Department Systems (DEEDS) Who owns the health records of patients treated in a healthcare facility? - ✔The facility
In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation? - ✔Precision Legally, which of the following is most important in determining the length of time a hospital must retain health records? - ✔Statute of Limitations The health information management (HIM) manager is concerned with a backlog in transcription of surgical reports. The medical staff rules and regulations stipulate that the surgeon should: - ✔Write a detailed postoperative progress note about the procedure performed One member of the medical staff reviewed a patient's history, examined the patient, and wrote findings and recommendations at the request of another member of the medical staff. The resulting medical report that documents the response of the reviewing medical staff member is a: - ✔Consultation report 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 less than ________ hours. - ✔30 days, 24 hours, 48 hours Burning, shredding, pulping, and pulverizing are all acceptable methods in which process? - ✔Destruction of paper-based health records Which of the following would be the best approach in starting a data governance program? - ✔Focus on one or a few small business imperatives A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a: - ✔Longitudinal health record Who is responsible for the content, quality, and signing of the discharge summary? - ✔Attending physician Under which circumstances may an updated entry be added to a patient's health record in place of a complete history and physical? - ✔When the patient is readmitted within 30 days of the initial treatment for the same condition The procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition is the: - ✔Principal procedure An HIM professional who is designing a health record system for a healthcare entity should check ________ to find out how long health records should be retained by the entity. - ✔state and federal law The clinical statement "microscopic sections of the gallbladder reveal a surface lined by tall columnar cells of uniform size and shape" would be documented on which health record form? -
a. 49496, Repair, initial inguinal hernia, full-term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated b. 49501, Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated c. 49507, Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated d. 49521, Repair recurrent inguinal hernia, any age; incarcerated or strangulated - ✔c. 49507, Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated What type of health record policies dictate how long individual health records must remain available for authorized use? - ✔Retention policies One of benefits of this type of data entry is that it is easy to determine if the data are complete. - ✔Structured data What term is used to refer to an organized collection of data that has been stored electronically to facilitate easy access? - ✔Database In which metadata architecture model is all of the healthcare entity's patient health information stored in one system? - ✔Centralized A core data set developed by the American Society for Testing and Materials (ASTM) to communicate a patient's past and current health information as the patient transitions from one care setting to another is: - ✔Continuity of care record The function that includes compiling the pertinent information from the health record, based on predetermined data sets, to enter into a separate database is called: - ✔Abstracting A procedure that attempts to obstruct the blood flow to a malignant tumor would be coded to which root operation in ICD-10-PCS? - ✔Occlusion Bob Jones is considering contractors for his company's medical benefits, and he is reviewing health plans from two different entities. Which of the following databases should he consult to compare the performance of the two health plans? - ✔Healthcare Effectiveness Data and Information Set (HEDIS) In data quality management, the process of translating data into information to be utilized by an application is called: - ✔Analysis A patient has HIV with disseminated candidiasis. What is the correct code assignment? B20 Human immunodeficiency virus [HIV] disease B37.0 Candidal stomatitis Oral thrush B37.7 Candidal sepsisDisseminated candidiasis Systemic candidiasis B37.89 Other sites of candidiasis
Candidal osteomyelitis - ✔B20, B37. What term is used in reference to raw facts generally stored as characters, words, symbols, measurements, or statistics? - ✔Data Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? - ✔Derived What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? - ✔Clinical practice guidelines When a healthcare entity destroys health records after the acceptable retention period has been met, a certificate of destruction is created. How long must the healthcare entity maintain the certificate of destruction? - ✔Permanently A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus A41.89 Other specified sepsis A41.9 Sepsis, unspecified organism B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding R10.9 Unspecified abdominal pain - ✔A41.01, K57. A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.8 Type 1 diabetes mellitus with unspecified complications I96 Gangrene, not elsewhere classified - ✔E10. The patient has a biopsy of the colon followed by a hemicolectomy. In the ICD-10-PCS coding system, which procedure(s) are coded? - ✔Both the biopsy and the hemicolectomy Of the following, what is the most likely to happen to the health records of a physician's patient when that physician leaves an office practice? - ✔It will be retained by the practice The data that describe other data in order to facilitate data quality are found in the: - ✔Data dictionary Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into
✔For regulatory, operational, and financial purposes Personal information about patients such as their names, ages, and addresses is considered what type of information? - ✔Administrative To ensure authentication of data entries, which type of signature is the most secure? - ✔Digital Mrs. Bolton is an angry patient who resents her physician "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is: - ✔Noncompliant and hostile toward staff Who is responsible for ensuring the quality of health record documentation? - ✔Provider Which of the following is an example of a 1:1 relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to clinics d. Patients to hospital beds - ✔d. Patients to hospital beds The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of: - ✔Preventing potential medication errors due to misinterpretation According to the UHDDS definition, ethnicity should be recorded on a patient record as:
- ✔Hispanic, non-Hispanic Which of the following is a component of the resident assessment instrument? - ✔A standard Minimum Data Set (MDS) The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following? - ✔Authorship Which of the following is not an appropriate method for destroying paper-based health records? - ✔Degaussing Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32405, Biopsy, lung or mediastinum, percutaneous needle b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) - ✔b. 37609, Ligation or biopsy, temporal artery A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? - ✔Inpatient
A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code for professional fee reporting? - ✔-24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period The legal health record for disclosure consists of: - ✔The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? - ✔Uniform Ambulatory Care Data Set A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA? - ✔Catheter-associated urinary tract infection Identify the level in the data model that describes how the data is stored within the database: - ✔Physical data model The purpose of the data dictionary is to ________ definitions and ensure consistency of use. - ✔Standardize Which of the following is a graphical display of the relationships between tables in a database? - ✔ERD A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of? - ✔Edit check Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. a. 54401, Insertion of penile prosthesis; inflatable (self-contained) b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir c. 54440, Plastic operation of penis for injury d. 54400, Insertion of penile prosthesis, non-inflatable (semi-rigid) - ✔a. 54401, Insertion of penile prosthesis; inflatable (self-contained) Which of the following keywords precedes the listing of variables to be returned from an SQL query? - ✔SELECT An alteration of the health information by modification, correction, addition, or deletion is known as a(n): - ✔Amendment
b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) c. 33212, Insertion of pacemaker pulse generator only; with existing single lead d. 33222, Relocation of skin pocket for pacemaker - ✔d. 33222, Relocation of skin pocket for pacemaker The statement "All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88" represents a possible case definition for what type of registry? - ✔Trauma registry A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables? - ✔One-to-many Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered: - ✔Primary data source The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called: - ✔Information governance Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use? - ✔UHDDS Ensuring that only the most recent report is available for viewing is known as: - ✔Version control Secondary data sources provide information that is ________ available by looking at individual health records. - ✔not easily In long-term care, the resident's comprehensive assessment is based on data collected in the: - ✔Minimum Data Set (MDS) Which of the following are considered dimensions of data quality? - ✔Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency Appropriate documentation of health record destruction must be maintained permanently no matter how the process is carried out. This documentation usually takes the form of a: - ✔Certificate of destruction What is a primary purpose for documenting and maintaining health records? - ✔Effective communication among caregivers for continuity of care Quality has several components, including appropriateness, technical excellence, ________, and acceptability. - ✔Accessibility
The practices or methods that defend against charges questioning the integrity of the data and documents are called: - ✔Nonrepudiation Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different sur - ✔Physician Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? - ✔Case finding The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure. - ✔Object-oriented database What tool is used to sort data in a variety of ways to assist in the study of certain data elements? - ✔Indexes A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): - ✔Data dictionary Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to: - ✔File the incomplete records with a notation about the physician's death The first deliverable from a legal health record (LHR) definition project is a: - ✔List of LHR stakeholders When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n): - ✔Secondary data source The name of the government agency that has led the development of basic data sets for health records and computer databases is: - ✔The National Committee on Vital and Health Statistics What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met? - ✔Qualitative analysis Which of the following is a concept designed to help standardize clinical content for sharing between providers? - ✔Continuity of care record Which of the following makes the indexing of scanned health records more efficient by entering metadata automatically? - ✔Barcodes A patient had a radical resection of soft tissue sarcoma of the left thigh. In ICD-10-PCS what would the root operation be for this procedure? - ✔Excision A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR ________. - ✔Maintenance plan Reviewing a health record for missing signatures and medical reports is called: -
