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RHIA Exam | 202 5 Questions & Answers
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An audit trail is a good tool for which of the following? - ✔✔Reconstructing electronic events The kids foundation related to children's hospital is mailing fundraising information to the families of all patients who have been treated at children's in the past three years. based on the facts given: - ✔✔children's hospital must have notified the patients or patients guardians of this disclosure in the notice of privacy practices A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes: - ✔✔Spoliation A breach occurs when unsecured protected health information is accessed or released. The secretary of HHS and local media must be notified if this threshold of patient records breached has been met or exceeded - ✔✔ 500 The security rule leaves the method for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be - ✔✔its own characteristics and environment Mary Smith 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? - ✔✔DEEDS- Data Elements for ER Department 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
The 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. 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 Which of the following statements does not pertain to paper-based health records? - ✔✔They have a built in access control mechanism. A number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year (for ex 03 - 0001 ) is a _ number - ✔✔Accession Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking? - ✔✔Reliability In ICD 10 CM this note means "not coded here"? - ✔✔Excludes 1 When an entity relational diagram is implemented as a relational database, an entity will become an: - ✔✔Table 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 Under what access security mechanism would an individual be allowed access to ePHI if he or she has a proper login and password, belongs to a specified group, and his or her workstation is located in a specific place within the facility? - ✔✔Context-based Which of the following is a rule established by an administrative agency of government? - ✔✔Regulation
The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: - ✔✔Physician Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, Susan is a - ✔✔Workforce member Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremys medical information is: - ✔✔Not protected by the NPP because it is part of a personnel record If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: - ✔✔Comply with the patients request and keep the information private (omnibus rule) The Person or entity authentication standard requires methods for verifying that a person is who he or she claims to be. Any of the following meets this standard except: - ✔✔Unit level password 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: - ✔✔Health record matrix 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 residents care? - ✔✔Minimum Data Set Which of the following is an example an example of a M:M relationship? - ✔✔Patients to consulting physicians Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of potential breach of: - ✔✔Authorship integrity
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 A clinic has a contract with the city government to perform all new employee physicals and work injury evaluations. Is it appropriate that a patients family history of cancer be reported to the employer? - ✔✔Yes, unless the employer has allowed for such exclusion. Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician? - ✔✔Privileged communication 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 the coder allowed access to the system? - ✔✔Role-based The privacy rule generally requires documentation related to its requirements to be retained: - ✔✔ 6 years Mrs Davis is preparing to undergo hernia repair surgery at Deconess Hospital. Select the best statement of the following options. - ✔✔The surgeon should obtain Mrs. Davis informed consent Which legal doctrine was established by the Darling v. Charleston Community hospital case of 1965? - ✔✔Corporate negligence Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers? - ✔✔National Practitioner Data Bank Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room. - ✔✔Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record.
As a preliminary step in designing an IS strategy, it is important for the steering committee to conduct a scan of the external environment and to: - ✔✔Conduct an internal environment assessment If an analyst wishes to determine the root cause of claim denials during June via a random sample, what is the sampling unit? - ✔✔Claims In which stage of the system life cycle would data be collected from system users regarding their needs?
- ✔✔Analysis What architectural model of health information exchange allows participants to access data in point to point exchange? - ✔✔Federated- inconsistent databases Which of the following represents the correct sequence from low to high of levels of interoperability? - ✔✔Basic, functional, semantic There were 25 inpatient deaths, including newborns, at Community Memorial Hospital during the month of June. The hospital performed five autopsies during the same period. The gross autopsy rate for the hospital for June was: - ✔✔ 20 % ( 5 / 25 = 0. 2 * 100 ) In purchasing an EHR system from a vendor, what does due diligence refer to? - ✔✔Checking references The MPI includes which of the following? - ✔✔Patients date of birth, gender, and health record number The director of the health information department wanted to determine the level of the physicians satisfaction with the departments services. The director surveyed the physicians who came to the department. What type of sample is this? - ✔✔Convenience Working with the healthcare entity's integration team to ensure that ADT interfaces are properly built and tested is the responsibility of the: - ✔✔MPI Manager
In which of the following examples does the gender of the patient constitute information rather than a data element? - ✔✔In a study comparing the incidence of myocardial infarctions in black males as compared to white females The HIPAA methods titled Expert Determination and Safe Harbor are ways in which the following can be achieved legally - ✔✔Deidentification large hospital is planning for an EHR but wants to ensure it has adequate source systems in place to support it. Each of the ancillary departments has a separate information system, and each has claimed that the product is the best on the market and that the vendor has promised the system will interface with any EHR on the market. Identify the PM mistake in this situation - ✔✔Lack of sponsorship An HIM professional who accurately reports HIV status of an audit that indicates health problems meets the ethical standards for: - ✔✔Public health A distance learning method in which groups of employees in multiple classroom locations may listen to and see the material presented at the same time via satellite or telephone is called: - ✔✔Videoconferencing As an EHR implementation project proceeds, additional hospital departments add requirements for the system, and the project becomes more complex. This is known as - ✔✔Scope creep Fifty percent of our HIM staff have a nationally recognized credential. This is an example of what type of indicator? - ✔✔System Based on the financial data listed what was Triads total net assets before posting net income for the year? - ✔✔(assets-liability=net assets) (cash+A/R+building+land)-(A/R+mortgage)= 1 , 500 , 000 Based on the financial data, what was Triads net income? - ✔✔Revenue - Expenses 25000000 - 2250000 = 250 ,0 00
The facilities Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding audit review should be performed? - ✔✔Focused audit A polyp was removed from a patients colon during a colonoscopy procedure. The physician and pathologist document the polyp as probable adenocarcinoma of the colon. Which of the following actions should the coding professional take to code this encounter? - ✔✔Code "polyp" All of the following are goals for a clinical documentation improvement program except - ✔✔Preventing billing for bundled services What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals? - ✔✔State licensure agencies Most facilities begin counting days in accounts receivable at which of the following times? - ✔✔Date the claim drops Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for - ✔✔Spouses or widowers of veterans meeting specific criteria Which of the following accreditation categories would the JC assign to a hospital that did not meet all of the standards at the time of initial on site survey, had a level of standards in noncompliance, had requirements for improvements (RFIs) in excess of the published level for a year and subsequently underwent an additional onsite follow-up survey? - ✔✔Contingent accrediation Which of the following lists contains only entities that have roles in the various Medicare improper payment review processes? - ✔✔MAC (Medicare Audit Contactor), RAC (Recovery Audit Contractors), and QIO (Quality improvement Organization) Physician normal charge $ 340 Medicare fee schedule $ 300 Patient has met his deductible - ✔✔$ 240 (8 0 % of 300 )
What is the benefit of comparing the coding assigned by coders to the coding that appears on the claim?
- ✔✔May find claim generation issues that cannot be found in other ways Which of the following is not true of a PHR? - ✔✔It will replace the legal records of providers How are hospital compare measures used by CMS - ✔✔Hospitals that report all measures receive the full payment update Technology that electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print stream originated is called - ✔✔Computer output laser disk (COLD) technology What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document? - ✔✔Digital signature It is impossible to have health information interoperability or health information exchange without the following: - ✔✔Complete, publicity available standards The JC and CMS identify core measures that provide an indication of a healthcare facility's performance. Some of the core measure data sets include which of the following? - ✔✔Pneumonia, congestive heart failure, and myocardial infarction Medical identity thefts are situations in which the following occurs: - ✔✔When demographic and financial information is used to acquire medical services The technology commonly utilized for automated claims processing (sending bills directly to third party payers) is: - ✔✔Electronic data interchange Which of the following healthcare entities mission is to reduce medicare improper payments through detection and collection of overpayments, identification, identification of underpayments, and implementation of actions that will prevent future improper payments? - ✔✔Recovery audit contractor
Which health record format is arranged in chronological order with documentation from various sources intermingled? - ✔✔Integrated To complete a comprehensive assessment and collect information for the Minimum Data Set for Long- Term Care, the coordinator must use which of the following? - ✔✔Resident Assessment Instrument A barrier to effective computer-assisted coding is the: - ✔✔Poor quality of documentation A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is the correct root operation? - ✔✔Extirpation Changes and updates to ICD- 9 - CM are managed by the ICD- 9 - CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and who? - ✔✔CMS Who is responsible for ensuring the quality of health record documentation? - ✔✔Provider Which of the following is an example of a 1 : 1 relationship? - ✔✔Patients to hospital beds According to the UHDDS definition, ethnicity should be recorded on a patient record as: - ✔✔Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown Which of the following is a component of the resident assessment instrument? - ✔✔A standard Minimum Data Set (MDS) HIM professionals sometimes monitor the records of current inpatients as well as closed records after the patients have been discharged or transferred. What is this process called? - ✔✔Ongoing record review Which of the following is a graphical display of the relationship between tables in a database? - ✔✔ERD (Entity Relationship Diagram)
Which of the following keywords precedes the listing of variables to be returned from an SQL query? - ✔✔SELECT The process of providing proof of the authorship of health record documentation is called: - ✔✔Authentication Regardless of the healthcare setting, accreditation and Regulatory standards require a separate Healthcare record for each: - ✔✔Individual patient Which of the following is a business role with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? - ✔✔Data definition steward Record consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: - ✔✔Hybrid health records 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: - ✔✔Patient data source What is the traditional paper format for a hospital patient care record? - ✔✔Source-oriented Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is _. - ✔✔UHDDS Quality has several components, including appropriateness, technical excellence, acceptability, and: - ✔✔Accessibility 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 surgeons? - ✔✔Physician
The federal physician self-referral statute is also known as the: - ✔✔Stark law The medical record committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinics practice of calling out a patients full name in the waiting room is not in compliance with HIPAA regulations and that only the patients first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? - ✔✔There is no violation of HIPAA in announcing a patients name, but the committee may want to consider implementing practices that might reduce this practice. A hospital currently includes the patients social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity breach risk and wants the information removed. The physicians and others in the hospital are not cooperating, saying they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? - ✔✔Avoid displaying the number on any document, screen, or data collection field Which of the following is NOT an identifier under the Privacy Rule? - ✔✔Age 75 Which of the following must be reported to the medical examiner? - ✔✔Accidental deaths Which of the following is an administrative safeguard action? - ✔✔Documentation retention guidelines Which of the following does NOT have to be included in a covered entity's notice of privacy practices? - ✔✔Patients signature and email address Health Insurance Portability and Accountability Act states that " used for the purposes of treatment, payment, or healthcare operations foes not require patient authorization to allow providers access, use , or disclosure." However, only the information needed to satisfy the specified purpose can be used or disclosed. - ✔✔Protected health informaiton, minimum necessary Per HITECH, as accounting of disclosure must include disclosures made during the previous: - ✔✔ 3 years
In the case of behavioral healthcare information a healthcare provider may disclose health information on a patient without the patients authorization in which of the following situations? - ✔✔Court order, duty to warn, and involuntary commitment proceeding Covered entities must retain documentation of their security policies for at least: - ✔✔Six years from the date when last in effect According to the Privacy Rule, which of the following is true about authorization? - ✔✔A description of each of the other purposes for which the covered entity is premitted or required to use or disclose PHI without the individuals written consent or authorizaiton Regarding an individuals right of access per HIPAA, a covered entity: - ✔✔May require individuals to make their requests in writing Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true?
- ✔✔The privacy rule minimum necessary requirement does not apply. The confidentiality of incident reports is generally protected in cases when the report is filed in: - ✔✔The hospital risk manager's office Which one of the following has access to personally identifiable data without authorization or subpoena? - ✔✔Public health departments for disease reporting purposes An original goal of HIPAA Administrative Simplification was to standardize - ✔✔The electronic transmission of health data To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? - ✔✔Base charges on the cost of labor and supplies for copying and postage if copies are mailed.
The health record of Kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wants to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: - ✔✔Business records exception Which of the following would be included in an accounting of disclosure? - ✔✔Patient information faxed to the bank Which standard in the Security Rule provides guidance for covered entities to secure laptops and other small portable mobile technologies used within the healthcare facility? - ✔✔Device and media controls standard A valid subpoena duces tecum seeking health records does not have to: - ✔✔Be signed by the plaintiff and defendant Which of the following fundraising solicitations violates HIPAA? - ✔✔One sent to cardiac patients only When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against the: - ✔✔Governments interests in protecting human life A nurse administrator who is not typically on call to cover staffing shortages gets called in over the weekend to staff the emergency department. She does not have access to enter notes since this is not a part of her typical role. In order to meet the intent of the HIPAA Security Rule, the hospital policy should include a: - ✔✔Provision to allow her emergency access to the system Which of the following presents the greatest risk of large-scale health information breaches? - ✔✔Laptop theft Which of the following statements is true with regard to responding to requests from individuals for access to their PHI? - ✔✔A cost-based fee may be charged for making a copy of the PHI. What type of safeguards comprise over half of all the safeguards included in the security rule? - ✔✔Administrative safeguards
What is the most constant threat to health information integrity? - ✔✔Humans In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? - ✔✔X 12 N This data collection tool is used when one needs to gather data on sample observations in order to detect patterns - ✔✔Check Sheet To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of reliability check is called: - ✔✔Interrater Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specific period of time? - ✔✔Prevalence This type of chart is used to focus attention on any variation in a process and helps the team to determine whether that variation is normal or a result of special circumstances. - ✔✔Control chart The process of process of preventing the spread of communicable disease is compliance with applicable legal requirements is performed in this quality management function. - ✔✔Infection control A _ is a range of values, such that the probability of that range covering the true value of a parameter is a set probability or confidence. - ✔✔Confidence interval What is the term for health records maintained by patients or their families? - ✔✔Personal health records A current key function in the health information field whereby data is turned into useful information is: - ✔✔Data analytics In which phase of the Systems Development Life Cycle does initial training on a new information system generally occur? - ✔✔Implementation
