RHIA EXAM PREP 169 Questions with Verified Answers,100% CORRECT

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RHIA EXAM PREP 169 Questions with Verified Answers 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 - CORRECT 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 specific patients*? a. Orginal b. Source c. Protected d. Derived - CORRECT ANSWER d. Derived Which of the following data management domains would be responsible for establishing standards for data retention and storage? a. Data architecture management b. Metadata management c. Data life cycle management d. Master data management - CORRECT ANSWER c. Data life cycle management When a healthcare entity destroys the health records after the acceptable retention period has been met, a *certificate of destruction* is created. How long must the healthcare entity maintain the the certificate of destruction? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER d. Permanently Which of the following processes is an ancillary function of the health record? a. Admitting and registration information b. Billing and reimbursement c. Patient assessment and care planning d. Biomedical research - CORRECT ANSWER d. Biomedical research ***Ancillary function- medical services or supplies that are not provided by acute care hospitals, doctors, or healthcare professionals What are LOINC codes used for? a. Identifying test results b. Reporting test results c. Identifying tests unique to a specific company d. Reporting a code for reimbursement - CORRECT ANSWER a. Identifying test results Logical Observation Identifiers, Names and Codes (LOINC) is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results. While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Activities of daily living c. Discharge diagnosis d. Reason for encounter - CORRECT ANSWER d. Reason for encounter The inpatient data set that has been incorporated into federal law and is *required for Medicare reporting* is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-term Care d. Health Plan Employer Data and Information Set - CORRECT ANSWER b. Uniform Hospital Discharge Data Set Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete - CORRECT ANSWER b. It provides greater detail What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)? a. Face sheet b. Care plan c. Diagnosis plan d. Flow sheet - CORRECT ANSWER b. Care plan ***Care plan is required for patients in a LTCH Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin are all examples of: a. Auto-authentication fields b. Metadata c. Data d. Information fields - CORRECT ANSWER b. Metadata Data content standards are used to: a. Share data in the same way the users interpret data b. Share data in a unique way c. Share data between disparate systems d. Modify data - CORRECT ANSWER a. Share data in the same way the users interpret data A barrier to effective computer-assisted coding is the: a. Resistance of physicians b. Resistance of HIM professionals c. Poor quality of documentation d. Reduction of consistency without human coders - CORRECT ANSWER c. Poor quality of documentation Personal information about patients such as their names, ages, and addresses is considered what type of information? a. Clinical b. Administrative c. Operational d. Accreditation - CORRECT ANSWER b. Administrative To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual - CORRECT ANSWER a. Digital Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professionals - CORRECT ANSWER c. Provider A diagnosis described as "possible," "likely," or "rule out" is reported as if present for which type of patient records? a. Outpatient b. Inpatient c. Emergency room d. Physician office - CORRECT ANSWER b. Inpatient Identify the level in the data model that describes how the data is stored within the database: a. Conceptual data model b. Physical data model c. Logical data model d. Data manipulation language - CORRECT ANSWER b. Physical data model The purpose of the data dictionary is to _________________ definitions and ensure consistency of use. a. Identify b. Standardize c. Create d. Organize - CORRECT ANSWER b. Standardize A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: a. Spreadsheet b. Database c. File d. Data table - CORRECT ANSWER b. Database A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n): a. Implementation plan b. Information technology plan c. Migration plan d. Transition strategy - CORRECT ANSWER c. Migration plan Which of the following is the appropriate method for destroying electronic data? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing 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? a. Chief data officer b. Data definition steward c. Data production steward d. Auditing integrity - CORRECT ANSWER b. Data definition steward Because a health record contains *patient-specific data* and information about a patient that has been documented by the professionals who provided care or service to that patient, it is considered: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source - CORRECT ANSWER c. Primary data source Ensuring that only the most recent report is available for viewing is known as: a. Documentation integrity b. Authorship c. Validation d. Version control - CORRECT ANSWER d. Version control Secondary data source provide information that is _____ available by looking at individual health records. a. Not easily b. Easily c. Often d. Never - CORRECT ANSWER a. Not easily In long-term care, the resident's comprehensive assessment is based on data collected in the: a. UHDDS b. OASIS c. MDS d. HEDIS - CORRECT ANSWER c. MDS ***MDS- federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents The practices or methods that *defend against charges* questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation What tool is used to sort data in a variety of ways to assist in the study of certain data elements? a. Registries b. Indexes c. Clinical trials d. Statistical reports - CORRECT ANSWER b. Indexes A critical step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary - CORRECT ANSWER d. Data dictionary ***Data dictionary- descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology 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): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source - CORRECT ANSWER a. 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: a. The Centers for Medicare and Medicaid Services (CMS) b. The National Committee on Vital and Health Statistics (NCVHS) c. The American National Standards institute (ANSI) d. The National Institute of Health (NIH) - CORRECT ANSWER b. The National Committee on Vital and Health Statistics (NCVHS) Which of the following is a concept designed to help standardize *c*linical *c*ontent for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED - CORRECT ANSWER a. Continuity of care record Which of the following makes the indexing of scanned health records more efficient by *entering metadata automatically*? a. Barcodes b. Backscanning c. OCE d. CPOE - CORRECT ANSWER a. Barcodes Where can you find guidelines for the *retention and destruction* of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards To practice medicine, medical school students must pass a test before they can obtain a: a. Degree b. Licensure c. Residency d. Specialty - CORRECT ANSWER b. Licensure Which of the following is a mechanism that *records and examines activity* in information systems? a. eSignature laws b. Security audits c. Minimum necessary rules d. Access controls - CORRECT ANSWER b. Security audits The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. The care provided to the patient b. Identification of the record as the one subpoenaed c. The qualifications of the treating physicians d. Identification of the standard of care used to treat the patient - CORRECT ANSWER b. Identification of the record as the one subpoenaed Ensuring that data have been modified or accessed only by individuals who are authorized to do so, is a function of data: a. Data integrity b. Data quality c. Data granularity d. Logging functions - CORRECT ANSWER a. Data integrity Mr Martin has asked his physician's office to review a copy of his PHI. His request must be responded to no later than _________ after the request is made. a. 90 days b. 60 days c. 30 days d. 6 weeks - CORRECT ANSWER c. 30 days The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI: a. For as long as it is maintained b. For six years c. Forever d. For 12 months - CORRECT ANSWER a. For as long as it is maintained Under the HIPAA Security Rule, these types of safeguards have to do with *protecting the environment*: a. Administrative b. Physical c. Security d. Technical - CORRECT ANSWER b. Physical Which of the following controls external access to a network? a. Access controls b. Alarms c. Encryption d. Firewall - CORRECT ANSWER d. Firewall Which of the following must be reported to the medical examiner? a. Burns b. Accidental deaths c. Causes of injury d. Morbidity - CORRECT ANSWER b. Accidental deaths A visitor sign-in sheet to a computer area is an example of what type of control? a. Administrative b. Audit c. Facility access d. Workstation - CORRECT ANSWER c. Facility access Which of the following is an *administrative safeguard* action? a. Facility access control b. Documentation retention guidelines c. Maintenance control d. Media reuse - CORRECT ANSWER b. Documentation retention guidelines Authorization management involves: a. The process used to protect the reliability of a database b. Limiting user access to a database c. Allowing unlimited use of the database d. Developing definitions for database elements - CORRECT ANSWER b. Limiting user access to a database Per HITECH an *accounting of disclosures* must include disclosures made during the previous: a. 10 years b. 6 years c. 3 years d. 1 year - CORRECT ANSWER c. 3 years The age of majority in most states is: a. 16 and older b. 17 and older c. 18 and older d. 21 and older - CORRECT ANSWER c. 18 and older Employees in the Hospital Business Office may have legitimate access to patient health information *without patient authorization* based on what HIPAA standard/principle? a. Minimum necessary b. Compound authorization c. Accounting of disclosures d. Preemption - CORRECT ANSWER a. Minimum necessary Generally, policies addressing the confidentiality of quality improvement (QI) committee data (minutes, actions, and so forth) state that this kind of data is: a. Protected from disclosure b. Subject to release with patient authorization c. Generally available to interested parties d. May not be reviewed or released to external reviewers such as the Joint Commission - CORRECT ANSWER a. Protected from disclosure Covered entities must retain documentation of their security policies for at least: a. Five years b. Five years from the date of origination c. Six years from the date when last in effect d. Six years from the date of the last incident - CORRECT ANSWER c. Six years from the date when last in effect Under HIPAA, when is the patient's written authorization required to release their healthcare information? a. For purposes related to treatment b. For purposes related to payment c. For administrative healthcare operations d. For any purpose unrelated to treatment, payment, or healthcare operations - CORRECT ANSWER d. For any purpose unrelated to treatment, payment, or healthcare operations The confidentiality of incident reports is generally protected in cases when the report is filed in: a. The nursing notes b. The patient's health record c. The physician's progress notes d. The hospital risk manager's office - CORRECT ANSWER d. The hospital risk manager's office Which one of the following has access to personally identifiable data *without authorization* or subpoena? a. Law enforcement in a criminal case b. The patient's attorney c. Public health departments for disease reporting purposes d. Workers' compensation for disability claim settlement - CORRECT ANSWER c. Public health departments for disease reporting purposes An original goal of HIPAA Administrative Simplification was to standardize: a. Privacy notices given to patients b. The electronic transmission of health data c. Disclosure of information for treatment purposes d. The definition of PHI - CORRECT ANSWER b. The electronic transmission of health data Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN - CORRECT ANSWER c. Password and swipe card Which of the following is a "public interest and benefit" exception to the authorization requirement? a. Payment b. PHI regarding victims of domestic violence c. Information requested by a patient's attorney d. Treatment - CORRECT ANSWER b. PHI regarding victims of domestic violence Under the Privacy Rule, which of the following must be included in a patient accounting of disclosures? a. State-mandated report of a sexually transmitted disease b. Disclosure pursuant to a patient's signed authorization c. Disclosure necessary to meet the national security or intelligence requirements d. Disclosure for payment purposes - CORRECT ANSWER a. State-mandated report of a sexually transmitted disease What information process must be the legal counsel of Smithville Hospital perform in order to prepare for a lawsuit against the hospital? a. Information governance b. E-discovery c. Transparency d. Enterprise information management - CORRECT ANSWER b. E-discovery What is the most common method for implementing entity authentication? a. Personal identification number b. Biometric identification systems c. Token systems d. Password systems - CORRECT ANSWER d. Password systems A _____ helps a healthcare entity proactively ensure that the information they store and maintain is only being accessed in the *normal course of business*. a. Contingency plan b. Workflow analysis c. Documentation audit d. Security audit - CORRECT ANSWER d. Security audit E discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended with legislation? a. Federal Rules of Evidence b. State Rules of Evidence c. Federal Rules of Civil Procedure d. State Rules of Civil Procedure - CORRECT ANSWER c. Federal Rules of Civil Procedure Which of the following presents the greatest risk of large-scale health information breaches? a. Unlocked rooms b. Computer monitors positioned toward high-traffic areas c. Unattended computer workstations d. Laptop theft - CORRECT ANSWER d. Laptop theft What type of safeguards comprise over half of all the safeguards included in the security rule? a. Physical safeguards b. Technical safeguards c. Administrative safeguards d. Security safeguards - CORRECT ANSWER c. Administrative safeguards What is the most constant threat to health information integrity? a. Natural threats b. Environmental threats c. Internal disaster d. Humans - CORRECT ANSWER d. Humans This data collection tool is used when one needs to gather data on sample observations in order to detect patterns. a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool - CORRECT ANSWER a. 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: a. Precision b. Recheck c. Interrater d. Construct - CORRECT ANSWER c. 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 specified period of time? a. Prevalence b. Incidence c. Frequency d. Distribution - CORRECT ANSWER a. Prevalence This type of chart is used to *focus attention on any variation in the process* and helps the team to determine whether that variation is normal or a result of special circumstances. a. Pareto chart b. Pie chart c. Control chart d. Line chart - CORRECT ANSWER c. Control chart ***Control chart- measures key processes over time Which application uses statistical techniques to *determine the likelihood of certain events occurring together*? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering - CORRECT ANSWER a. Predictive modeling This statistical inference measure both the *strength* of a *relationship* between two variables and the functional relationship between them. a. Correlation b. T-test c. Simple linear regression d. Standard deviation - CORRECT ANSWER c. Simple linear regression This type of data display tool is used to illustrate *frequency distributions* of *continuous variables*, such as *age and length of stay (LOS)* a. Bar graph b. Histogram c. Pie chart d. Scatter diagram - CORRECT ANSWER b. Histogram How long should the master patient index be maintained? a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently - CORRECT ANSWER d. Permanently A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the: a. Mean b. Mode c. Standard deviation d. Standard variance - CORRECT ANSWER c. Standard deviation A current key function in the health information field whereby *data is turned into useful information* is: a. Data mining b. Decision analysis c. Clinical decision support d. Data analytics - CORRECT ANSWER d. Data analytics What tern is used for a *centralized database* that captures, sorts, and processes patient data and then sends it back to the user? a. Clinical data repository b. Data exchange standard c. Central processor d. Digital system - CORRECT ANSWER a. Clinical data repository The _____ is a standardized assessment of *consumer perspectives* regarding healthcare access and quality in hospitals. a. HCAHPS b. CG-CAHPS c. AHRQ-CAHPS d. ONC-CAHPS - CORRECT ANSWER a. HCAHPS Hospital Consumer Assessment of Healthcare Providers The Administrative Simplification portion of Title II of HIPAA addresses which of the following? a. Creating standardized forms for release of information throughout the industry b. Computer memory requirements for health plans maintaining patient health information c. Security regulations for personal health records d. Uniform standards for transaction and code sets - CORRECT ANSWER d. Uniform standards for transaction and code sets A ____ is a *range of values*, such that the probability of that range covering the true value of a parameter is a set of probability or confidence. a. Confidence interval b. Hypothesis c. Proportion d. Median - CORRECT ANSWER a. Confidence interval Which index, often considered the *most important resource in a healthcare facility*, is a database of patients within a facility or associated group of facilities? a. Facility-specific index b. Disease index c. Master patient index d. Operation index - CORRECT ANSWER c. Master patient index According to the Medicare Conditions of Participation, how long must health records be retained? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER b. Five years Change management includes: a. Identifying problems b. Being available to listen to staff c. Redesigning processes d. Educating staff on new processes - CORRECT ANSWER b. Being available to listen to staff Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors - CORRECT ANSWER a. Achieving legitimate optimization The purpose of Regional Extension Centers is to: a. Implement meaningful use b. Support providers in adopting EHR with technical assistance c. Develop standards for HI systems d. Provide funding for expanding the adoption of HI technology - CORRECT ANSWER b. Support providers in adopting EHR with technical assistance Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area? a. Serial-unit filing system b. Serial filing system c. Unit filing system d. Terminal-digit filing system - CORRECT ANSWER d. Terminal-digit filing system Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards Covered entities must retain documentation of their security policies for at least: a. Five years b. Five years from the date of origination c. Six years from the date when last in effect d. Six years from the date of the last incident - CORRECT ANSWER c. Six years from the date when last in effect In addition to bar codes on medical record documents, what other forms of recognition characteristics enhance the accuracy of forms indexing features? a. Access controls b. COLD c. OCR d. Workflow - CORRECT ANSWER c. OCR ***OCR (Optical Character Recognition) **The capability to retrieve documents from an electronic document management system (EDMS) is determined by the underlying technology used to store the documents Which of the following requires financial institutions to develop written medical identity theft programs? a. HIPAA Security Rule b. HITECH Act c. Fair and Accurate Credit Transactions Act d. HIPAA Privacy and Security Rule - CORRECT ANSWER c. Fair and Accurate Credit Transactions Act The probability of making a Type I error based on a particular set of data is called the _____. a. Sampling value b. Hypothesis test c. A-probability d. P-value - CORRECT ANSWER d. P-value A database will be created solely for use in a research study that is being conducted. Which of the following is best suited for this scenario? a. Relational database model b. Data repository c. Data mart d. Data warehouse - CORRECT ANSWER c. Data mart ***Data mart- a subset of the data warehouse designed for a single purpose or specialized use In which type of health information exchange architectural model does the entity operate much like an application service provider (ASP) or bank vault? a. Consolidated b. Federated-consistent databases c. Federated-inconsistent databases d. Switch - CORRECT ANSWER b. Federated-consistent databases ***Federated-consistent databases- very similar to the consolidated architecture in which the data repository is partitioned but centrally managed This type of data display tool is used to illustrate *frequency distributions of continuous variables*, such as age or length of stay (LOS). a. Bar graph b. Histogram c. Pie chart d. Scatter diagram - CORRECT ANSWER b. Histogram The practices or methods that defend against charges questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation ***Data nonrepudiation- the methods by which the data are maintained in an accurate form after their creation, free of unauthorized changes, modifications, updates, or similar changes Which of the following are technologies and methodologies for rendering protected health information unstable, unreadable, or indecipherable to unauthorized individuals as a method to prevent a breach of PHI? a. Encryption and destruction b. Recovery and encryption c. Destruction and redundancy d. Interoperability and recovery - CORRECT ANSWER a. Encryption and destruction If parties to a contract agree to hold each other harmless for each other's actions or inactions, this is referred to as a(n): a. Indemnification b. Liability c. Offer d. Warranty - CORRECT ANSWER a. Indemnification Charges for items that must be *reported separately* but are *used together*, such as interventional radiology imaging and injection procedures are called: a. Insurance code mappings b. Charge codes c. Exploding charges d. Revenue Codes - CORRECT ANSWER c. Exploding charges What process must Colin, the HIM operations manager, perform to ensure that all patient information is contained within the correct electronic file in the EHR? a. Data modeling b. Data mapping c. Data audit d. Data architecture - CORRECT ANSWER c. Data audit ***Data audit- an organizational procedure for monitoring the quality of data by analyzing reports for anomalies, inaccuracies, and missing data Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation? a. The record is not in compliance because the physical examination must be completed within 24 hours of admission b. The record is not in compliance because the physical examination must be completed within 48 hours of admission c. The record is in compliance because the physical examination must be completed within 48 hours d. The record is in compliance because the physical examination was completed within 72 hours of admission - CORRECT ANSWER a. The record is not in compliance because the physical examination must be completed *within 24 hours of admission* A strategy can be a useful too because it: a. Provides a record of progress toward goals b. Provides a visual framework for integrating strategies c. Enables others to better understand the vision underlying change d. Enables assignment of essential resources to executing the plan - CORRECT ANSWER b. Provides a visual framework for integrating strategies Which of the following statements describes a critical skill for a strategic manager? a. Ability to change direction quickly b. Ability to deliver results on budget c. Ability to envision relationships between trends and opportunities d. Ability to design jobs and match peoples' skills to them - CORRECT ANSWER c. Ability to envision relationships between trends and opportunities A coding service had 400 discharges records to code in March. The service coded 200 within 3 days, 100 within 5 days, 50 within 8 days, and 50 within 10 days. The average turnaround time (TAT) for coding in March was: a. 3 days b. 5 days c. 6.5 days d. 9 days - CORRECT ANSWER b. 5 days ***TAT calculation: (200x3)+(100x5)+(50x8)/400= 5 days 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? a. Chief data officer b. Data definition steward c. Data production steward d. Subject matter expert - CORRECT ANSWER b. Data definition steward 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? a. Excision b. Repair c. Resection d. Destruction - CORRECT ANSWER a. Excision This statistical inference measures both the strength of a relationship between two variables and the functional relationship between them. a. Correlation b. T-test c. Simple linear regression d. Standard deviation - CORRECT ANSWER c. Simple linear regression Which of the following is used to reconcile accounts in the patient accounting department? a. Explanation of benefits b. Medicare code editor c. Preauthorization form d. Fee schedule - CORRECT ANSWER a. Explanation of benefits It is the year 201X. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? a. Conversion factor b. RVU c. GPCI d. Weighted discount - CORRECT ANSWER a. Conversion factor ***Conversion factor- an across-the-board multiplier that sets the allowance for the relative values (a constant) A quality data review that is based on specific problems *after an initial baseline review* that has been completed in a hospital is called a(n): a. Focused inpatient review b. Compliance initiative c. Internal audit d. Concurrent review - CORRECT ANSWER a. Focused inpatient review Which type of architecture has *one powerful central computer* that performs all processing and storage functions while sending and receiving data *to or from various terminals and printers*? a. Client or server b. Mainframe computer c. Super computer d. Web-based - CORRECT ANSWER b. Mainframe computer ***Mainframe computer- use a single large computer with many terminals directly connected to it and sharing the resources of the single computer When describing the typical length of stay for patients admitted for congestive heart failure, which is the most appropriate measure of *central tendency* when there are a number of long stay outliers? a. Minimum b. Mean c. Median d. Mode - CORRECT ANSWER c. Median With what agency may patients file a complaint if they suspect medical identify theft violations? a. Internal Revenue Service b. Office of Civil Rights c. Centers for Medicare and Medicaid Services d. Federal Trade Commission - CORRECT ANSWER d. Federal Trade Commission The health record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wants to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: a. Admissibility exception b. Discovery exception c. Direct evidence exception d. Business records exception - CORRECT ANSWER d. Business records exception For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - CORRECT ANSWER a. Structured data Which of the following items are packaged under the Medicare hospital outpatient prospective payment system (OPPS)? a. Recovery room and medical visits b. Medical visits and supplies (other than pass-through) c. Anesthesia and ambulance services d. Supplies (other than pass-through) and recovery room - CORRECT ANSWER d. Supplies (other than pass-through) and recovery room ***Under Medicare hospital outpatient prospective payment system (OPPS), services such as *recovery room, supplies (other than pass-through), and anesthesia* are included in this reimbursement method Which of the following is an administrative safeguard action? a. Facility access control b. Documentation retention guidelines c. Maintenance record d. Media reuse - CORRECT ANSWER b. Documentation retention guidelines ***Administrative safeguards- policies and procedures and documentation retention to *manage the selection, development, implementation, and maintenance of security measures* to safeguard ePHI and manage the conduct of the covered entities or business associates' workforce Which of the following elements is found in a charge description master? a. ICD-10-CM code b. Procedure or service charge c. Patient disposition d. Procedural service date - CORRECT ANSWER b. Procedure or service charge ***Charge description master contains elements such as- department and item number, item description, revenue code, HCPCS code, price, and activity status If a health plan analyst wanted to determine if the readmissions rates for two hospitals were statistically different, what is the null hypothesis? a. The readmission rates are not equal b. The readmission rates are equal c. The readmission rate for one hospital is larger than the other d. The readmission rate for one hospital is smaller than the other - CORRECT ANSWER b. The readmission rates are equal 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: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source - CORRECT ANSWER c. Primary data source One of the most common issues that healthcare organizations fail to do well in the strategic process is: a. Develop a vision b. Develop strategies c. Execute the implementation plan d. Communicate the plan - CORRECT ANSWER c. Execute the implementation plan This type of chart is used to focus attention on any variation in the process and helps the team to determine whether that variation is normal or a result of special circumstances: a. Pareto chart b. Pie chart c. Control chart d. Line chart - CORRECT ANSWER c. Control chart This EHR implementation strategy, virtually every nursing unit, department, clinic, or other organizational unit *goes live at the same time with a given component of the EHR. a. Phased roll-out b. Big bang roll-out c. Pilot d. Straight turnover - CORRECT ANSWER b. Big bang roll-out To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? a. Brain injury b. Chronic myelogenous leukemia c. Acute myocardial infarction d. Cancer - CORRECT ANSWER a. Brain injury ***Inpatient rehabilitation facility (IRF)- must have an inpatient population in which at least 60% of the patients required intensive rehabilitation services in one of the 13 conditions: -stroke -spinal cord injury -congenital deformity -amputation -major multiple trauma -fracture of femur -brain injury -neurological disorders -burns -active polyarticular rheumatoid arthritis -systemic vascuitides -severe or advanced osteo-arthritid -knee or hip replacement A healthcare entity remains committed to purchasing a vendor's product, which the entity finds solid in its financial and administrative applications but weaker in clinical applications. Which is the term for this strategy? a. Bridge b. Best-of-fit c. Best-of-breed d. Legacy - CORRECT ANSWER b. Best-of-fit ***Many organizations find their best-of-fit financial or administrative and operational system vendor is not as strong in EHR as they would desire ***Best-of-breed organizations find it difficult and costly to sustain this approach Which one of the following is an example of a clinical information system? a. Laboratory information system b. Human resource management system c. Patient registration system d. Staff management system - CORRECT ANSWER a. Laboratory information system ***Clinical information systems- contain primarily clinical or health-related data that are used to diagnose, treat, monitor, and manage patient care The name of the government agency that has led the development of basic data sets for health records and computer databases is the: a. The Centers for Medicare and Medicaid Services b. The National Committee on Vital and Health Statistics c. The American National Standards Institute d. The National Institute of Health - CORRECT ANSWER b. The National Committee on Vital and Health Statistics (NCVHS) Data mining is a process that involves which of the following? a. Using reports to measure outcomes b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns c. Producing summary reports for management to run the daily activities of the healthcare entity d. Producing detailed reports to track productivity - CORRECT ANSWER b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns ***In data mining, the analyst performs exploratory data analysis to determine trends and identify patterns in the data set Which of the following is an organization that develops standards related to the interoperability of health information technology? a.National Health Information Network b. National Committee on Vital and Health Statistics c. Health Level 7 d. EHR Collaborative - CORRECT ANSWER c. Health Level 7 In a typical acute-care setting, aging of accounts reports are monitored in which revenue cycle area? a. Preclaims submission b. Claims processing c. Accounts receivable d. Claims reconciliation or collections - CORRECT ANSWER c. Accounts receivable A clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid: a. NCCI edits b. Upcoding c. Coding without a completed face sheet d. Assumption coding - CORRECT ANSWER d. Assumption coding What kind of planning addresses long-term needs and sets comprehensive plans of action? a. Tactical b. Operational c. Strategic d. Administrative - CORRECT ANSWER c. Strategic The technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: a. Administrative safeguards b. Technical safeguards c. Physical safeguards d. Integrity controls - CORRECT ANSWER b. Technical safeguards Employees in the Hospital Business Office may have legitimate access to patient health information without patient authorization based on what HIPAA standard/principle? a. Minimum necessary b. Compound authorization c. Accounting of disclosures d. Preemption - CORRECT ANSWER a. Minimum necessary Which financial statement reflects the extent to which a healthcare entity's revenues exceed it expenses? a. Balance sheet b. Statement of cash flows c. Statement of retained earnings d. Income statement - CORRECT ANSWER d. Income statement Personal information about patients such as their names, ages, and addresses is considered what type of information? a.Clinical b. Administrative c. Operational d. Accreditation - CORRECT ANSWER b. Administrative A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary - CORRECT ANSWER d. Data dictionary Which application users statistical techniques to determine the likelihood of certain events occurring together? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering - CORRECT ANSWER a. Predictive modeling The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on: a. Query rate b. Principal diagnosis c. Case-mix index d. Record review rate - CORRECT ANSWER c. Case-mix index Which of the following is a concept designed to help standardize clinical content for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED - CORRECT ANSWER a. Continuity of care record ***Continuity of care record- allows documentation of care delivery from one healthcare experience to another A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirement is generally called an LHR _____. a. Maintenance plan b. Management plan c. Attribute plan d. Strategic plan - CORRECT ANSWER a. Maintenance plan A protocol to pass data from the system of one vendor to the information system off another vendor is called: a. OLAP b. Integration c. TCP/IP d. Interface - CORRECT ANSWER d. Interface The federal physician self-referral statute is also known as the: a. Sherman Anti-Trust Act b. Deficit Reduction Act c. False Claim Act d. Stark Law - CORRECT ANSWER d. Stark Law 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? a. Original b. Source c. Protected d. Derived - CORRECT ANSWER d. Derived To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of reliability check is called: a. Precision b. Recheck c. Interrater d. Construct - CORRECT ANSWER c. Interrater Which of the following is required in a risk analysis according to the Security Rule? a. Determine the likelihood of threat occurrence and the potential impact b. Focus on improved efficiency c. Implement successful system migration and interoperability d. Develop a sustainable business plan - CORRECT ANSWER a. Determine the likelihood of threat occurrence and the potential impact For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the a. Interdisciplinary patient care plan b. Discharge summary c. Transfer record d. Problem list - CORRECT ANSWER d. Problem list As part of a quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the: A. prenatal record. B. labor and delivery record. C. postpartum record. D. discharge summary. - CORRECT ANSWER A. prenatal record. As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman: a. A new H&P is required for every inpatient admissiond b. That you apologize for not noticing the H&P she provided c. The H&P is acceptable as long as she documents any interval changes d. Joint Commission standards do not allow copies of any kind in the original record - CORRECT ANSWER c. The H&P is acceptable as long as she documents any interval changes Joint Commission requires the attending physician to countersign health record documentation that is entered by: a. Interns or medical students b. Midwives c. Consulting physicians d. Physician partners - CORRECT ANSWER a. Interns or medical students Discharge summary documentation must include: a. A detailed history of the patient b. A note from social services or discharge planning c. Significant findings during hospitalization d. Correct codes for significant procedures - CORRECT ANSWER c. Significant findings during hospitalization The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate: a. Quality of care through the use of pre-established criteria b. Adverse effects and contraindications of drugs utilized during hospitalization c. Potentially compensable events d. Completeness, adequacy, and quality of documentation - CORRECT ANSWER d. Completeness, adequacy, and quality of documentation The foundation for communicating all patient care goals in long-term care settings is the: a. Legal assessment b. Labor and delivery record c. Interdisciplinary patient care plan c. Uniform Hospital Discharge Data Set - CORRECT ANSWER c. Interdisciplinary patient care plan Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages? A. Health Record Committee B. Utilization Review Committee C. Risk Management Committee D. Joint Conference Committee - CORRECT ANSWER A. Health Record Committee As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it. Another step you will need to take is to: a. Authorize access to information collected based on level of data sensitivity b. Prevent all nonclinicians' access to any confidential information in the system c. Establish firewalls to protect aggregate data collected within your facility d. Establish passwords for all customers, both internal and external, who request access to the information in your system - CORRECT ANSWER a. Authorize access to information collected based on level of data sensitivity As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that will contribute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for *decision support regarding drug dosages and contraindications*. You think they are ready for a: a. Computer-output-to-laser-disk system b. Electronic medication administration record system c. Electronic document management system d. Computerized provider order-entry system - CORRECT ANSWER d. Computerized provider order-entry system The best example of point-of-care service and documentation is: a. Using an automated tracking system to locate a record b. Using occurrence screens to identify adverse events c. Doctors using voice recognition systems to dictate radiology reports d. Nurses using beside terminals to record vital signs - CORRECT ANSWER d. Nurses using beside terminals to record vital signs Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to: a. placement of hospital logo b. Signature line for authentication c. Use of box design d. Bar code placement - CORRECT ANSWER d. Bar code placement Which of the following is a form or view that is typically seen in the health record of a long-term care patient, but is rarely seen in records of an acute care patient? a. Pharmacy consultation b. Medical consultation c. Physical exam d. Emergency record - CORRECT ANSWER a. Pharmacy consultation As the Data Security Officer for your institution, you plan to implement a log-on process for electronic signing that is LEAST susceptible to improper delegation of use. The method you will recommend is: a. Password assigned by system administrator b. Password assigned by user c. Biometrics-based identifier d. Encryption - CORRECT ANSWER c. Biometrics-based identifier In an acute care hospital, a complete history and physical may not be required for a new admission when: a. the patient is readmitted for a similar problem within 1 year b. the patient's stay is less than 24 hours c. the patient has an uneventful course in the hospital d. a legible copy of a recent H&P performed in the attending physician's office is available - CORRECT ANSWER d. a legible copy of a recent H&P performed in the attending physician's office is available You are developing a *complete data dictionary* for your facility. Which fo the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? a. Minimum Data Set b. Uniform Hospital Discharge Data Set c. Conditions of Participation d. Federal Register - CORRECT ANSWER b. Uniform Hospital Discharge Data Set Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should : A. complete a new cancer abstract. B. assign a new accession number. C. update the follow-up file. D. complete a new master index file. - CORRECT ANSWER C. update the follow-up file. In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each resident as defined in the: a. UHDDS b. MDS c. Uniform Clinical Data Set d. Uniform Ambulatory Core Data - CORRECT ANSWER b. MDS You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of *COP regulations*, you expect that a(n) ________ will be added to his health record. a. consultation report b. advance directive c. interval summary d. interdisciplinary care plan - CORRECT ANSWER a. consultation report An example of objective entry in the health record supplied by a health care practitioner is the: a. past medical history b. physical assessment c. chief complaint d. review of systems - CORRECT ANSWER b. physical assessment In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing: a. integrated progress notes b. interdisciplinary treatment plans c. source-oriented records d. SOAP notes - CORRECT ANSWER a. integrated progress notes Which of the following services is LEAST likely to be provided by a facility accredited by CARF? a. chronic pain management b. Palliative care c. Brain injury management d. Vocational evaluation - CORRECT ANSWER b. Palliative care Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff? a. disease index b. procedure index c. master patient index d. physician index - CORRECT ANSWER d. physician index - CORRECT ANSWER [Show More]

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