RHIA Exam Prep Questions and Answers Graded A+

RHIA Exam Prep Questions and Answers Graded A+ What term is used in reference to objective descriptions of processes, procedures, people, and other observable objects and activities? ✔✔Data Which of the following pro ...

RHIA Exam Prep Questions and Answers Graded A+ What term is used in reference to objective descriptions of processes, procedures, people, and other observable objects and activities? ✔✔Data Which of the following processes is an ancillary function of the health record? ✔✔Biomedical Research What term is used in reference to electronically accessed information that provides physicians with pertinent health information beyond the health record itself? ✔✔Clinical Practice Guidelines To which of the following authorities do hospitals report vital statistics? ✔✔National Vital Statistics System An attempt to contain hospital inpatient costs and improve quality by restructuring services is called: ✔✔Patient-focused care What organization was established in 1847 to represent the interests of physicians across the United States? ✔✔American Medical Association Today, to practice medicine, medical school students must pass a test before they can obtain a: ✔✔License For healthcare organizations, this modern process began with the adoption of the Minimum Standards: ✔✔Accreditation Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? ✔✔Credentialing Which of the following is a mechanism that records and examines activity in information systems? ✔✔Audit controls Which of the following is the goal of quantitative analysis performed by HIM professionals? ✔✔Identifying deficiencies early so they can be completed What are LONIC codes used for? ✔✔Identifying test results While the focus of inpatient data collection is on the principle diagnosis, the focus of outpatient data collection is on the: ✔✔Reason for encounter The inpatient data set incorporated into federal law and required for Medicare reporting is the: ✔✔Uniform Hospital Discharge Data Set In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? ✔✔X12N This 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 LTCH. ✔✔Care Plan Which of the following is a component of the Resident Assessment Instrument? ✔✔A standard Minimum Data Set Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? ✔✔Nurse working on the unit where the patient is located Who is responsible for ensuring the quality of health record documentation? ✔✔Provider Of the following, what is the most likely to happen to the health records of a physician's patient when a physician leaves an office practice? ✔✔It will be retained by the practice Which health record format is arranged in chronological order with documentation from various sources intermingled? ✔✔Electronic Staff disagreements within the health record should be: ✔✔Avoided Mrs. Bolton is an angry patient who resents her physicians "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 The___is/are used to complete comprehensive assessments and collect information for the Minimum Data Set for Long-term Care (MDS). ✔✔Resident Assessment Instrument One technology used for computer-assisted coding is: ✔✔Natural language processing A barrier to effective computer-assisted coding is the: ✔✔Poor quality of documentation According to the UHDDS definition, ethnicity should be recorded on a patient record as: ✔✔Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown A coding supervisor checks coding quality each month by having two or more coders code the same set of records and then comparing the results. This process addresses the data quality element of: ✔✔Reliability A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is: ✔✔Continuity of Care Record A consumer interested in comparing the performance of health plans should review data from: ✔✔HEDIS Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and: ✔✔CMS A computer software program that supports a coder in assigning correct codes is called a(n): ✔✔Encoder Diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? ✔✔Inpatient Patient has HIV with disseminated candidiasis; what is the correct code assignment? ✔✔042, 112.5 A 65 year old woman was admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? ✔✔038.11, 562.11