RHIT PRACTICE EXAM 1 - 150 QUESTIONS 2023 LATEST UPDATE

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the s ...

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? a. CARF b. DEEDS c. UACDS d. UHDDS d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient. Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: a. Content and structure standards b. Security standard c. Transaction standards d. Vocabulary standards d. Vocabulary standards Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field, such as to provide consistent descriptions of medical terms for an individual's condition in the health record. Patient care managers use the data documented in the health record to: a. Determine the extent and effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care b. Evaluate patterns and trends of patient care Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place. At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: a. Data comprehensiveness b. Data consistency c. Data currency d. Data granularity b. Data consistency Consistency means ensuring the patient data is reliable and the same across the entire patient encounter. In other words, patient data within the record should be the same and should not contradict other data also in the patient record. A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record a. Vital signs record The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information. Which of the following is a key characteristic of the problem-oriented health record? a. Allows all providers to document in the health record b. Uses laboratory reports and other diagnostic tools to determine health problems c. Provides electronic documentation in the health record d. Uses an itemized list of the patient's past and present health problems d. Uses an itemized list of the patient's past and present health problems The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. Which of the following is true regarding the reporting of communicable diseases? a. They must be reported by the patient to the health department. b. The diseases to be reported are established by state law. c. The diseases to be reported are established by HIPAA. d. They are never reported because it would violate the patient's privacy. b. The diseases to be reported are established by state law. All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department. A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to get their input d. Contact CMS to determine what data sets are required to be collected b. Identify data content requirements for all areas of the organization Data content standards allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes. A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports c. Medication administration record and clinical laboratory reports Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed. Which of the following is considered the authoritative resource in locating a health record? a. Disease index b. Master patient index c. Patient directory d. Patient registry b. Master patient index (MPI) The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information. The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a: a. Data chargemaster report b. Data dictionary c. Database management system d. Data map d. Data map Data mapping is a process that allows for connections between two systems. For example, mapping two different coding systems to show the equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose. A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations? a. Consultation b. Medical history c. Physical examination d. Progress notes a. Consultation The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record. The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration a. Laboratory As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected. This creates new challenges for organizations because merge functionality could be different in each system or module, which in turn creates data redundancy. When duplicates are identified, the department managers need to be notified. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare. What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? a. Risk management analysis b. Qualitative analysis c. Gap analysis d. Document management analysis c. Gap analysis The gap analysis process compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis. Once complete, the HIM professional would analyze the data and develop a plan for correction.