RHIA EXAM 25 Questions with Verified Answers,100% CORRECT

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RHIA EXAM 25 Questions with Verified Answers Quantitative analysis - CORRECT ANSWER HIM professionals analyze medical records for any missing reports, forms, or required signatures and deletions. ... Which of the following is not usually a component of acute care patient records? medical history nurse assessment problem list progress notes - CORRECT ANSWER problem list The attending physician is responsible for which of the following types of acute care documentation? consultation report Discharge summary Laboratory report Pathology report - CORRECT ANSWER Discharge summary Which of the following is an example of clinical data? Admitting diagnosis Data and time of admission Insurance information Health record number - CORRECT ANSWER admitting diagnosis A nurse is responsible for which of the following types of acute care documentation? Operative report Medication record Radiology report Therapy assessment - CORRECT ANSWER Medication record The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the _____. Anesthesia report Progress notes Operative report Recovery room report - CORRECT ANSWER Operative report Which type of specialized record includes care provided prior to arrival at a healthcare setting and time and means of arrival Ambulatory care record Emergency care record Ambulatory surgery record Pediatric record - CORRECT ANSWER Emergency care record Documentation standards and guidelines are published by a variety of private and public organizations, including the __________ for the purpose of accreditation - The Joint Commission - American Health Information Management Association - National Committee for Quality Insurance - American Association of Professional Coders - CORRECT ANSWER The Joint Commission Which of the following is true of computer-based records? usually supported by all healthcare providers can be accessed by multiple end users simultaneously has a clear definition and technological standards permits minimal risks to healthcare privacy and security - CORRECT ANSWER can be accessed by multiple end users simultaneously Which of the following represents documentation of the patient's current and past health status? Physical exam Medical history Physician orders Patient consent - CORRECT ANSWER Medical history Which of the following contains the physician's findings based on an examination of the patient? Physical exam Discharge summary Medical history Patient insurance - CORRECT ANSWER Physical exam What is the function of a consultation report? Provides a chronological summary of the patient's medical history and illness Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care Concisely summarizes the patient's treatment and stay in the hospital Documents the physicians instructions to other parties involved in providing care to the patient - CORRECT ANSWER Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care What is the function of physician's orders? - CORRECT ANSWER To document the physician's instructions to other parties involved in providing care to a patient an example of an advance directive? - CORRECT ANSWER Living will In a medical history, which of the following is a detailed chronological description of the development of the patient's illness? - CORRECT ANSWER History of present illness Patient history questionnaires are most often used in: - CORRECT ANSWER Ambulatory care Which of the following may be managed in an electronic document management system (EDMS): - CORRECT ANSWER Document images, email, PACS A critical element of data retrieval planning is designing: - CORRECT ANSWER Screen layout Discrete data may be entered into an EHR via: - CORRECT ANSWER Macro Point and click Voice command Natural language processing: - CORRECT ANSWER Converts narrative information to discrete data A local area network using Internet-based protocols is: - CORRECT ANSWER Ethernet As part of an EHR system selection, due diligence should be done: - CORRECT ANSWER prior to contracting for an EHR product Our team has written a plan that describes what systems will be implemented in what order in our transition to the EHR. We completed our: - CORRECT ANSWER migration path Removing health records from storage area to allow space for more current records is called_____. - CORRECT ANSWER purging records The services provided by HIM departments in acute care hospitals usually include all the following except: - CORRECT ANSWER Medical billing [Show More]

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