RHIA Domain 1Exam 116 Questions with Verified Answers,100% CORRECT

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RHIA Domain 1Exam 116 Questions with Verified Answers Primary responsibility of coder - CORRECT ANSWER Ensure quality of coded data Responsible for quality and completion of discharge summary - ... CORRECT ANSWER Attending Physician Data set for px that does not require an overnight stay - CORRECT ANSWER Uniform Ambulatory Care Data Set Records not completed within designated timeframe - CORRECT ANSWER Delinquent Records Provide information not easily determined from looking at records - CORRECT ANSWER Secondary Data Sources Decision-making and authority over data-related matters - CORRECT ANSWER Data Governance Number assigned according to number of entry into a registry each year - CORRECT ANSWER Accession Number Includes information about trauma cases - CORRECT ANSWER DEEDS Problem-oriented frameworks for assessment after problems have been identified - CORRECT ANSWER Resident Assessment Protocols Snapshot of patient Disease processes Critical paths Clinical pathways - CORRECT ANSWER Care Plan Dimensions of Data Quality - CORRECT ANSWER Relevancy Granularity Timeliness Currency Accuracy Precision Consistency Barrier to computer-assisted coding - CORRECT ANSWER Poor quality of documentation Graphical display of relationships between tables in a database - CORRECT ANSWER ERD Accreditation and regulatory standards require a different record for each - CORRECT ANSWER patient Component of Resident Assessment Instrument - CORRECT ANSWER A standard minimum data set Documenting when and how a record was destroyed - CORRECT ANSWER Certificate of Destruction Before list of elements to be returned from a SQL query - CORRECT ANSWER SELECT Documenting depth and breadth of data in entity requires - CORRECT ANSWER Identifying the needs of all data consumers Document imaging is part of... - CORRECT ANSWER Record creation, capture, or receipt After ERD is implemented, an entity becomes... - CORRECT ANSWER Table Most important aspect of determining record retention - CORRECT ANSWER Statute of Limitations Record that follows a patient's care over time - CORRECT ANSWER Longitudinal Record Data collected on large populations and stored in databases - CORRECT ANSWER Aggregate Data Accessing and reviewing the work of colleagues in the same profession - CORRECT ANSWER Peer Review Mandating display format (ex: xxx-xx-xxxx) - CORRECT ANSWER Mask Contains diagnosis and summary of care already given - CORRECT ANSWER Transfer Record Data related to a patient's diagnosis and treatment - CORRECT ANSWER Clinical Discrepancies between two coders compromise - CORRECT ANSWER Reliability Discharge summary must be completed within - CORRECT ANSWER 30 days Discharge summary for transfers must be completed within - CORRECT ANSWER 24 hours Discharge summaries are not requires for LOS less than - CORRECT ANSWER 48 hours Example of M:M relationship - CORRECT ANSWER Patient to Consulting Physicians Chief Complaint - CORRECT ANSWER Reason for presentation Errors in medical record should not be - CORRECT ANSWER Obliterated Coded - CORRECT ANSWER Grouped into meaningful categories by classification system Retention Program - CORRECT ANSWER Inventory of records Format Location Preservation Period Principal Function of Health Records - CORRECT ANSWER Repository of clinical documentation relevant to patient care Common form of problem-oriented format - CORRECT ANSWER SOAP form of progress notes ER Record - CORRECT ANSWER Time and means of arrival Treatment record Discharge instructions Who owns records? - CORRECT ANSWER Healthcare org Abbreviations - CORRECT ANSWER Should only have one meaning ICD-10-PCS Null Character - CORRECT ANSWER Z Same order in any location - CORRECT ANSWER Universal H&P Exam - CORRECT ANSWER Must be placed in the record before a procedure is performed Compromising Authorship Integrity - CORRECT ANSWER Borrowing records from other sources Displaying past documentation as present Occlusion - CORRECT ANSWER Restricting blood flow Backlog in transcription - CORRECT ANSWER Write a detailed note about procedure Provider examines patient at request of another provider - CORRECT ANSWER Consultation Report In the absence of data dictionary - CORRECT ANSWER Establish data dictionary policy with associated standards Destruction of Paper Records - CORRECT ANSWER Shredding, Pulping, Pulverizing No degaussing No rounding up doses - CORRECT ANSWER Precision Paper records do not have - CORRECT ANSWER Built-in control mechanism No new H&P - CORRECT ANSWER Readmitted within 30 days for same condition Principal Procedure - CORRECT ANSWER Definitive treatment of main condition Vocabulary Standards - CORRECT ANSWER Standardizing medical terminology Analog Data - CORRECT ANSWER Photographic, Film Autoauthentication - CORRECT ANSWER Provider signs statement at all records are improved unless corrections made in time frame Not allowed HIM should check for record retention - CORRECT ANSWER State and federal law Continuity of Care Record - CORRECT ANSWER ASTM, for transitions between settings Not coded here - CORRECT ANSWER Excludes1 Migration Plan - CORRECT ANSWER Steps and process for adopting system Verbal Orders - CORRECT ANSWER Person receiving should read back to ensure accuracy Analysis - CORRECT ANSWER Translating data to info Database - CORRECT ANSWER Organized collection of data stored electronically Centralized - CORRECT ANSWER All patient stored in one system Abstracting - CORRECT ANSWER Compiling info from record into data set HEDIS - CORRECT ANSWER Insurance data set Validity - CORRECT ANSWER Error detection Ancillary - CORRECT ANSWER Biomedical research Diabetes - CORRECT ANSWER Only code diabetes with manifestation If biopsy and -ectomy - CORRECT ANSWER Code both Quantitative Analysis - CORRECT ANSWER identifying deficiencies LOINC - CORRECT ANSWER Identifying test results Auditing Integrity - CORRECT ANSWER Not knowing when modified CMS - CORRECT ANSWER Sits on ICD council with NCHS Inpatient - CORRECT ANSWER Code as if it exists Provider - CORRECT ANSWER Responsible for quality of documentation Authentication - CORRECT ANSWER Proof of authorship Disaster Recovery - CORRECT ANSWER In time of disaster, how do you document CMS Record Retention - CORRECT ANSWER 5 years CPT Codes - CORRECT ANSWER Pick one with or for optiond Degaussing - CORRECT ANSWER Destroying electronic data Information Governance - CORRECT ANSWER Org structures, policies, and procedures with info Standardized Data Sets - CORRECT ANSWER Data can be compared nationally Physician Index - CORRECT ANSWER Compare number and quality of patients with operation Source-Oriented - CORRECT ANSWER Traditional paper format from a hospital patient Hybrid Health Records - CORRECT ANSWER Records consisting of multiple electronic systems First Deliverable of LHR Project - CORRECT ANSWER List of LHR stakeholders Nonrepudiation - CORRECT ANSWER Practices to defend against charges questioning integrity Object-Oriented Database - CORRECT ANSWER Contains data and relationships in a single structure If physician dies - CORRECT ANSWER File records as incomplete with notice about death NCVHS - CORRECT ANSWER Developing basic data sets Stillborn - CORRECT ANSWER Use mother's record Important to enter data into database - CORRECT ANSWER To reveal patterns Accreditation standards keep - CORRECT ANSWER Retention and Destruction guidelines Index - CORRECT ANSWER Sorts data to assist in studying Maintenance Plan - CORRECT ANSWER Regular review of polocies and procedires Principal Dx - CORRECT ANSWER Not primary Standard Deviation - CORRECT ANSWER Sq Root of Variance Disruption in Unit Numbering - CORRECT ANSWER Continuity of care issues Discharge Instructions - CORRECT ANSWER Med, Diet, Follow-Up, Condition Dialysis - CORRECT ANSWER Peritonial= abd, Hemo = artificial CPOE - CORRECT ANSWER Reduces med errors HHC - CORRECT ANSWER Suitability of residence Physician Quality Measures - CORRECT ANSWER Assessment and Screening Courtesy - CORRECT ANSWER Occasional admitting Mortician - CORRECT ANSWER Files death certificates E/M - CORRECT ANSWER MDM Exam History HHC Components - CORRECT ANSWER Equip Discharge/Term Living Arrangement If you don't agree with dr. - CORRECT ANSWER Can find another Credentials Committee - CORRECT ANSWER Review credentials, behavior, and med staff appt -otomy - CORRECT ANSWER Open OP focuses on - CORRECT ANSWER Reason for encounter Integrated - CORRECT ANSWER All together in chronological order Extirpation - CORRECT ANSWER Pulling out Do Not Use Abbreviations - CORRECT ANSWER Preventing med errors [Show More]

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