RHIA EXAM PREP DOMAIN II|83 Questions with Verified Answers,100% CORRECT

Document Content and Description Below

RHIA EXAM PREP DOMAIN II|83 Questions with Verified Answers Master or Enterprise patient index - CORRECT ANSWER is critical to identifying patients and ensuring proper record linkage The health ... record consist of - CORRECT ANSWER handwritten notes, transcribed reports, electronic data, digital images Continuity of care - CORRECT ANSWER is improved by the sharing of patient information between providers Standards and regulations - CORRECT ANSWER have a great impact on what is documented in the health record The American College of Surgeons (ACS) - CORRECT ANSWER developed the minimum standards for hospitals in the early 20th century. The Joint Commission succeeded the ACS in standardization The health record - CORRECT ANSWER is the major source of information about any healthcare facility and is routinely surveyed to obtain knowledge about the facilities care process or performance. State Licensure - CORRECT ANSWER establishes requirements for patient records content, format, retention and use. Licensure is required for healthcare facilities to remain in operation. By laws and rules are - CORRECT ANSWER developed by the medical staff and approved by the (BOT) board of trustees or governing body in the facility. Longitudinal health record - CORRECT ANSWER contains various encounters, records from numerous health care delivery settings. It is valuable because it reduces medical errors, duplication of testing and repetition. It improves decision making for providers and care for the patients The medical record is - CORRECT ANSWER maintained in two broad areas Administrative and demographic and clinical data The legal health record - CORRECT ANSWER must identify the sources, medium, paper images, video, or audio, and location Meaningful use - CORRECT ANSWER functional and quality reporting criteria 3 subsystems of the United States legal system - CORRECT ANSWER Judicial, Regulatory, and Administrative Judicial legal system - CORRECT ANSWER allows a wronged party to seek retribution Regulatory legal system - CORRECT ANSWER regulates how an action is met of seeking retribution Administrative legal system - CORRECT ANSWER controls government administrative operations such as licensing, accrediting bodies, Medicare, Medicaid, and federal and state government programs Federal Register - CORRECT ANSWER publishes revisions to existing administrative rules for healthcare related information updated by MCOP and HIPAA Civil Law - CORRECT ANSWER most healthcare encounters fall into this category HIPAA privacy rule - CORRECT ANSWER criminal provisions only have felony crimes Torts - CORRECT ANSWER harm through wrongful conduct and seeks compensation and to discourage the wrongdoer from continuing wrongful acts Three categories of tort liability exist - CORRECT ANSWER negligence, intentional torts, and products liability Accreditation Agencies - CORRECT ANSWER are offered through non-governmental agencies Hospital standards - CORRECT ANSWER are developed by Joint Commission Accreditation - CORRECT ANSWER is voluntary but can be a requirement for some licensures Joint Commission focus - CORRECT ANSWER is not legally mandated. the focus is on the entire hospital Medicare Condition of Participation - CORRECT ANSWER sets standards for hospitals and are government regulations 1965 Griswold v. Connecticut case - CORRECT ANSWER recognized the need/right to privacy California - CORRECT ANSWER recognized the right to privacy through its states constitution. 1996 HIPAA enacted by Congress - CORRECT ANSWER addresses fraud and abuse in the healthcare system The controlled substance act - CORRECT ANSWER controls the use of narcotics, depressants and stimulants. drugs are classified into schedules The Federal Food, Drug and Cosmetic Act - CORRECT ANSWER includes medical device amendments of 1976 and covers products, most equipments and supplies Retention periods for the health record - CORRECT ANSWER is determined by federal and state laws HIPAA - CORRECT ANSWER does not provide access to oral information, psychotherapy notes, information compiled for civil, criminal or administrative action Violation of HIPAA prior to 2/18/2009 - CORRECT ANSWER $100 per violation Violation of HIPAA after 2/18/2009 and (CE) covered entity did not know - CORRECT ANSWER not less than $100 or more than 50,000/ violation not to exceed 1.5 million during a calendar year HIPAA violation due to reasonable cause and not willful neglect - CORRECT ANSWER not less than $1,000 or more than $50,000/violation HIPAA violation due to willful neglect and corrected in a 30 day period - CORRECT ANSWER not less than 10,000 or more than 50,000/ per violation HIPAA violation due to wilfull neglect and not corrected - CORRECT ANSWER not less than $50,000/violation or more than 1.5 million / violation Beneficence - CORRECT ANSWER release of information to benefit the patient such as payment for a claim Non-maleficence - CORRECT ANSWER non-release of information to groups such as the media requesting information on a famous person Autonomy - CORRECT ANSWER ensures only the patient makes decisions regarding their health Justice - CORRECT ANSWER HIM applies rules fairly and consistently for all Implied Conscent - CORRECT ANSWER is giving in emergency situations where a patient lacks the capacity to communicate Privacy - CORRECT ANSWER is the right of a patient to control how much information is disclosed HIPAA defers - CORRECT ANSWER to state laws on issues regarding minors The Freedom of Information Act (FOIA) 1996 - CORRECT ANSWER is a federal law that applies to only federal agencies such as the military. Access to the information is given without an authorization The Device and Media Controls Standards - CORRECT ANSWER require organization to develop policies and procedure for the final disposition The Device and Medical Controls four specifications - CORRECT ANSWER disposal, media reuse, accountability, and data backup NPP - CORRECT ANSWER the notice of privacy practices The Notice of Privacy Practices regarding CE - CORRECT ANSWER must include in their statement example of (TPO) treatment, payment, and healthcare operations other disclosures permitted without authorization and individual rights CE - CORRECT ANSWER Covered Entity DRS - CORRECT ANSWER designated record set The designated record set - CORRECT ANSWER is a group of records maintained by or for a covered entity that records billing, or maintains enrollment, payment, claims adjudication which may be used to make decisions about an individual How long does the Covered entity have to respond to a request for phi maintained offsite - CORRECT ANSWER 60 days The first fundamental strategy in reducing security threats - CORRECT ANSWER is establishing a security organization The Security Rule - CORRECT ANSWER outlines a set of regulations that include administrative, technical and physical safeguards intended to ensure confidentiality, integrity, and avalibility of EPHI. The Privacy Rule (HIPAA) - CORRECT ANSWER allows reasonable cost-based charges for labor, postage, and supplies involved in photocopying health information for the patient. Humans - CORRECT ANSWER are the most common threat to health information integrity Psychotherapy notes - CORRECT ANSWER patients aren't allowEd the rights to access their own notes according to HIPAA privacy rule Incident reports - CORRECT ANSWER are not considered part of the health record Competent adults - CORRECT ANSWER and those who created a living will when of sound mind, even though now incompetent, have the right to refuse treatment Healthcare Integrity & protection Data bank - CORRECT ANSWER was created to collect info on the legal actions both civil and criminal taken against licensed healthcare providers HIE - CORRECT ANSWER health information exchange NHIN - CORRECT ANSWER National Health Information Network Exchange HITECH - CORRECT ANSWER Health Information Technology for Economic and Clinical Health Act Health Information exchange - CORRECT ANSWER is the electronic movement of health information among organizations according to standards and protocol National Health Information Network Exchange - CORRECT ANSWER allows patients to receive the best coordinated care wherever a patient presents for care Stage 1 meaningful use - CORRECT ANSWER requires providers to test the exchange of HIM using a secure encrypted process Stage 2 meaningful use - CORRECT ANSWER requires a provider to transmit 10 percent of its summary of care documents during transitions of care or for the purposes of referral Health Information Technology for Economic and Clinical Health Act - CORRECT ANSWER properly trains the workforce to be meaningful users of the EHR Models of health information exchange - CORRECT ANSWER centralized, decentralized and hybrid Centralized HIE model - CORRECT ANSWER single db, returns quicker results, a question of who owns the data, changes require multiple transactions and may not update all at once Decentralized HIE model - CORRECT ANSWER db is maintained at each participant facility, no question of ownership of data The Hybrid HIE model - CORRECT ANSWER has both centralized and federated models The ultimate goal of an HIE - CORRECT ANSWER is to enhance the quality and safety of patient care Interoperability - CORRECT ANSWER allows different information systems and software applications to communicate and exchange data ONC - CORRECT ANSWER OFFICE OF THE NATIONAL COORDINATOR for HEALTH INFORMATION TECHNOLOGY The office of the national coordinator for Health Info Technology - CORRECT ANSWER is a presidential directive developed to implement a strategic plan to guide implementation of interoperable HIT Paper to EHR - CORRECT ANSWER include the upgrade from legacy data sets toward a more comprehensive core data set for continuity of care CCR - CORRECT ANSWER continuity of care record CCD - CORRECT ANSWER continuity of care document Continuity of care record /document - CORRECT ANSWER ensures the most relevant and timely health information can be sent electronically from one provider to another HIE security and privacy requires - CORRECT ANSWER the use of usernames, passwords ro security tokens such as public key infrastructure (PKI), digital certifications to access the system [Show More]

Last updated: 1 year ago

Preview 1 out of 8 pages