RHIT Practice Exam 2 Questions and Answers
Which of the following data sets would be most helpful in developing a hospital
trauma data registry?
a. DEEDS
b. MDS
c. OASIS
d. UACDS - ANS-a. DEEDS
In 1997, the Centers for Disease Control and Prevention (CDC), through its National
Center for Injury Prevention and Control (NCIPC), published a data set called Data
Elements for Emergency Department Systems (DEEDS). The purpose of this data
set is to support the uniform collection of data in hospital-based emergency
departments and to reduce incompatibilities in emergency department records.
The HIM manager was asked by the medical director to present the hospital's policy
on deletion of erroneous information from the electronic health record to the
medical staff. This policy requires that the original documentation is retained in the
EHR along with the corrected documentation. Which of the following is a key
component of this policy?
a. The new documentation must be reviewed by the chief of the medical staff
b. Natural language processing would be utilized to delete erroneous information
c. The new and old documentation would be included in the same document with a
comment section.
d. The new documentation needs to be reviewed by the risk manager. - ANS-c. The
new and old documentation would be included in the same document with a
comment section.
Policies and procedures need to be in place to address amendments and corrections
in the EHR. In the event that an amendment, addendum, or deletion needs to be
made the EHR should retain the previous version of the document and identify who
made the change along with the date and time that the change was made.
Which of the following can assist managers with the tasks of monitoring
productivity and forecasting budgets?
a. Intermediary bulletins
b. Mapping errors
c. Revenue codes
d. Workload statistics - ANS-d. Workload statistics
Workload statistics can assist managers with the tasks of monitoring productivity
and provide data regarding resources used, such as equipment, personnel,
,services, and supplies.
A dietary department donated its old laptop to a school. Some old patient data were
still on the computer. What controls would have minimized this security breach?
a. Access controls
b. Device and media controls
c. Facility access controls
d. Workstation controls - ANS-b. Device and media controls
Device and media controls require the facility to specify proper use of electronic
media and devices (external drives, backup devices, etc.). Included in this
requirement are controls and procedures regarding the receipt and removal of
electronic media that contain protected health information and the movement of
such data within the facility. The entity must also address procedures for the
transfer, removal, or disposal, including reuse or redeployment, of electronic media.
The coder assigned separate codes for individual tests when a combination code
exists. This is an example of which of the following?
a. Upcoding
b. Complex coding
c. Query
d. Unbundling - ANS-d. Unbundling
Unbundling occurs when individual components of a complete procedure or service
are billed separately instead of using a combination code.
Secondary data is used for multiple reasons including:
a. Assisting researchers in determining effectiveness of treatments
b. Assisting physicians and other healthcare providers in providing patient care
c. Billing for services provided to the patient
d. Coding diagnoses and procedures treated - ANS-a. Assisting researchers in
determining effectiveness of treatments
Secondary data is used in research. Data taken from health records and entered
into disease oriented databases can help researchers determine the effectiveness of
alternate treatment methods. They also can quickly demonstrate survival rates at
different stages of diseases.
Dr. Jones comes into the HIM department and requests that the HIM director
provide a list of his records from the previous year that show a principal diagnosis
of myocardial infarction. What would the HIM director use to provide this list?
a. A disease index
b. A master patient index
c. An operative index
,d. A physician index - ANS-a. A disease index
A disease index is a listing in diagnosis code number order for patients discharged
from the facility during a particular time period.
A hospital is planning to allow coding professionals to work at home. The hospital is
in the process of identifying strategies to minimize the security risks associated
with this practice. Which of the following would be best to ensure that data
breaches are minimized when the home computer is unattended?
a. User name and password
b. Encryption
c. Cable locks
d. Automatic session log-off - ANS-d. Automatic session log-off
In the HIPAA Security Rule, one of the technical safeguards standards is access
control. This includes automatic log-off, which ensures processes that terminate an
electronic session after a predetermined time of inactivity.
A PI Team is concerned with the time it is taking for patients to get through the
registration process. To better understand the causes or reasons for the delay in
this process the PI Team would like to gather observational data. What data
collection tool would be appropriate for this team to develop for their observation
data?
a. Check sheet
b. Ordinal data tool
c. Balance sheet
d. Nominal data tool - ANS-a. Check sheet
A check sheet is used to gather data based on sample observations in order to
detect patterns. When preparing to collect data, a team should consider the four W
questions: Who will collect the data? What data will be collected? Where will the
data be collected? When will the data be collected?
Which of the following is on the list of the hospital-acquired conditions provision of
the inpatient prospective payment system?
a. Congestive heart failure
b. Acute myocardial infarction
c. Stage III or IV pressure ulcers
d. Diabetic retinopathy - ANS-c. Stage III or IV pressure ulcers
The hospital-acquired conditions (HAC) provision is an additional component of pay-
forperformance utilizing reported ICD-10-CM diagnosis codes and the present-on-
admission (POA) indicator to identify quality issues. A Stage III or IV pressure ulcer
not present on admission or identified with the POA indicator on the claim would
not be paid for as a CC or MCC because it would be considered an HAC.
, Which of the following describes incomplete records that are not completed by the
physician within the time frame specified in the healthcare facility's policies?
a. Suspended records
b. Delinquent records
c. Loose records
d. Default records - ANS-b. Delinquent records
Physicians and other practitioners are notified when they have incomplete health
records requiring their attention. If a health record remains incomplete for a
specified number of days, as defined in the medical staff rules and regulations, the
record is considered to be a delinquent record.
As CIO, you have initiated discussions of information governance (IG) with your C-
suite colleagues. Since your background is in HIM, you stress the importance of
information protection and data quality. You mention all of the following in your
discussion as to why quality data is important to data governance (DG) and IG, but
as an HIM professional, you feel the most important is __________.
a. To make informed decisions
b. To evaluate patient care and population health
c. To decrease security breaches
d. To evaluate business processes - ANS-c. To decrease security breaches
Data governance and information governance programs rely on quality data and
information for all the reasons listed in the question. However, confidentiality,
privacy and security are the cornerstones of HIM. Therefore, to decrease security
breaches is the most important reason.
Community Hospital's HIM department conducted a random sample of 150 inpatient
health records to determine the discharge summary completion timeliness rate.
Thirteen discharges were determined to be out of compliance with completion
standards. Which of the following percentages represents the timeliness rate for
discharge summaries at Community Hospital?
a. 8.7%
b. 9.5%
c. 41.5%
d. 91.3% - ANS-d. 91.3%
Hospitals set completion standards based on this requirement. Record completion
would include the discharge summary
(137/150) × 100 = 91.3%
Which of the following refers to guarding against improper information modification
or destruction?
Which of the following data sets would be most helpful in developing a hospital
trauma data registry?
a. DEEDS
b. MDS
c. OASIS
d. UACDS - ANS-a. DEEDS
In 1997, the Centers for Disease Control and Prevention (CDC), through its National
Center for Injury Prevention and Control (NCIPC), published a data set called Data
Elements for Emergency Department Systems (DEEDS). The purpose of this data
set is to support the uniform collection of data in hospital-based emergency
departments and to reduce incompatibilities in emergency department records.
The HIM manager was asked by the medical director to present the hospital's policy
on deletion of erroneous information from the electronic health record to the
medical staff. This policy requires that the original documentation is retained in the
EHR along with the corrected documentation. Which of the following is a key
component of this policy?
a. The new documentation must be reviewed by the chief of the medical staff
b. Natural language processing would be utilized to delete erroneous information
c. The new and old documentation would be included in the same document with a
comment section.
d. The new documentation needs to be reviewed by the risk manager. - ANS-c. The
new and old documentation would be included in the same document with a
comment section.
Policies and procedures need to be in place to address amendments and corrections
in the EHR. In the event that an amendment, addendum, or deletion needs to be
made the EHR should retain the previous version of the document and identify who
made the change along with the date and time that the change was made.
Which of the following can assist managers with the tasks of monitoring
productivity and forecasting budgets?
a. Intermediary bulletins
b. Mapping errors
c. Revenue codes
d. Workload statistics - ANS-d. Workload statistics
Workload statistics can assist managers with the tasks of monitoring productivity
and provide data regarding resources used, such as equipment, personnel,
,services, and supplies.
A dietary department donated its old laptop to a school. Some old patient data were
still on the computer. What controls would have minimized this security breach?
a. Access controls
b. Device and media controls
c. Facility access controls
d. Workstation controls - ANS-b. Device and media controls
Device and media controls require the facility to specify proper use of electronic
media and devices (external drives, backup devices, etc.). Included in this
requirement are controls and procedures regarding the receipt and removal of
electronic media that contain protected health information and the movement of
such data within the facility. The entity must also address procedures for the
transfer, removal, or disposal, including reuse or redeployment, of electronic media.
The coder assigned separate codes for individual tests when a combination code
exists. This is an example of which of the following?
a. Upcoding
b. Complex coding
c. Query
d. Unbundling - ANS-d. Unbundling
Unbundling occurs when individual components of a complete procedure or service
are billed separately instead of using a combination code.
Secondary data is used for multiple reasons including:
a. Assisting researchers in determining effectiveness of treatments
b. Assisting physicians and other healthcare providers in providing patient care
c. Billing for services provided to the patient
d. Coding diagnoses and procedures treated - ANS-a. Assisting researchers in
determining effectiveness of treatments
Secondary data is used in research. Data taken from health records and entered
into disease oriented databases can help researchers determine the effectiveness of
alternate treatment methods. They also can quickly demonstrate survival rates at
different stages of diseases.
Dr. Jones comes into the HIM department and requests that the HIM director
provide a list of his records from the previous year that show a principal diagnosis
of myocardial infarction. What would the HIM director use to provide this list?
a. A disease index
b. A master patient index
c. An operative index
,d. A physician index - ANS-a. A disease index
A disease index is a listing in diagnosis code number order for patients discharged
from the facility during a particular time period.
A hospital is planning to allow coding professionals to work at home. The hospital is
in the process of identifying strategies to minimize the security risks associated
with this practice. Which of the following would be best to ensure that data
breaches are minimized when the home computer is unattended?
a. User name and password
b. Encryption
c. Cable locks
d. Automatic session log-off - ANS-d. Automatic session log-off
In the HIPAA Security Rule, one of the technical safeguards standards is access
control. This includes automatic log-off, which ensures processes that terminate an
electronic session after a predetermined time of inactivity.
A PI Team is concerned with the time it is taking for patients to get through the
registration process. To better understand the causes or reasons for the delay in
this process the PI Team would like to gather observational data. What data
collection tool would be appropriate for this team to develop for their observation
data?
a. Check sheet
b. Ordinal data tool
c. Balance sheet
d. Nominal data tool - ANS-a. Check sheet
A check sheet is used to gather data based on sample observations in order to
detect patterns. When preparing to collect data, a team should consider the four W
questions: Who will collect the data? What data will be collected? Where will the
data be collected? When will the data be collected?
Which of the following is on the list of the hospital-acquired conditions provision of
the inpatient prospective payment system?
a. Congestive heart failure
b. Acute myocardial infarction
c. Stage III or IV pressure ulcers
d. Diabetic retinopathy - ANS-c. Stage III or IV pressure ulcers
The hospital-acquired conditions (HAC) provision is an additional component of pay-
forperformance utilizing reported ICD-10-CM diagnosis codes and the present-on-
admission (POA) indicator to identify quality issues. A Stage III or IV pressure ulcer
not present on admission or identified with the POA indicator on the claim would
not be paid for as a CC or MCC because it would be considered an HAC.
, Which of the following describes incomplete records that are not completed by the
physician within the time frame specified in the healthcare facility's policies?
a. Suspended records
b. Delinquent records
c. Loose records
d. Default records - ANS-b. Delinquent records
Physicians and other practitioners are notified when they have incomplete health
records requiring their attention. If a health record remains incomplete for a
specified number of days, as defined in the medical staff rules and regulations, the
record is considered to be a delinquent record.
As CIO, you have initiated discussions of information governance (IG) with your C-
suite colleagues. Since your background is in HIM, you stress the importance of
information protection and data quality. You mention all of the following in your
discussion as to why quality data is important to data governance (DG) and IG, but
as an HIM professional, you feel the most important is __________.
a. To make informed decisions
b. To evaluate patient care and population health
c. To decrease security breaches
d. To evaluate business processes - ANS-c. To decrease security breaches
Data governance and information governance programs rely on quality data and
information for all the reasons listed in the question. However, confidentiality,
privacy and security are the cornerstones of HIM. Therefore, to decrease security
breaches is the most important reason.
Community Hospital's HIM department conducted a random sample of 150 inpatient
health records to determine the discharge summary completion timeliness rate.
Thirteen discharges were determined to be out of compliance with completion
standards. Which of the following percentages represents the timeliness rate for
discharge summaries at Community Hospital?
a. 8.7%
b. 9.5%
c. 41.5%
d. 91.3% - ANS-d. 91.3%
Hospitals set completion standards based on this requirement. Record completion
would include the discharge summary
(137/150) × 100 = 91.3%
Which of the following refers to guarding against improper information modification
or destruction?
