Registered Health Information Technician (RHIT)
Mock Examination – Comprehensive Health
Information Management Practice
1. A patient was admitted for a procedure and the HIM professional discovers that the
physician failed to document a post-operative note. According to Joint Commission
standards, which action is most appropriate?
A. Ask the physician to write the note immediately and backdate it to the time of surgery.
B. Allow the nurse’s intraoperative notes to serve as a substitute for the physician’s note.
C. Note the deficiency and require the physician to complete the documentation as a late
entry.
D. File the record as is because the surgical report covers all necessary details.
Correct Answer: C
Explanation: The Joint Commission requires specific documentation, including post-
operative notes, for all surgical procedures. Backdating documentation is considered
fraudulent, so a ‘late entry’ is the only compliant way to correct a deficiency. This ensures
the integrity of the legal health record while maintaining regulatory compliance.
Candidates often mistakenly think backdating is acceptable if the information is accurate,
but the timing of the entry must always be transparent.
,2. An HIM manager is evaluating the department’s ‘Days in Accounts Receivable’ (AR). If the
total AR is $2,000,000 and the average daily revenue is $50,000, what is the ‘Days in AR’?
A. 25 days
B. 40 days
C. 50 days
D. 100 days
Correct Answer: B
Explanation: The formula for Days in AR is Total AR divided by Average Daily Revenue
($2,000,000 / $50,000 = 40). This metric is critical for assessing the efficiency of the
revenue cycle and the organization’s cash flow. Monitoring this helps identify delays in
insurance processing or billing errors. A common mistake is using the monthly revenue
instead of the daily average in the denominator.
3. A coding audit reveals that a coder consistently reports a code for ‘Sepsis’ when the
physician only documented ‘Urosepsis’. What should the HIM supervisor do?
A. Instruct the coder to continue as sepsis is the more severe condition.
B. Change all affected records to reflect the UTI code without physician consultation.
C. Automatically assign the code for Systemic Inflammatory Response Syndrome (SIRS).
D. Educate the coder that ‘Urosepsis’ is a clinical term, not a specific ICD-10-CM code, and
requires a query for clarification.
,Correct Answer: D
Explanation: In ICD-10-CM, ‘urosepsis’ does not have a unique code and is often used
loosely by clinicians; coding guidelines require a query to determine if the patient has
simple UTI or systemic sepsis. Accurate coding is vital for data integrity and appropriate
reimbursement. Coding based on assumptions of severity without clinical documentation is
a compliance risk. Candidates often forget that clinical terms used by doctors do not always
map directly to coding classifications.
4. Which of the following would be the most effective tool to display the ‘vital few’ causes of
medical record delinquency?
A. Flowchart
B. Scatter Diagram
C. Gantt Chart
D. Pareto Chart
Correct Answer: D
Explanation: The Pareto Chart is based on the 80/20 rule, which suggests that 80% of
problems stem from 20% of causes. It helps HIM managers prioritize quality improvement
efforts by visualizing which factors contribute most to deficiencies. Using this tool ensures
limited resources are focused on the areas with the highest impact. A common mistake is
using a flowchart, which tracks processes but does not prioritize causes based on
frequency or impact.
, 5. During a risk analysis, an HIM professional identifies that employees are sharing passwords
to access the EHR. Which HIPAA Security rule standard does this violate?
A. Person or Entity Authentication
B. Audit Controls
C. Integrity
D. Transmission Security
Correct Answer: A
Explanation: Person or Entity Authentication requires procedures to verify that a person
seeking access to electronic protected health information (ePHI) is who they claim to be.
Sharing passwords undermines accountability and makes it impossible to track who
performed specific actions in the record. This is a fundamental security requirement for
protecting patient data from unauthorized access. Candidates often confuse this with Audit
Controls, which focus on recording activity rather than the verification of identity.
6. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease
(COPD) and influenza. How should this be sequenced in ICD-10-CM?
A. The COPD code should be primary followed by influenza.
B. The influenza code should be primary followed by COPD.
C. Either code can be primary depending on the physician’s preference.
D. A combination code for influenza with COPD should be used.
Mock Examination – Comprehensive Health
Information Management Practice
1. A patient was admitted for a procedure and the HIM professional discovers that the
physician failed to document a post-operative note. According to Joint Commission
standards, which action is most appropriate?
A. Ask the physician to write the note immediately and backdate it to the time of surgery.
B. Allow the nurse’s intraoperative notes to serve as a substitute for the physician’s note.
C. Note the deficiency and require the physician to complete the documentation as a late
entry.
D. File the record as is because the surgical report covers all necessary details.
Correct Answer: C
Explanation: The Joint Commission requires specific documentation, including post-
operative notes, for all surgical procedures. Backdating documentation is considered
fraudulent, so a ‘late entry’ is the only compliant way to correct a deficiency. This ensures
the integrity of the legal health record while maintaining regulatory compliance.
Candidates often mistakenly think backdating is acceptable if the information is accurate,
but the timing of the entry must always be transparent.
,2. An HIM manager is evaluating the department’s ‘Days in Accounts Receivable’ (AR). If the
total AR is $2,000,000 and the average daily revenue is $50,000, what is the ‘Days in AR’?
A. 25 days
B. 40 days
C. 50 days
D. 100 days
Correct Answer: B
Explanation: The formula for Days in AR is Total AR divided by Average Daily Revenue
($2,000,000 / $50,000 = 40). This metric is critical for assessing the efficiency of the
revenue cycle and the organization’s cash flow. Monitoring this helps identify delays in
insurance processing or billing errors. A common mistake is using the monthly revenue
instead of the daily average in the denominator.
3. A coding audit reveals that a coder consistently reports a code for ‘Sepsis’ when the
physician only documented ‘Urosepsis’. What should the HIM supervisor do?
A. Instruct the coder to continue as sepsis is the more severe condition.
B. Change all affected records to reflect the UTI code without physician consultation.
C. Automatically assign the code for Systemic Inflammatory Response Syndrome (SIRS).
D. Educate the coder that ‘Urosepsis’ is a clinical term, not a specific ICD-10-CM code, and
requires a query for clarification.
,Correct Answer: D
Explanation: In ICD-10-CM, ‘urosepsis’ does not have a unique code and is often used
loosely by clinicians; coding guidelines require a query to determine if the patient has
simple UTI or systemic sepsis. Accurate coding is vital for data integrity and appropriate
reimbursement. Coding based on assumptions of severity without clinical documentation is
a compliance risk. Candidates often forget that clinical terms used by doctors do not always
map directly to coding classifications.
4. Which of the following would be the most effective tool to display the ‘vital few’ causes of
medical record delinquency?
A. Flowchart
B. Scatter Diagram
C. Gantt Chart
D. Pareto Chart
Correct Answer: D
Explanation: The Pareto Chart is based on the 80/20 rule, which suggests that 80% of
problems stem from 20% of causes. It helps HIM managers prioritize quality improvement
efforts by visualizing which factors contribute most to deficiencies. Using this tool ensures
limited resources are focused on the areas with the highest impact. A common mistake is
using a flowchart, which tracks processes but does not prioritize causes based on
frequency or impact.
, 5. During a risk analysis, an HIM professional identifies that employees are sharing passwords
to access the EHR. Which HIPAA Security rule standard does this violate?
A. Person or Entity Authentication
B. Audit Controls
C. Integrity
D. Transmission Security
Correct Answer: A
Explanation: Person or Entity Authentication requires procedures to verify that a person
seeking access to electronic protected health information (ePHI) is who they claim to be.
Sharing passwords undermines accountability and makes it impossible to track who
performed specific actions in the record. This is a fundamental security requirement for
protecting patient data from unauthorized access. Candidates often confuse this with Audit
Controls, which focus on recording activity rather than the verification of identity.
6. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease
(COPD) and influenza. How should this be sequenced in ICD-10-CM?
A. The COPD code should be primary followed by influenza.
B. The influenza code should be primary followed by COPD.
C. Either code can be primary depending on the physician’s preference.
D. A combination code for influenza with COPD should be used.
