RHIT Exam Preparation
A hospital interested in finding out if a physician has any adverse licensure actions should review data
from:
A) UHDDS
B) OASIS-C
C) NPDB
D) ORYXcorrect answerC) NPDB
The National Practitioner Data Bank (NPDB) was mandated under the Health Care Quality Improvement
Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and
certain professional review actions (such as denial of medical staff privileges) taken by healthcare
entities such as hospitals against physicians, dentists, and other healthcare providers as well as private
accrediting organizations and peer review organizations (Sharp 2016, 185).
A quantitative review of the health record for missing reports and signatures that occurs when the
patient is in the hospital is referred to as a:
A) Peer Review
B)Prospective Review
C) Retrospective Review
D) Concurrent Reviewcorrect answerD) Concurrent Review
The quantitative analysis or record content review process can be handled in a number of ways. Some
acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using
this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review
each patient's record. This type of process is usually referred to as a concurrent review because review
occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64).
The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the
following would be the position for this argument?
A) I am concerned that the users will not know how to perform the copy/paste function.
,B) I am unable to identify the author.
C) I am concerned about the time that it takes to copy/paste the documentation
D) I am unable to print the data outcorrect answerB) I am unable to identify the author
In the EHR, the user is able to copy and paste free text from one patient or patient encounter to
another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to
documentation integrity of using copy functionality includes the inability to identify the author of the
documentation (Sayles 2016b, 69).
In determining the data collection requirements for Medicare and Medicaid patients in a long-term care
facility, the health information technician would consult standards from:
A) CARF
B) CMS
C) NCQA
D) The Joint Commissioncorrect answerB) CMS
The Resident Assessment Instrument (RAI) is submitted electronically to each state health department
and then to the Centers for Medicare and Medicaid Services (CMS). At CMS, demographic and quality
indicator information is compiled and provided as feedback to each facility (Brickner 2016, 102).
Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI)
against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the
following is used to match patients so that patient information can be merged?
A) Outguide
B) Audit Trail
C) Algorithm
D) Encodercorrect answerC) Algorithm
An algorithm is used in a healthcare facility to match patients so that patient information can be
merged. This process helps to maintain an accurate MPI and avoid duplicates, overlays, and overlaps
(Sayles 2016b, 58).
The process in which a healthcare organization addresses the provider documentation issues that are
conflicting, ambiguous, or incomplete is called:
,A) Releasing Information
B) Coding
C) Casefinding
D) Queryingcorrect answerD) Querying
Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the
health record regarding any significant reportable condition or procedure. The query is directed to the
provider who originated the progress note or other report in question. This could include the attending
physician, consulting physician, or the surgeon. In most cases, a query for abnormal test results would
be directed to the attending physician (Brinda 2016, 163).
This type of healthcare organization review is conducted at the request of the healthcare facility seeking
accreditation.
A) Complimentary review
B) Vocational review
C) Compulsory review
D) Voluntary reviewcorrect answerD) Voluntary review
In healthcare today, many different agencies develop and monitor standards on the quality of
healthcare services. These agencies accomplish their missions through a comprehensive review process.
Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or
certification (Shaw and Carter 2015, 406).
Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list?
A) It applies to only preprinted forms
B) It applies to orders and medication-related documentation
C) It applies to all documentation in the health record
D) It applies to only medication-related orderscorrect answerB) It applies to orders and medication-
related documentation
, The "Do Not Use" abbreviation list applies to all orders and all medication-related documentation that is
handwritten (including free-text computer entry) or on preprinted forms (Shaw and Carter 2015, 249).
The Medical Record Committee is assessing various strategies to improve documentation in the health
record. Concerns have been raised that current documentation practices may be insufficient to support
diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be
the best first step to help improve physician documentation?
A) Contact CMS for assistance
B) Determine the type and volume of documentation problems
C) Change the medical staff bylaws to require improved documentation practice
D) Implement a documentation score card for each medical specialtycorrect answerB) Determine the
type and volume of documentation problems
The first step in improving any problem is to identify the root causes of the problem and then develop
and take appropriate actions to fit the cause of the problem. Options a, c, and d do not provide a
process for identifying the root cause of the documentation problems (Carter and Palmer 2016, 515;
Sayles and Gordon 2016, 671).
When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is
determined by:
A) Clinical knowledge
B) Credential
C) Position on the staff
D) Clinical privilegescorrect answerD) Clinical privileges
The medical staff is generally referred to as independent practitioners. They include individuals
permitted by law and the organization to provide patient care services without direction or supervision,
within the scope of their license and individually granted clinical privileges (Shaw and Carter 2015, 345).
Which of the following is the key to the identification and access of a patient's health record?
A) Outguide
B) Disease Index
C) Master Patient Index
A hospital interested in finding out if a physician has any adverse licensure actions should review data
from:
A) UHDDS
B) OASIS-C
C) NPDB
D) ORYXcorrect answerC) NPDB
The National Practitioner Data Bank (NPDB) was mandated under the Health Care Quality Improvement
Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and
certain professional review actions (such as denial of medical staff privileges) taken by healthcare
entities such as hospitals against physicians, dentists, and other healthcare providers as well as private
accrediting organizations and peer review organizations (Sharp 2016, 185).
A quantitative review of the health record for missing reports and signatures that occurs when the
patient is in the hospital is referred to as a:
A) Peer Review
B)Prospective Review
C) Retrospective Review
D) Concurrent Reviewcorrect answerD) Concurrent Review
The quantitative analysis or record content review process can be handled in a number of ways. Some
acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using
this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review
each patient's record. This type of process is usually referred to as a concurrent review because review
occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64).
The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the
following would be the position for this argument?
A) I am concerned that the users will not know how to perform the copy/paste function.
,B) I am unable to identify the author.
C) I am concerned about the time that it takes to copy/paste the documentation
D) I am unable to print the data outcorrect answerB) I am unable to identify the author
In the EHR, the user is able to copy and paste free text from one patient or patient encounter to
another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to
documentation integrity of using copy functionality includes the inability to identify the author of the
documentation (Sayles 2016b, 69).
In determining the data collection requirements for Medicare and Medicaid patients in a long-term care
facility, the health information technician would consult standards from:
A) CARF
B) CMS
C) NCQA
D) The Joint Commissioncorrect answerB) CMS
The Resident Assessment Instrument (RAI) is submitted electronically to each state health department
and then to the Centers for Medicare and Medicaid Services (CMS). At CMS, demographic and quality
indicator information is compiled and provided as feedback to each facility (Brickner 2016, 102).
Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI)
against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the
following is used to match patients so that patient information can be merged?
A) Outguide
B) Audit Trail
C) Algorithm
D) Encodercorrect answerC) Algorithm
An algorithm is used in a healthcare facility to match patients so that patient information can be
merged. This process helps to maintain an accurate MPI and avoid duplicates, overlays, and overlaps
(Sayles 2016b, 58).
The process in which a healthcare organization addresses the provider documentation issues that are
conflicting, ambiguous, or incomplete is called:
,A) Releasing Information
B) Coding
C) Casefinding
D) Queryingcorrect answerD) Querying
Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the
health record regarding any significant reportable condition or procedure. The query is directed to the
provider who originated the progress note or other report in question. This could include the attending
physician, consulting physician, or the surgeon. In most cases, a query for abnormal test results would
be directed to the attending physician (Brinda 2016, 163).
This type of healthcare organization review is conducted at the request of the healthcare facility seeking
accreditation.
A) Complimentary review
B) Vocational review
C) Compulsory review
D) Voluntary reviewcorrect answerD) Voluntary review
In healthcare today, many different agencies develop and monitor standards on the quality of
healthcare services. These agencies accomplish their missions through a comprehensive review process.
Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or
certification (Shaw and Carter 2015, 406).
Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list?
A) It applies to only preprinted forms
B) It applies to orders and medication-related documentation
C) It applies to all documentation in the health record
D) It applies to only medication-related orderscorrect answerB) It applies to orders and medication-
related documentation
, The "Do Not Use" abbreviation list applies to all orders and all medication-related documentation that is
handwritten (including free-text computer entry) or on preprinted forms (Shaw and Carter 2015, 249).
The Medical Record Committee is assessing various strategies to improve documentation in the health
record. Concerns have been raised that current documentation practices may be insufficient to support
diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be
the best first step to help improve physician documentation?
A) Contact CMS for assistance
B) Determine the type and volume of documentation problems
C) Change the medical staff bylaws to require improved documentation practice
D) Implement a documentation score card for each medical specialtycorrect answerB) Determine the
type and volume of documentation problems
The first step in improving any problem is to identify the root causes of the problem and then develop
and take appropriate actions to fit the cause of the problem. Options a, c, and d do not provide a
process for identifying the root cause of the documentation problems (Carter and Palmer 2016, 515;
Sayles and Gordon 2016, 671).
When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is
determined by:
A) Clinical knowledge
B) Credential
C) Position on the staff
D) Clinical privilegescorrect answerD) Clinical privileges
The medical staff is generally referred to as independent practitioners. They include individuals
permitted by law and the organization to provide patient care services without direction or supervision,
within the scope of their license and individually granted clinical privileges (Shaw and Carter 2015, 345).
Which of the following is the key to the identification and access of a patient's health record?
A) Outguide
B) Disease Index
C) Master Patient Index
