RHIT EXAM QUESTIONS WITH COMPLETE SOLUTION - LATEST 2023/2024 (100% VERIFIED)

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record? written signature of the provider of care identifiable initials of a nurse writing a nursing note a unique identification code entered by the person making the report delegated use of computer key by radiology secretary - Answer delegated use of computer key by radiology secretary The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation? interpretation of a radiologic study impressions of a cardiologist asked to determine whether patient is a good surgical risk technical interpretation of electrocardiogram tissue examination done by the pathologist - Answer impressions of a cardiologist asked to determine whether patient is a good surgical risk As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document past and current activities, such as smoking and drinking habits. a chronological description of patient's present condition from time of onset to present. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant. objective symptoms observed by the physician. - Answer subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant. Which of the following services is LEAST likely to be provided by a facility accredited by CARF? palliative care vocational evaluation chronic pain management brain injury management - Answer palliative care A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the integrated progress notes. nurses' notes. incident report. doctors' progress notes. - Answer incident report. When developing a data collection template, the most effective approach first considers facility preference. applicable accreditation standards. hardware requirements. the end user's needs. - Answer the end user's needs. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of legal analysis. quantitative review. peer review. qualitative review. - Answer qualitative review. Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. Baby Boy Doe admitted 1/3/2016, died 1/4/2016 Baby Boy Hiltz, born 1/5/2015, maintained normal status, discharged 1/7/2015 Baby Boy Hiltz's mother admitted 1/5/2016, C-section delivery, and discharged 1/7/2016 Patient admitted with COPD 1/4/2016 and discharged 1/7/2016 - Answer Baby Boy Hiltz, born 1/5/2015, maintained normal status, discharged 1/7/2015 The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the Joint Commission manual. CARF manual. Conditions of Participation for Rehabilitation Facilities. Medical Staff Bylaws, Rules, and Regulations. - Answer CARF manual. The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave documented in both the progress notes and the discharge summary. documented in an incident report and filed in the patient's health record. reported as a potentially compensable event. reported to the Executive Committee. - Answer documented in both the progress notes and the discharge summary. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the CARF manual. Joint Commission accreditation manual. hospital bylaws. Federal Register. - Answer Federal Register. As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the postpartum record. discharge summary. labor and delivery record. prenatal record. - Answer prenatal record. You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? Conditions of Participation Federal Register Minimum Data Set Uniform Hospital Discharge Data Set - Answer Uniform Hospital Discharge Data Set As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use accession register. patient index. patient abstracts. follow-up files. - Answer accession register. The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing concurrent record analysis. point-of-care documen