RHIT EXAM PREP QUESTIONS AND ANSWERS 2024 |updated version|

Example of Point-of-Service care & documentation answer is: - RN using a terminal to record vital signs. There's a difference between computer application in health care and clinical application of computers What do I find in Medical Staff Rules & Regulations? answer is: - Doc requirements for pts' records, time frame for completion of MRs, penalties for failure to comply C these requirements Auto authentication. Why doesn't TJC approve it? answer is: - No guarantee that MD actually reviewed the MR & did sign it electronically. Some facilities do use auto athentication In what setting Interdisciplinary plan of care is used? answer is: - LTC TJC compliance rate for Delinquent records is answer is: - Under 50% Who is responsible for accurateness & completeness of pts MRs? answer is: - MDs (not HIM director, RNs or other administrative positions) Dictated Operative report is due answer is: - Immediately after surgery. If transcription service is down, the surgeon has to write a detailed OP note One of Utilization Review functions answer is: - Compare severity of illness & Intensity of service warrant acute care level One of Clinical Care Eval processes answer is: - Quality of follow-up care Tumor registry cases accession numbers answer is: - Each case in Tumor registry is assigned a unique accession number. Ex: 10-001 (10- year the case was entered in a database, 001 - case #1) What is accession register? answer is: - Permanent log of all cases entered in a database (used in Tumor registry) What is R-ADT system? answer is: - Registration-Admission, DC & Transfer system. Best to use for tracking pts who have been transferred to a specialty unit Difference between ROS & H&P answer is: - 1) Review of Systems - record of subjective Sx that a pt may have forgotten to mention 2) H&P - record of Objective Sx MD is observing & other info (social Hx, Hx of present illness) Recommendation for improvement from TJC answer is: - # of delinquent records is >50% AND Delinquent records missing H&P >2% of the Average monthly DCs Integrated vs Separated Progress notes answer is: - Integrated - all providers from every discipline record progress notes sequentially on the same form vs Separated - every discipline has its own designated form to record their Progress notes LTC pt care plans rely on documentation found in answer is: - 1) Interdisciplinary pt care plan 2) DC summary 3) Transfer records Ambulatory care providers rely on documentation found in answer is: - Problem list Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality Improvement Program) answer is: - MI - pt is DC'd on ASA, beta blockers or other heart Rxs Stroke - pt is DC'd on an anti-thrombotic Pneumonia - pt had blood culture before 1st Abx started Regional health information organizations answer is: - Support health information exchange within a geographic region One essential item on Physical exam answer is: - General appearance as assessed by MD (Chief complaint, ROS & Family Hx - medical Hx provided by the pt) Elements of which data set do I collect if I'm a trauma registrar? answer is: - DEEDs (Data Elements for EDs) - recommended data set for hospital-based EDs Data set for Acute Care hospitals answer is: - UHDDS (Uniform Hospital Data Set) - required data set for Acute Care hospitals Data set for LTC answer is: - MDS (Minimum Data Set) - required data set for LTCs ORYX answer is: - An initiative of TJC that implements 5 core measures to improve safety and quality of health care. 5 core measures of ORYX answer is: - CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA at arrival & DC, beta-blockers, blood culture, smoking cessation advice, etc. ORYX has more core measure sets. A hospital chooses the set according to the type of pts it treats (can be one core & rest non-core) Quantitative vs Qualitative analysis of MRs answer is: - Quantitative - check presence or absence of necessary sigs, reports vs Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of documentation NOT clinical care Index with Unique Identifier codes answer is: - Physician index - not real MDs name, but codes. To protect MDs identity POMR answer is: - Problem Oriented MR. Helps index documentation throughout MR H&P time standard to meet TJC & CoP requirements answer is: - 24 hrs after admission or prior to surgery DC summary records answer is: - Significant findings during hospitalization Time frame and copies of recent H&P per TJC answer is: - Copies of recent H&P done in MD's office is allowed in lieu of admission H&P as long as the interval note (interval changes) are present upon admission When can Interval note replace H&P upon admission? answer is: - 1) If pt is re-admitted within 30 days for the same problem & copy of recent H&P is available; 2) If copy of recent H&P done in MD's office is available upon admission Indices in hospital answer is: - 1) MPI - cross-reference of pt's name & MR number; 2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of a Dz cases); 3) Physician index - a listing of cases in order by MD's name or number; 4) Operation index - a listing of operations performed Most serious delinquencies answer is: - 1) H&P; 2) Operative report; Formal release of pt from hospital is answer is: - DC order. If DC order is missing - pt is assumed to leave AMA Who can accept VOs? answer is: - Persons designated by hospital's P&Ps and State & Federal laws When is problem list required? answer is: - On 3rd visit RHIO answer is: - Regional Health Information Organization - network allowing providers to access pts MRs Info on MR supplied by a pt answer is: - Health Hx, CC & ROS - all subjective