RHIA Domain 1Revised Questions and Answers / Sure A+

A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. D50.0, N93.8 b. D62, N93.8 c. N93.8, D50.0 d. D50.0, D25.9 - a. D50.0, N93.8 A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Abdominal pain b. Cholelithiasis c. Exploratory laparoscopy d. Ruptured appendix - a. Abdominal pain A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records c. Perform a quality check on all health record systems in the practice d. Develop a listing and categorize all information requests for health information over the past two years - b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: a. Problem-oriented progress notes b. Charting by exception