RHIA Mock Exam Revised Questions and Answers / Sure A+

"Mother died of breast cancer, father still living but has heart disease" is an example of what type of health record documentation? A. Discharge summary B. History report C. Physician's order D. Physician's progress note - B. History report 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 urinalysis. The x-ray revealed possible cholelithiasis and the urinalysis showed an elevated white blood count. The patient was taken to surgery for an exploratory laparotomy and a ruptured appendix was discovered. After an appendectomy was performed and appropriate postoperative care given, the patient was discharged from the hospital on 1/20. According to Joint Commission standards, the surgeon's operative report must be written or dictated and filed on the patient's health record: A. Before discharge B. Immediately after surgery C. Within 24 hours D. Within 48 hours - B. Immediately after surgery A database rule that states "patient gender must be recorded as M=male, F=female, and U= unknown" is referred to as: A. Authorization management B. Data map C. Application control D. Knowledge management - C. Application control A drug interaction alert would be a typical function of a _____. A. data warehouse