RHIT Exam prep | Questions And Answers Latest {2024- 2025} A+ Graded | 100%
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Example of Point-of-Service care & documentation - 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? - 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? - 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? - LTC
TJC compliance rate for Delinquent records is - Under 50%
Who is responsible for accurateness & completeness of pts MRs? - MDs (not HIM director, RNs or other
administrative positions)
Dictated Operative report is due - Immediately after surgery. If transcription service is down, the
surgeon has to write a detailed OP note
One of Utilization Review functions - Compare severity of illness & Intensity of service warrant acute
care level
One of Clinical Care Eval processes - Quality of follow-up care
Tumor registry cases accession numbers - 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? - Permanent log of all cases entered in a database (used in Tumor registry)
,What is R-ADT system? - Registration-Admission, DC & Transfer system. Best to use for tracking pts who
have been transferred to a specialty unit
Difference between ROS & H&P - 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 - # of delinquent records is >50% AND Delinquent records
missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - 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 - 1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in - Problem list
Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality
Improvement Program) - 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 - Support health information exchange within a geographic
region
One essential item on Physical exam - 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? - DEEDs (Data Elements for EDs) -
recommended data set for hospital-based EDs
Data set for Acute Care hospitals - UHDDS (Uniform Hospital Data Set) - required data set for Acute Care
hospitals
Data set for LTC - MDS (Minimum Data Set) - required data set for LTCs
ORYX - An initiative of TJC that implements 5 core measures to improve safety and quality of health
care.
5 core measures of ORYX - 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 - 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 - Physician index - not real MDs name, but codes. To protect MDs
identity
POMR - Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements - 24 hrs after admission or prior to surgery
DC summary records - Significant findings during hospitalization
, Time frame and copies of recent H&P per TJC - 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? - 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 - 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 - 1) H&P;
2) Operative report;
Formal release of pt from hospital is - DC order. If DC order is missing - pt is assumed to leave AMA
Who can accept VOs? - Persons designated by hospital's P&Ps and State & Federal laws
When is problem list required? - On 3rd visit
RHIO - Regional Health Information Organization - network allowing providers to access pts MRs
Info on MR supplied by a pt - Health Hx, CC & ROS - all subjective
Data comprehensiveness - Presence of all required data elements
CARF - Commission on Accreditation of Rehab Facilities
Pt certification period in Home Health - 60 days. Certification period is a summary on each pt
Verified
Example of Point-of-Service care & documentation - 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? - 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? - 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? - LTC
TJC compliance rate for Delinquent records is - Under 50%
Who is responsible for accurateness & completeness of pts MRs? - MDs (not HIM director, RNs or other
administrative positions)
Dictated Operative report is due - Immediately after surgery. If transcription service is down, the
surgeon has to write a detailed OP note
One of Utilization Review functions - Compare severity of illness & Intensity of service warrant acute
care level
One of Clinical Care Eval processes - Quality of follow-up care
Tumor registry cases accession numbers - 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? - Permanent log of all cases entered in a database (used in Tumor registry)
,What is R-ADT system? - Registration-Admission, DC & Transfer system. Best to use for tracking pts who
have been transferred to a specialty unit
Difference between ROS & H&P - 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 - # of delinquent records is >50% AND Delinquent records
missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - 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 - 1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in - Problem list
Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality
Improvement Program) - 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 - Support health information exchange within a geographic
region
One essential item on Physical exam - 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? - DEEDs (Data Elements for EDs) -
recommended data set for hospital-based EDs
Data set for Acute Care hospitals - UHDDS (Uniform Hospital Data Set) - required data set for Acute Care
hospitals
Data set for LTC - MDS (Minimum Data Set) - required data set for LTCs
ORYX - An initiative of TJC that implements 5 core measures to improve safety and quality of health
care.
5 core measures of ORYX - 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 - 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 - Physician index - not real MDs name, but codes. To protect MDs
identity
POMR - Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements - 24 hrs after admission or prior to surgery
DC summary records - Significant findings during hospitalization
, Time frame and copies of recent H&P per TJC - 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? - 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 - 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 - 1) H&P;
2) Operative report;
Formal release of pt from hospital is - DC order. If DC order is missing - pt is assumed to leave AMA
Who can accept VOs? - Persons designated by hospital's P&Ps and State & Federal laws
When is problem list required? - On 3rd visit
RHIO - Regional Health Information Organization - network allowing providers to access pts MRs
Info on MR supplied by a pt - Health Hx, CC & ROS - all subjective
Data comprehensiveness - Presence of all required data elements
CARF - Commission on Accreditation of Rehab Facilities
Pt certification period in Home Health - 60 days. Certification period is a summary on each pt
