RHIT
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.
You must name each form for bar coding and indexing into a document management system. The
unnamed document in front of you includes a microscopic description of tissue excised during
surgery. The document type you are most likely to give to this form is: - answer Pathology report
A health record analyst needs to quickly compare all lab values during one hospitalization. The
paper-based health record format best suited for this purpose is - answer Source Oriented
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 -
answer Federal Register
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy
for a physician's verbal orders in accordance with Joint Commission standards and state law. Your
first area of concern is the qualifications of those individuals in your facility who have been
authorized to record verbal orders. For this information, you will consult. - answer Hospital Bylaws,
Rules, and Regulations
Medicare rules state that the use of verbal orders should be infrequent, and used only when the
orders cannot be written or given electronically. In addition, verbal orders must be - answer
accepted by persons authorized by hospital regulations and procedures
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. - answer documented in
both the progress notes and discharge summary
Joint Commission standards require that at least one post-anesthesia visit be recorded on the health
records of operative patient. Does this post-anesthesia note carry a time requirement? - answer
yes, within 24 hours of surgery
Discharge summary documentation must include - answer significant findings during hospitalization
The protection of a patient's health information is addressed in each of the following EXCEPT: -
answer A)Health Insurance Portability and Accountability Act
B)Privacy Act C) Drug Abuse and Treatment Act
, ** D) U.S. Patriot Act **
The failure to obtain the written consent of the patient before performing a surgical procedure may
constitute - answer battery
A written authorization from the patient releasing copies of his or her medical records is required by
all of the following EXCEPT: - answer the hospital attorney for the facility where the patient is
treated
When developing a record retention policy, the HIM professionals should consider all of the
following EXCEPT: - answer the thickness of the records
A valid authorization for the disclosure of health information should not be - answer dated prior to
discharge of the patient
Who is legally responsible for obtaining the patient's informed consent for surgery? - answer the
surgeon performing the surgery
A signed consent for release of information dated December 1, 2005, is received with a request for
the chart from the patient's admission of 12/5/05. Indicate the appropriate response from the
options below. - answer Request another authorization dated after the discharge date
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that
sets forth all of the following EXCEPT: - answer covered entities provide every patient with its
annual business report
Which of the following is considered confidential information? - answer patient's diagnosis
Which would be the better "best practice" for handling fax transmission of a physician's orders? -
answer Treat faxed orders like verbal orders and require authentication of the orders by
appropriate medical staff within the required time period.
The proper method for correcting a documentation error in a medical record is for the author to -
answer draw a single line through the incorrect information, date, and initial the change
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.
You must name each form for bar coding and indexing into a document management system. The
unnamed document in front of you includes a microscopic description of tissue excised during
surgery. The document type you are most likely to give to this form is: - answer Pathology report
A health record analyst needs to quickly compare all lab values during one hospitalization. The
paper-based health record format best suited for this purpose is - answer Source Oriented
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 -
answer Federal Register
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy
for a physician's verbal orders in accordance with Joint Commission standards and state law. Your
first area of concern is the qualifications of those individuals in your facility who have been
authorized to record verbal orders. For this information, you will consult. - answer Hospital Bylaws,
Rules, and Regulations
Medicare rules state that the use of verbal orders should be infrequent, and used only when the
orders cannot be written or given electronically. In addition, verbal orders must be - answer
accepted by persons authorized by hospital regulations and procedures
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. - answer documented in
both the progress notes and discharge summary
Joint Commission standards require that at least one post-anesthesia visit be recorded on the health
records of operative patient. Does this post-anesthesia note carry a time requirement? - answer
yes, within 24 hours of surgery
Discharge summary documentation must include - answer significant findings during hospitalization
The protection of a patient's health information is addressed in each of the following EXCEPT: -
answer A)Health Insurance Portability and Accountability Act
B)Privacy Act C) Drug Abuse and Treatment Act
, ** D) U.S. Patriot Act **
The failure to obtain the written consent of the patient before performing a surgical procedure may
constitute - answer battery
A written authorization from the patient releasing copies of his or her medical records is required by
all of the following EXCEPT: - answer the hospital attorney for the facility where the patient is
treated
When developing a record retention policy, the HIM professionals should consider all of the
following EXCEPT: - answer the thickness of the records
A valid authorization for the disclosure of health information should not be - answer dated prior to
discharge of the patient
Who is legally responsible for obtaining the patient's informed consent for surgery? - answer the
surgeon performing the surgery
A signed consent for release of information dated December 1, 2005, is received with a request for
the chart from the patient's admission of 12/5/05. Indicate the appropriate response from the
options below. - answer Request another authorization dated after the discharge date
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that
sets forth all of the following EXCEPT: - answer covered entities provide every patient with its
annual business report
Which of the following is considered confidential information? - answer patient's diagnosis
Which would be the better "best practice" for handling fax transmission of a physician's orders? -
answer Treat faxed orders like verbal orders and require authentication of the orders by
appropriate medical staff within the required time period.
The proper method for correcting a documentation error in a medical record is for the author to -
answer draw a single line through the incorrect information, date, and initial the change
