RHIT Practice Exam Compliance (CENGAGE)
As the compliance officer for a large physician practice group, you are interested in researching the
original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You
begin by googling - ANSWER:HITECH Act
A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the
medical staff as well as to administration the powerful impact that precise documentation has on the
internal and external data reporting. In this role, he/she is acting as a(n) - ANSWER:educator
Referring to the data below, determine the delinquent record rate for Springfield Hospital.
SPRINGFIELD HOSPITAL QUARTERLY STATISTICS
Average monthly discharges
1,820
Average monthly operative procedures
458
Number of incomplete records
1,002
Number of delinquent records
590
CALCULATION:
Using the basic rate formula, calculate as follows:
Delinquent records × 100 divided by average monthly discharges, or
(590 x 100) divided by (1,820) = 32.4% - ANSWER:32%
In the past, Joint Commission standards have focused on promoting the use of a facility-approved
abbreviation list to be used by hospital care providers. With the advent of the commission's national
patient safety goals, the focus has shifted to the - ANSWER:use of prohibited or "dangerous"
abbreviations
You have been appointed as chair of the Health Record Committee at a new hospital. Your committee
has been asked to recommend time-limited documentation standards for inclusion in the medical staff
bylaws, rules, and regulations. The committee documentation standards must meet the standards of
both the Joint Commission and the Medicare Conditions of Participation. The standards for the history
, and physical exam documentation are discussed first. You advise them that the time period for
completion of this report should be set at - ANSWER:24 hours after admission or prior to surgery
In an acute care hospital, a complete history and physical may not be required for a new admission when
- ANSWER:a legible copy of a current H&P performed in the attending physician's office is available.
All of these are quality improvement strategies EXCEPT - ANSWER:error-based penalites
Your facility has a team that has been working to develop a strong performance improvement model,
and they have come up with the model shown above. The team asks if you see anything missing from
the model. You tell them they (See WORD document) - ANSWER:are missing a step requiring ongoing
monitoring and reassessment
Which of the following reports would normally be considered a consultation? - ANSWER:impressions of a
cardiologist asked to determine whether patient is a good surgical risk
The federally mandated resident assessment instrument used in long-term care facilities consists of
three basic components, including the new care area assessment, utilization guidelines, and the -
ANSWER:MDS
A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable
medications with cheap outdated ones purchased on the Internet and then sold the good drugs for
profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be
held responsible for the pharmacist's negligent acts under the doctrine of - ANSWER:respondeat
superior.
In conducting an educational session for your staff about implementing a benchmarking program, you
tell your staff that when an organization uses benchmarking, it is important to compare your facility's
outcomes to - ANSWER:facilities with superior performance.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now
required to use a preoperative verification process to confirm the patient's true identity and to confirm
that necessary documents such as X-rays or medical records are available. They must also develop and
use a process for - ANSWER:marking the surgical site.
Resources that produce little-to-no value to the organization, such as non-utilized talent, inventory
miscalculations, and staff members waiting for information so they can do their jobs, is known as
_______, which must be reduced, if not eliminated, in a lean managed organization. - ANSWER:waste
As a trauma registrar working in an emergency department, you want to begin comparing your trauma
care services to other hospital-based emergency departments. To ensure that your facility is collecting
the same data as other facilities, you review elements from which data set? - ANSWER:DEEDS
Joint Commission standards require that a complete history and physical be documented on the health
records of operative patients. Does this report carry a time requirement? - ANSWER:yes, prior to surgery
A clinical documentation specialist performs many duties. These include reviewing the data and looking
for trends or patterns over time, as well as noting any variances that require further investigation. In this
role, the CDS professional is acting as a(n) - ANSWER:analyst
As the compliance officer for a large physician practice group, you are interested in researching the
original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You
begin by googling - ANSWER:HITECH Act
A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the
medical staff as well as to administration the powerful impact that precise documentation has on the
internal and external data reporting. In this role, he/she is acting as a(n) - ANSWER:educator
Referring to the data below, determine the delinquent record rate for Springfield Hospital.
SPRINGFIELD HOSPITAL QUARTERLY STATISTICS
Average monthly discharges
1,820
Average monthly operative procedures
458
Number of incomplete records
1,002
Number of delinquent records
590
CALCULATION:
Using the basic rate formula, calculate as follows:
Delinquent records × 100 divided by average monthly discharges, or
(590 x 100) divided by (1,820) = 32.4% - ANSWER:32%
In the past, Joint Commission standards have focused on promoting the use of a facility-approved
abbreviation list to be used by hospital care providers. With the advent of the commission's national
patient safety goals, the focus has shifted to the - ANSWER:use of prohibited or "dangerous"
abbreviations
You have been appointed as chair of the Health Record Committee at a new hospital. Your committee
has been asked to recommend time-limited documentation standards for inclusion in the medical staff
bylaws, rules, and regulations. The committee documentation standards must meet the standards of
both the Joint Commission and the Medicare Conditions of Participation. The standards for the history
, and physical exam documentation are discussed first. You advise them that the time period for
completion of this report should be set at - ANSWER:24 hours after admission or prior to surgery
In an acute care hospital, a complete history and physical may not be required for a new admission when
- ANSWER:a legible copy of a current H&P performed in the attending physician's office is available.
All of these are quality improvement strategies EXCEPT - ANSWER:error-based penalites
Your facility has a team that has been working to develop a strong performance improvement model,
and they have come up with the model shown above. The team asks if you see anything missing from
the model. You tell them they (See WORD document) - ANSWER:are missing a step requiring ongoing
monitoring and reassessment
Which of the following reports would normally be considered a consultation? - ANSWER:impressions of a
cardiologist asked to determine whether patient is a good surgical risk
The federally mandated resident assessment instrument used in long-term care facilities consists of
three basic components, including the new care area assessment, utilization guidelines, and the -
ANSWER:MDS
A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable
medications with cheap outdated ones purchased on the Internet and then sold the good drugs for
profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be
held responsible for the pharmacist's negligent acts under the doctrine of - ANSWER:respondeat
superior.
In conducting an educational session for your staff about implementing a benchmarking program, you
tell your staff that when an organization uses benchmarking, it is important to compare your facility's
outcomes to - ANSWER:facilities with superior performance.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now
required to use a preoperative verification process to confirm the patient's true identity and to confirm
that necessary documents such as X-rays or medical records are available. They must also develop and
use a process for - ANSWER:marking the surgical site.
Resources that produce little-to-no value to the organization, such as non-utilized talent, inventory
miscalculations, and staff members waiting for information so they can do their jobs, is known as
_______, which must be reduced, if not eliminated, in a lean managed organization. - ANSWER:waste
As a trauma registrar working in an emergency department, you want to begin comparing your trauma
care services to other hospital-based emergency departments. To ensure that your facility is collecting
the same data as other facilities, you review elements from which data set? - ANSWER:DEEDS
Joint Commission standards require that a complete history and physical be documented on the health
records of operative patients. Does this report carry a time requirement? - ANSWER:yes, prior to surgery
A clinical documentation specialist performs many duties. These include reviewing the data and looking
for trends or patterns over time, as well as noting any variances that require further investigation. In this
role, the CDS professional is acting as a(n) - ANSWER:analyst
