RHIA Study Guide with Complete
Solutions
Select the appropriate situation for which a final progress note may legitimately be
substituted for a discharge summary in an inpatient medical record. - ANSWER-Baby
Boy Hiltz, born 1/5/20, maintained normal status, discharged 1/7/20
Final Progress Note May substitute for a discharge summary in the following cases: -
ANSWER-1. patients who are hospitalized less than 48 hours with problems of a minor
nature, normal newborns, and uncomplicated obstetrical deliveries.
2. patients with complications and length of stay don't qualify.
An effective information governance system should include all of the following
principles: - ANSWER-1. Principle of availability
2. Principle of disposition
3. Principle of retention
NOT: the principle of interoperability
the principle of interoperability - ANSWER-relates to the technical standards required for
the exchange of health information between facilities, while information governance is
primarily focused on the internal use and usefulness of data maintained within the
organization.
the principle of availability - ANSWER-ensures the timely and efficient retrieval of
information when needed by an authorized personnel.
the principle of disposition - ANSWER-is designed to create processes for the
appropriate disposition of information that is no longer needed by the organization
the principle of retention - ANSWER-considers the proper retention of information based
on regulatory requirements those from external requesters
The Quality Payment Program includes - ANSWER-Advanced Alternative Payment
Models(APM) & Merit-Based Incentive Payment System(MIPS)
The final HITECH Omnibus Rule expanded some of HIPPA's original requirements,
including changes in immunization disclosures. As a result, where states require
immunization records of a minor prior to admitting a student to a school, a covered
entity is permitted to disclose proof of immunization to a school without... - ANSWER-
written authorization of the parent.
,(an agreement must still be obtained and documented, but no signature by he parent is
required.
You have been appointed as chair of Health Record Committee at a new hospital. Your
committee has asked to recommend time-related documentation standards for inclusion
in the medical staff by laws, rules and regulations. the committee documented
standards must meet the standards of both Joint Commission & Medicare Conditions of
Participation. The standards for the history & physical exam documentation are
discussed first. You advise them that the time period for completion of this report should
be set as.. - ANSWER-24 hours after admission & prior to surgery
(This time requirement complies with both Joint Commission & COP standards.
Which of the following is a secondary data source that would be used to quickly gather
the health records of a juvenile patient treated for diabetes with in the past 6 months -
ANSWER-Disease Index(a listing of diagnosis code numbers that matches the codes to
the patients who had those diseases)
NOT:
pediatric census sheet
procedure index
patient register
While data governance focuses primarily on managing data as it is bein created within a
healthcare system, information governance focuses instead on managing..... -
ANSWER-the output of those systems.
NOT:
data currency
the granularity of the healthcare systems
data accuracy
data governance - ANSWER-refers to information created in different systems used in
healthcare
Information Governance - ANSWER-manages information output
Data currency - ANSWER-relates to capturing data that is up to date
Data Accuracy - ANSWER-The extent to which data are free of identifiable errors. Tied
closely to data input more than output
Granularity - ANSWER-refers to collecting data at the correct level of detail
Setting up a drop down menu to make sure that the registration clerk collects "gender"
as "male, female, or unknown" is an example of ensuring data - ANSWER-
Precision(refers to data that is precise and collected in its exact form so there will be no
variability in the data)
NOT:
, validity(refers to the accuracy of data)
reliability(refers to its consistency)
timeliness(refers to data being available within a time frame helpful to the user)
As a new manager at an 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 the - ANSWER-hospital bylaws, rules and regulations
NOT:
policy and procedure manual
Federal Register
consolidated manual for hospitals
*Although Joint C., CMS, and state laws may include standards for verbal orders, the
specific information regarding which employees have been given authority to transcribe
verbal orders in your facility should be located in your hospital's bylaws, rules, and
regulations
As the Chair of a Forms Review Committee, you need to track the field name of a
particular data field and the security levels applicable to that field. Your best source for
this information would be the - ANSWER-facility's data dictionary(should include
security levels for each field as well as definitions for all entities).
NOT:
glossary of healthcare terms
MDS
UHDDS
*type of data set for collecting data in long-term MDS & acute care UHDDS facilities.
The healthcare providers at your hospital do a very thorough job of periodic open record
review to ensure the completeness of record documentation. A qualitative review of
surgical records would likely include checking for documentation regarding.... -
ANSWER-the presence or absence of such items as preoperative & postoperative
diagnosis description of findings and specimens removed.
*"Whether a postoperative infection occurred and how it was treated" represents an
appropriate job for the infection control officer. The quality of follow-up care represents
the clinical care evaluation process, rather than the review of quality documentation.
"whether the severity of illness and/or intensity of service warranted acute level care is a
function of the utilization review program. The correct answer is " the presence or
absence of such items as preoperative and postoperative diagnosis, description of
findings, and specimens removed."
Improving clinical outcomes and optimal continuity of care for patients are common
goals of clinical documentation improvement programs in acute care hospitals.
Additionally, CDI programs may work together with UM programs to - ANSWER-reduce
clinical denials for medical necessity.(clinical documentation improvement programs are
designed to improve clinical documentation specificity, thus supporting the medical
Solutions
Select the appropriate situation for which a final progress note may legitimately be
substituted for a discharge summary in an inpatient medical record. - ANSWER-Baby
Boy Hiltz, born 1/5/20, maintained normal status, discharged 1/7/20
Final Progress Note May substitute for a discharge summary in the following cases: -
ANSWER-1. patients who are hospitalized less than 48 hours with problems of a minor
nature, normal newborns, and uncomplicated obstetrical deliveries.
2. patients with complications and length of stay don't qualify.
An effective information governance system should include all of the following
principles: - ANSWER-1. Principle of availability
2. Principle of disposition
3. Principle of retention
NOT: the principle of interoperability
the principle of interoperability - ANSWER-relates to the technical standards required for
the exchange of health information between facilities, while information governance is
primarily focused on the internal use and usefulness of data maintained within the
organization.
the principle of availability - ANSWER-ensures the timely and efficient retrieval of
information when needed by an authorized personnel.
the principle of disposition - ANSWER-is designed to create processes for the
appropriate disposition of information that is no longer needed by the organization
the principle of retention - ANSWER-considers the proper retention of information based
on regulatory requirements those from external requesters
The Quality Payment Program includes - ANSWER-Advanced Alternative Payment
Models(APM) & Merit-Based Incentive Payment System(MIPS)
The final HITECH Omnibus Rule expanded some of HIPPA's original requirements,
including changes in immunization disclosures. As a result, where states require
immunization records of a minor prior to admitting a student to a school, a covered
entity is permitted to disclose proof of immunization to a school without... - ANSWER-
written authorization of the parent.
,(an agreement must still be obtained and documented, but no signature by he parent is
required.
You have been appointed as chair of Health Record Committee at a new hospital. Your
committee has asked to recommend time-related documentation standards for inclusion
in the medical staff by laws, rules and regulations. the committee documented
standards must meet the standards of both Joint Commission & Medicare Conditions of
Participation. The standards for the history & physical exam documentation are
discussed first. You advise them that the time period for completion of this report should
be set as.. - ANSWER-24 hours after admission & prior to surgery
(This time requirement complies with both Joint Commission & COP standards.
Which of the following is a secondary data source that would be used to quickly gather
the health records of a juvenile patient treated for diabetes with in the past 6 months -
ANSWER-Disease Index(a listing of diagnosis code numbers that matches the codes to
the patients who had those diseases)
NOT:
pediatric census sheet
procedure index
patient register
While data governance focuses primarily on managing data as it is bein created within a
healthcare system, information governance focuses instead on managing..... -
ANSWER-the output of those systems.
NOT:
data currency
the granularity of the healthcare systems
data accuracy
data governance - ANSWER-refers to information created in different systems used in
healthcare
Information Governance - ANSWER-manages information output
Data currency - ANSWER-relates to capturing data that is up to date
Data Accuracy - ANSWER-The extent to which data are free of identifiable errors. Tied
closely to data input more than output
Granularity - ANSWER-refers to collecting data at the correct level of detail
Setting up a drop down menu to make sure that the registration clerk collects "gender"
as "male, female, or unknown" is an example of ensuring data - ANSWER-
Precision(refers to data that is precise and collected in its exact form so there will be no
variability in the data)
NOT:
, validity(refers to the accuracy of data)
reliability(refers to its consistency)
timeliness(refers to data being available within a time frame helpful to the user)
As a new manager at an 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 the - ANSWER-hospital bylaws, rules and regulations
NOT:
policy and procedure manual
Federal Register
consolidated manual for hospitals
*Although Joint C., CMS, and state laws may include standards for verbal orders, the
specific information regarding which employees have been given authority to transcribe
verbal orders in your facility should be located in your hospital's bylaws, rules, and
regulations
As the Chair of a Forms Review Committee, you need to track the field name of a
particular data field and the security levels applicable to that field. Your best source for
this information would be the - ANSWER-facility's data dictionary(should include
security levels for each field as well as definitions for all entities).
NOT:
glossary of healthcare terms
MDS
UHDDS
*type of data set for collecting data in long-term MDS & acute care UHDDS facilities.
The healthcare providers at your hospital do a very thorough job of periodic open record
review to ensure the completeness of record documentation. A qualitative review of
surgical records would likely include checking for documentation regarding.... -
ANSWER-the presence or absence of such items as preoperative & postoperative
diagnosis description of findings and specimens removed.
*"Whether a postoperative infection occurred and how it was treated" represents an
appropriate job for the infection control officer. The quality of follow-up care represents
the clinical care evaluation process, rather than the review of quality documentation.
"whether the severity of illness and/or intensity of service warranted acute level care is a
function of the utilization review program. The correct answer is " the presence or
absence of such items as preoperative and postoperative diagnosis, description of
findings, and specimens removed."
Improving clinical outcomes and optimal continuity of care for patients are common
goals of clinical documentation improvement programs in acute care hospitals.
Additionally, CDI programs may work together with UM programs to - ANSWER-reduce
clinical denials for medical necessity.(clinical documentation improvement programs are
designed to improve clinical documentation specificity, thus supporting the medical
