RHIT Practice Exam 1 - 150 Questions With
Correct Answers
A |health |record |technician |has |been |asked |to |review |the |discharge |patient |
abstracting |module |of |a |proposed |new |electronic |health |record |(EHR). |Which |of |
the |following |data |sets |would |the |technician |consult |to |ensure |the |system |collects
|all |federally |required |discharge |data |elements |for |Medicare |and |Medicaid |
inpatients |in |an |acute-care |hospital?
a. |CARF
b. |DEEDS
c. |UACDS
d. |UHDDS |- |CORRECT |ANSWER✔✔-d. |UHDDS |(Uniform |Hospital |Discharge |Data |Set)
The |Uniform |Hospital |Discharge |Data |Set |(UHDDS) |data |characteristics |include |
patient-specific |items |on |every |inpatient.
Standardizing |medical |terminology |to |avoid |differences |in |naming |various |health |
conditions |and |procedures |(such |as |the |synonyms |bunionectomy, |McBride |procedure,
|and |repair |of |hallux |valgus) |is |one |purpose |of:
a. |Content |and |structure |standards
b. |Security |standard
c. |Transaction |standards
d. |Vocabulary |standards |- |CORRECT |ANSWER✔✔-d. |Vocabulary |standards
,Vocabulary |standards |are |a |list |or |collection |of |clinical |words |or |phrases |with |
their |meanings; |also, |the |set |of |words |used |by |an |individual |or |group |within |a |
particular |subject |field, |such |as |to |provide |consistent |descriptions |of |medical |terms
|for |an |individual's |condition |in |the |health |record.
Patient |care |managers |use |the |data |documented |in |the |health |record |to:
a. |Determine |the |extent |and |effects |of |occupational |hazards
b. |Evaluate |patterns |and |trends |of |patient |care
c. |Generate |patient |bills |and |third-party |payer |claims |for |reimbursement
d. |Provide |direct |patient |care |- |CORRECT |ANSWER✔✔-b. |Evaluate |patterns |and |
trends |of |patient |care
Patient |care |managers |are |responsible |for |the |overall |evaluation |of |services |
rendered |for |their |particular |area |of |responsibility. |To |identify |patterns |and |trends,
|they |take |details |from |individual |health |records |and |put |all |the |information |
together |in |one |place.
At |admission, |Mrs. |Smith's |date |of |birth |is |recorded |as |3/25/1948. |An |audit |of |
the |EHR |discovers |that |the |numbers |in |the |date |of |birth |are |transposed |in |
reports. |This |situation |reflects |a |problem |in:
a. |Data |comprehensiveness
b. |Data |consistency
c. |Data |currency
d. |Data |granularity |- |CORRECT |ANSWER✔✔-b. |Data |consistency
Consistency |means |ensuring |the |patient |data |is |reliable |and |the |same |across |the |
entire |patient |encounter. |In |other |words, |patient |data |within |the |record |should |be
|the |same |and |should |not |contradict |other |data |also |in |the |patient |record.
,A |health |data |analyst |has |been |asked |to |compile |a |listing |of |daily |blood |pressure
|readings |for |patients |with |a |diagnosis |of |hypertension |who |were |treated |on |the |
medical |unit |within |a |two-week |period. |What |clinical |report |would |be |the |best |
source |to |gather |this |information?
a. |Vital |signs |record
b. |Initial |nursing |assessment |record
c. |Physician |progress |notes
d. |Admission |record |- |CORRECT |ANSWER✔✔-a. |Vital |signs |record
The |vital |signs |record |is |comprised |of |blood |pressure |readings, |temperature, |
respiration, |and |pulse, |making |it |the |best |source |to |gather |this |type |of |
information.
Which |of |the |following |is |a |key |characteristic |of |the |problem-oriented |health |
record?
a. |Allows |all |providers |to |document |in |the |health |record
b. |Uses |laboratory |reports |and |other |diagnostic |tools |to |determine |health |problems
c. |Provides |electronic |documentation |in |the |health |record
d. |Uses |an |itemized |list |of |the |patient's |past |and |present |health |problems |- |
CORRECT |ANSWER✔✔-d. |Uses |an |itemized |list |of |the |patient's |past |and |present |
health |problems
The |problem-oriented |health |record |is |better |suited |to |serve |the |patient |and |the |
end |user |of |the |patient's |information. |The |key |characteristic |of |this |format |is |an |
itemized |list |of |the |patient's |past |and |present |social, |psychological, |and |health |
problems.
, Which |of |the |following |is |true |regarding |the |reporting |of |communicable |diseases?
a. |They |must |be |reported |by |the |patient |to |the |health |department.
b. |The |diseases |to |be |reported |are |established |by |state |law.
c. |The |diseases |to |be |reported |are |established |by |HIPAA.
d. |They |are |never |reported |because |it |would |violate |the |patient's |privacy. |- |
CORRECT |ANSWER✔✔-b. |The |diseases |to |be |reported |are |established |by |state |law.
All |states |have |a |health |department |with |a |division |that |is |required |to |track |and
|record |communicable |diseases. |When |a |patient |is |diagnosed |with |one |of |the |
diseases |from |the |health |department's |communicable |disease |list, |the |facility |must |
notify |the |state |public |health |department.
A |new |health |information |management |(HIM) |director |has |been |asked |by |the |
hospital |CIO |to |ensure |data |content |standards |are |identified, |understood, |
implemented, |and |managed |for |the |hospital's |EHR |system. |Which |of |the |following |
should |be |the |HIM |director's |first |step |in |carrying |out |this |responsibility?
a. |Call |the |EHR |vendor |and |ask |to |review |the |system's |data |dictionary
b. |Identify |data |content |requirements |for |all |areas |of |the |organization
c. |Schedule |a |meeting |with |all |department |directors |to |get |their |input
d. |Contact |CMS |to |determine |what |data |sets |are |required |to |be |collected |- |
CORRECT |ANSWER✔✔-b. |Identify |data |content |requirements |for |all |areas |of |the |
organization
Data |content |standards |allow |organizations |to |collect |data |once |and |use |it |many |
times |in |many |ways. |They |also |assist |in |data |storage |and |mining |as |well |as |
sharing |data |with |external |organizations |for |use |in |benchmarking |and |other |
purposes.
Correct Answers
A |health |record |technician |has |been |asked |to |review |the |discharge |patient |
abstracting |module |of |a |proposed |new |electronic |health |record |(EHR). |Which |of |
the |following |data |sets |would |the |technician |consult |to |ensure |the |system |collects
|all |federally |required |discharge |data |elements |for |Medicare |and |Medicaid |
inpatients |in |an |acute-care |hospital?
a. |CARF
b. |DEEDS
c. |UACDS
d. |UHDDS |- |CORRECT |ANSWER✔✔-d. |UHDDS |(Uniform |Hospital |Discharge |Data |Set)
The |Uniform |Hospital |Discharge |Data |Set |(UHDDS) |data |characteristics |include |
patient-specific |items |on |every |inpatient.
Standardizing |medical |terminology |to |avoid |differences |in |naming |various |health |
conditions |and |procedures |(such |as |the |synonyms |bunionectomy, |McBride |procedure,
|and |repair |of |hallux |valgus) |is |one |purpose |of:
a. |Content |and |structure |standards
b. |Security |standard
c. |Transaction |standards
d. |Vocabulary |standards |- |CORRECT |ANSWER✔✔-d. |Vocabulary |standards
,Vocabulary |standards |are |a |list |or |collection |of |clinical |words |or |phrases |with |
their |meanings; |also, |the |set |of |words |used |by |an |individual |or |group |within |a |
particular |subject |field, |such |as |to |provide |consistent |descriptions |of |medical |terms
|for |an |individual's |condition |in |the |health |record.
Patient |care |managers |use |the |data |documented |in |the |health |record |to:
a. |Determine |the |extent |and |effects |of |occupational |hazards
b. |Evaluate |patterns |and |trends |of |patient |care
c. |Generate |patient |bills |and |third-party |payer |claims |for |reimbursement
d. |Provide |direct |patient |care |- |CORRECT |ANSWER✔✔-b. |Evaluate |patterns |and |
trends |of |patient |care
Patient |care |managers |are |responsible |for |the |overall |evaluation |of |services |
rendered |for |their |particular |area |of |responsibility. |To |identify |patterns |and |trends,
|they |take |details |from |individual |health |records |and |put |all |the |information |
together |in |one |place.
At |admission, |Mrs. |Smith's |date |of |birth |is |recorded |as |3/25/1948. |An |audit |of |
the |EHR |discovers |that |the |numbers |in |the |date |of |birth |are |transposed |in |
reports. |This |situation |reflects |a |problem |in:
a. |Data |comprehensiveness
b. |Data |consistency
c. |Data |currency
d. |Data |granularity |- |CORRECT |ANSWER✔✔-b. |Data |consistency
Consistency |means |ensuring |the |patient |data |is |reliable |and |the |same |across |the |
entire |patient |encounter. |In |other |words, |patient |data |within |the |record |should |be
|the |same |and |should |not |contradict |other |data |also |in |the |patient |record.
,A |health |data |analyst |has |been |asked |to |compile |a |listing |of |daily |blood |pressure
|readings |for |patients |with |a |diagnosis |of |hypertension |who |were |treated |on |the |
medical |unit |within |a |two-week |period. |What |clinical |report |would |be |the |best |
source |to |gather |this |information?
a. |Vital |signs |record
b. |Initial |nursing |assessment |record
c. |Physician |progress |notes
d. |Admission |record |- |CORRECT |ANSWER✔✔-a. |Vital |signs |record
The |vital |signs |record |is |comprised |of |blood |pressure |readings, |temperature, |
respiration, |and |pulse, |making |it |the |best |source |to |gather |this |type |of |
information.
Which |of |the |following |is |a |key |characteristic |of |the |problem-oriented |health |
record?
a. |Allows |all |providers |to |document |in |the |health |record
b. |Uses |laboratory |reports |and |other |diagnostic |tools |to |determine |health |problems
c. |Provides |electronic |documentation |in |the |health |record
d. |Uses |an |itemized |list |of |the |patient's |past |and |present |health |problems |- |
CORRECT |ANSWER✔✔-d. |Uses |an |itemized |list |of |the |patient's |past |and |present |
health |problems
The |problem-oriented |health |record |is |better |suited |to |serve |the |patient |and |the |
end |user |of |the |patient's |information. |The |key |characteristic |of |this |format |is |an |
itemized |list |of |the |patient's |past |and |present |social, |psychological, |and |health |
problems.
, Which |of |the |following |is |true |regarding |the |reporting |of |communicable |diseases?
a. |They |must |be |reported |by |the |patient |to |the |health |department.
b. |The |diseases |to |be |reported |are |established |by |state |law.
c. |The |diseases |to |be |reported |are |established |by |HIPAA.
d. |They |are |never |reported |because |it |would |violate |the |patient's |privacy. |- |
CORRECT |ANSWER✔✔-b. |The |diseases |to |be |reported |are |established |by |state |law.
All |states |have |a |health |department |with |a |division |that |is |required |to |track |and
|record |communicable |diseases. |When |a |patient |is |diagnosed |with |one |of |the |
diseases |from |the |health |department's |communicable |disease |list, |the |facility |must |
notify |the |state |public |health |department.
A |new |health |information |management |(HIM) |director |has |been |asked |by |the |
hospital |CIO |to |ensure |data |content |standards |are |identified, |understood, |
implemented, |and |managed |for |the |hospital's |EHR |system. |Which |of |the |following |
should |be |the |HIM |director's |first |step |in |carrying |out |this |responsibility?
a. |Call |the |EHR |vendor |and |ask |to |review |the |system's |data |dictionary
b. |Identify |data |content |requirements |for |all |areas |of |the |organization
c. |Schedule |a |meeting |with |all |department |directors |to |get |their |input
d. |Contact |CMS |to |determine |what |data |sets |are |required |to |be |collected |- |
CORRECT |ANSWER✔✔-b. |Identify |data |content |requirements |for |all |areas |of |the |
organization
Data |content |standards |allow |organizations |to |collect |data |once |and |use |it |many |
times |in |many |ways. |They |also |assist |in |data |storage |and |mining |as |well |as |
sharing |data |with |external |organizations |for |use |in |benchmarking |and |other |
purposes.
