RHIT Mock Exam ALL sections with Complete Solution

In the past, the Joint Commission standards 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 - use of prohibited or "dangerous" abbreviations A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the - incident report For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the - problem list The federally mandated resident assessment instrument used in long term care facilities consists of three basic components, including the new care area assessments, utilization guidelines, and the - MDS or minimum data set As Director of HIT program, your community college has been selected to participate in the workforce develeopment of electronic health specialits as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need regular access to the Web site of this governmental agency. - ONC A qualitative review of a health record reveals that the h and p for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the h and p are true in the situation? Completion and charting of h and p indicates - noncompliance with JC standards. H and P must be completed within 24 hours The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is - 12-0001/00 because in accession number 12 represents the year the patient first entered the database, 0001 represents the first case entered that year, and 00 indicates no previous known neoplasm. Setting a drop down menu to make sure the registration clerk collects gender as male or female is a method of ensuring data - Precision Validity refers to the accuracy of data, while reliability refers to the consistency of the data. Timeliness refers to the data being available when needed, and precision refers to data values that are just large enough to support the application process. 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 Federal Register CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register. In an acute care hospital, a complete history and physical may not be required for a new admission when - A legible copy of a recent h and p performed in the attending physician's ofice is available. An interval h and p can be used when a patient is readmitted for the same or related problem within the 30 days, and no matter how long the patient stays an h and p is required. The authors of all entries in a health care record should be - clearly identified In creating a new form or computer view, the designer should be most driven by - needs of the users According to the following data, the most serious record delinquecy problem occurred in which month? Record Delinquency Mo. April May June % incomplete records 70% 88% 79% %delinquent records 51% 43% 61% % delinquent DT minssing H&P 3% 1.4% .05% - April, because JC reccommendation for improvement is indicated if the number of delinquent records is greater than 50% or if the % of delinquent records DT missing H&P exceeds 2% of average monthly discharges. The % of incomplete records is irrelevant An example of objective entry in the health record supplied by a health care practitioner is the - Physical Assessment. The medical history, including a review of systems and chief complaint, is information supplied by the patient. As Chair of the Health Record Committee you have been asked to reccommend a time limited documentation standard for inclusion in medical staff bylaws, rules, and regulations. that must meet standards of both JC and Medicare COP. For H&P you advise the time period for completion should be set at - 24 hours after admission or prior to surgery An example of a primary data source for health care statistics is the - hospital census Which of the following is LEAST likely to be identified by a definciency analysis technician - Discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatinet scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from - R-ADT system also known as the registration-admission, discharge and transfer system Which method of authorship or authentication of entries would be inappropriate to use in a patient's health record? - Delegated use of a computer hey by radiology secretary. Use of codes and stamped signatures MUST be confined to the owners and they are never to be used by anyone else. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of - Qualitative review Which of the four distinct components of the problem oriented record serves to help index documentation throughout the record - Problem list Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record - Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011 Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? - Use CPOE for medication orders Using a template to collect data for key reports may help to prompt caregivers to document all required elements in the patient record. This practice contributes to data - Comprehensiveness A primary focus of screen format design in a health record computer application should be to ensure that - The user is capturing essential data elements A quality improvement team is focusing on the unacceptable number of unsigned doctors' orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be - Developing an open record review process 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 mus be - recorded by persons authorized by hospital regulations and procedures. For inpatients, the first data item collected of clinical nature is usually - admitting diagnosis When asked to explain how review of systems differs form a physical exam you explain that the review of systems is used to document - Subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant Skilled nursing facilities chose to submit MDS data using RAVEN software, or software purchased commercially through a vendor provided the software meets - CMS standards In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26 - 00-06-26 What is the chief criterion for determining record inactivity? - Amount of space available for storage of newer records According to terminal digit filing, what would be the number of the record immediately after record -31 The function of a ______________ is limited to data retrieval - Clinical data repository A coder notes that a patient is taking prescrition Pilocarpine. The final Dx is CHF and DM. The coder should query about adding DX of - Glaucoma Which of the following classification systems was designed with the electronic systems in mind and is currently being used for problem lists, ICU monitoring, patient care assessments, data collections, medical research studies, clinical trials, disease surviellance, and image d? - SNOMED CT The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type is the - record-over-record method The most common type of registry located in hospitals of all sizes and in every region of the country is the - cancer registry The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment. The best source is the - Cancer registry abstracts All of the following items are packaged under the Medicare OPPS except - Medical Visits How many major Dx categories are there in the MS-DRG system? - 25 The standard form used by hospitals to request reimbursement