RHIT 11 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100% Verified
Discharge summary documentation must include - significant findings during hospitalization
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews
evaluate - completeness, adequacy, and quality of documentation
Quantitative and qualitative reviews performed on patient records by medical record personnel in either
a skilled nursing facility or inpatient psychiatric facility are generally in the form of - concurrent chart
review
The foundation for communicating all patient care goals in long-term care settings is the - individualized
patient care plan.
Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring
trends in delinquent health record percentages? - Health Record Committee
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 - source-oriented
In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the
process of ongoing record review. All health record reviews are presently performed by a team of HIM
department personnel. The committee meets quarterly and reports to a Quality Management
Committee. In reviewing Joint Commission standards, your first recommended change is to - provide for
record reviews to be performed by an interdisciplinary team of care providers
As the privacy officer of your facility, you have been charged with developing policies and procedures for
protecting the confidentiality and security of the clinical data collected in your computerized system.
One of the first steps you will take is to judge the value of information processed by your system and
classify it. Another step you will need to take is to - authorize access to information collected based on
level of data sensitivity
, A qualitative review of a health record reveals that the history and physical for a patient admitted on
June 26 was performed on June 30 and transcribed on July 1. Which of the following statements
regarding the history and physical is true in this situation? Completion and charting of the H&P indicates
- noncompliance with Joint Commission standards
As your acute care facility moves toward the adoption of an EHR, your planning committee is trying to
prioritize systems that will contribute to patient safety. Your physicians have indicated readiness to
enter data directly into the EHR, and they acknowledge the need for decision support regarding drug
dosages and contraindications. You think they are ready for a - computerized provider order-entry
system
You have been asked by a peer review committee to print a list of the medical record numbers of all
patients who had CABGs performed in the past year at your acute care hospital. Which secondary data
source could be used to quickly gather this information? - Operation index
Many of the principles of forms design apply to both paper-based and computer-based systems. For
example, the physical layout of the form and/or screen should be organized to match the way the
information is requested. Facilities that are scanning and imaging paper records as part of a computer-
based system must give careful consideration to - bar code placement
Which of the following is a form or view that is typically seen in the health record of a long-term care
patient, but is rarely seen in records of acute care patients? - Pharmacy consultation
One distinct advantage of the EHR over paper-based health records is the - accessibility of the record by
multiple data users
As the Data Security Officer for your institution, you plan to implement a log—on process for electronic
signing that is LEAST susceptible to improper delegation of use. The method you will recommend is -
biometrics-based identifier
In an acute care hospital, a complete history and physical may not be dictated for a new admission when
- a legible copy of a recent H&P performed in the attending physician's office is available.
You are developing a complete data dictionary for your facility. Which of the following resources will be
most helpful in providing standard definitions for data commonly collected in acute care hospitals? -
Uniform Hospital Discharge Data Set
Discharge summary documentation must include - significant findings during hospitalization
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews
evaluate - completeness, adequacy, and quality of documentation
Quantitative and qualitative reviews performed on patient records by medical record personnel in either
a skilled nursing facility or inpatient psychiatric facility are generally in the form of - concurrent chart
review
The foundation for communicating all patient care goals in long-term care settings is the - individualized
patient care plan.
Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring
trends in delinquent health record percentages? - Health Record Committee
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 - source-oriented
In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the
process of ongoing record review. All health record reviews are presently performed by a team of HIM
department personnel. The committee meets quarterly and reports to a Quality Management
Committee. In reviewing Joint Commission standards, your first recommended change is to - provide for
record reviews to be performed by an interdisciplinary team of care providers
As the privacy officer of your facility, you have been charged with developing policies and procedures for
protecting the confidentiality and security of the clinical data collected in your computerized system.
One of the first steps you will take is to judge the value of information processed by your system and
classify it. Another step you will need to take is to - authorize access to information collected based on
level of data sensitivity
, A qualitative review of a health record reveals that the history and physical for a patient admitted on
June 26 was performed on June 30 and transcribed on July 1. Which of the following statements
regarding the history and physical is true in this situation? Completion and charting of the H&P indicates
- noncompliance with Joint Commission standards
As your acute care facility moves toward the adoption of an EHR, your planning committee is trying to
prioritize systems that will contribute to patient safety. Your physicians have indicated readiness to
enter data directly into the EHR, and they acknowledge the need for decision support regarding drug
dosages and contraindications. You think they are ready for a - computerized provider order-entry
system
You have been asked by a peer review committee to print a list of the medical record numbers of all
patients who had CABGs performed in the past year at your acute care hospital. Which secondary data
source could be used to quickly gather this information? - Operation index
Many of the principles of forms design apply to both paper-based and computer-based systems. For
example, the physical layout of the form and/or screen should be organized to match the way the
information is requested. Facilities that are scanning and imaging paper records as part of a computer-
based system must give careful consideration to - bar code placement
Which of the following is a form or view that is typically seen in the health record of a long-term care
patient, but is rarely seen in records of acute care patients? - Pharmacy consultation
One distinct advantage of the EHR over paper-based health records is the - accessibility of the record by
multiple data users
As the Data Security Officer for your institution, you plan to implement a log—on process for electronic
signing that is LEAST susceptible to improper delegation of use. The method you will recommend is -
biometrics-based identifier
In an acute care hospital, a complete history and physical may not be dictated for a new admission when
- a legible copy of a recent H&P performed in the attending physician's office is available.
You are developing a complete data dictionary for your facility. Which of the following resources will be
most helpful in providing standard definitions for data commonly collected in acute care hospitals? -
Uniform Hospital Discharge Data Set
