RHIT Final Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%
Verified
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You
must name each form for bar coding and indexing into a document management system. The unnamed
document in front of you includes a microscopic description of tissue excised during surgery. The
document type you are most likely to give to this form is: - Pathology report
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 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
As a new 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. - Hospital Bylaws, Rules, and Regulations
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 must be - accepted by persons
authorized by hospital regulations and procedures
The lack of a discharge order may indicate that the patient left against medical advice. If this situation
occurs, you would expect to see the circumstances of the leave. - documented in both the progress
notes and discharge summary
Joint Commission standards require that at least one post-anesthesia visit be recorded on the health
records of operative patient. Does this post-anesthesia note carry a time requirement? - yes, within 24
hours of surgery
Discharge summary documentation must include - significant findings during hospitalization
, The protection of a patient's health information is addressed in each of the following EXCEPT: - A)Health
Insurance Portability and Accountability Act
B)Privacy Act C) Drug Abuse and Treatment Act
** D) U.S. Patriot Act **
The failure to obtain the written consent of the patient before performing a surgical procedure may
constitute - battery
A written authorization from the patient releasing copies of his or her medical records is required by all
of the following EXCEPT: - the hospital attorney for the facility where the patient is treated
When developing a record retention policy, the HIM professionals should consider all of the following
EXCEPT: - the thickness of the records
A valid authorization for the disclosure of health information should not be - dated prior to discharge of
the patient
Who is legally responsible for obtaining the patient's informed consent for surgery? - the surgeon
performing the surgery
A signed consent for release of information dated December 1, 2005, is received with a request for the
chart from the patient's admission of 12/5/05. Indicate the appropriate response from the options
below. - Request another authorization dated after the discharge date
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets
forth all of the following EXCEPT: - covered entities provide every patient with its annual business report
Which of the following is considered confidential information? - patient's diagnosis
Which would be the better "best practice" for handling fax transmission of a physician's orders? - Treat
faxed orders like verbal orders and require authentication of the orders by appropriate medical staff
within the required time period.
Verified
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You
must name each form for bar coding and indexing into a document management system. The unnamed
document in front of you includes a microscopic description of tissue excised during surgery. The
document type you are most likely to give to this form is: - Pathology report
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 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
As a new 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. - Hospital Bylaws, Rules, and Regulations
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 must be - accepted by persons
authorized by hospital regulations and procedures
The lack of a discharge order may indicate that the patient left against medical advice. If this situation
occurs, you would expect to see the circumstances of the leave. - documented in both the progress
notes and discharge summary
Joint Commission standards require that at least one post-anesthesia visit be recorded on the health
records of operative patient. Does this post-anesthesia note carry a time requirement? - yes, within 24
hours of surgery
Discharge summary documentation must include - significant findings during hospitalization
, The protection of a patient's health information is addressed in each of the following EXCEPT: - A)Health
Insurance Portability and Accountability Act
B)Privacy Act C) Drug Abuse and Treatment Act
** D) U.S. Patriot Act **
The failure to obtain the written consent of the patient before performing a surgical procedure may
constitute - battery
A written authorization from the patient releasing copies of his or her medical records is required by all
of the following EXCEPT: - the hospital attorney for the facility where the patient is treated
When developing a record retention policy, the HIM professionals should consider all of the following
EXCEPT: - the thickness of the records
A valid authorization for the disclosure of health information should not be - dated prior to discharge of
the patient
Who is legally responsible for obtaining the patient's informed consent for surgery? - the surgeon
performing the surgery
A signed consent for release of information dated December 1, 2005, is received with a request for the
chart from the patient's admission of 12/5/05. Indicate the appropriate response from the options
below. - Request another authorization dated after the discharge date
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets
forth all of the following EXCEPT: - covered entities provide every patient with its annual business report
Which of the following is considered confidential information? - patient's diagnosis
Which would be the better "best practice" for handling fax transmission of a physician's orders? - Treat
faxed orders like verbal orders and require authentication of the orders by appropriate medical staff
within the required time period.
