RHIA Exam Review - Mock Exam
Questions
Mock Exam Pre-Test (Condensed) - ANS 50 questions
(Domain I) 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?
- Physical exam
- Medical consultation
- Emergency record
- Pharmacy consultation - ANS Pharmacy consultation
(Domain I) For inpatients, the first data item collected of a clinical nature is usually:
- expected payer
- admitting diagnosis
- review of systems
- principal diagnosis - ANS admitting diagnosis
(Domain I) In the past, The Joint Commission standards have focused on promoting the use of a
facility-approved abbreviation list to be used by hospital care providers. With the advent of The Joint
Commission's national patient safety goals, the focus has shifted to the:
- prohibited use of leading zeros
- use of prohibited or dangerous abbreviations
- use of abbreviations in the final diagnosis
- flagrant use of specialty-specific abbreviations - ANS use of prohibited or dangerous abbreviations
(Domain I) The primary focus of screen format design in an EHR should be to ensure that:
- the user is capturing essential data elements
- data fields can be randomly accessed
,- programmers develop standard screen formats for all facilities in a system
- paper forms are easily converted to computer screens - ANS the user is capturing essential data
elements
(Domain I) Which of the following key data items would you expect to find recorded on an ER record,
but you would be less likely to find in an acute care record?
- time and means of arrival
- instructions for follow-up care
- physical findings
- lab and diagnostic test results - ANS time and means of arrival
(Domain I) Which of the following components of the problem-oriented record serves to index
documentation throughout the record?
- problem list
- initial plan
- database
- SOAP notes - ANS problem list
(Domain I) A quantitative review of a health record reveals that the history and physical for a patient
admitted on September 26 was performed on September 30 and transcribed on October 1. Which of
the following statements regarding completion and charting of the history and physical is true in this
situation?
- compliance with Medicare regulations
- compliance with Joint Commission standards for non-surgical patients
- compliance with Joint Commission standards
- noncompliance with Joint Commission standards - ANS noncompliance with Joint Commission
standards
(Domain I) Good screen design, along with alerts, makes it easier to ensure that all essential data
items have been captured. One essential item to be captured on the physical exam is:
,- family history as related by the patient
- general appearance as assessed by the physician
- smoking and alcohol intake status
- review of systems - ANS general appearance as assessed by the physician
(Domain I) Which of the following would be the most efficient use of secondary data sources to
gather the health records of all juvenile patients treated for diabetes, and all juvenile patients
treated for diabetes who have had surgery, within the past 6 months?
- procedure index
- disease index
- disease and procedure indexes
- pediatric census sheet - ANS disease index
(Domain I) For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the:
- discharge summary
- problem list
- interdisciplinary patient care plan
- transfer record - ANS problem list
(Domain II) It has been decided that the coders will have access to all ePHI in the EHR but they will
not be able to add or edit data. This process is known as:
- limited data set
- workforce clearance procedure
- information system activity review
- incidental disclosure - ANS workforce clearance procedure
(Domain II) According to the HIPAA Privacy Rule, PHI includes:
, - only paper individually identifiable health information
- non-individually identifiable health information in any format stored by a health care provider
- individually identifiable health information in any format stored by a health care provider or
business associate
- only electronic individually identifiable health information - ANS individually identifiable health
information in any format stored by a health care provider or business associate
(Domain II) Before we can proceed with our organization's risk analysis, we need to determine what
systems/information need to be protected. This step is known as:
- vulnerability
- control analysis
- risk determination
- system characterization - ANS system characterization
(Domain II) Mike has asked you to explain the rights he has per the HIPAA Privacy Rule. Which of the
following would you tell Mike is an example of a HIPAA patient right?
- he can challenge his bill
- he can ask to be contacted at an alternative site
- he can ask a patient advocate to sit in on all appointments at the healthcare organization
- he can discuss financial arrangements with business office staff - ANS he can ask to be contacted at
an alternative site
(Domain II) A healthcare organization had a security breach. The breach was identified on October
10. The investigation was completed on October 15. Identify the deadline that the organization has
to notify its patients.
- 60 days from October 15
- 30 days from October 10
- 60 days from October 10
- 30 days from October 15 - ANS 60 days from October 10
Questions
Mock Exam Pre-Test (Condensed) - ANS 50 questions
(Domain I) 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?
- Physical exam
- Medical consultation
- Emergency record
- Pharmacy consultation - ANS Pharmacy consultation
(Domain I) For inpatients, the first data item collected of a clinical nature is usually:
- expected payer
- admitting diagnosis
- review of systems
- principal diagnosis - ANS admitting diagnosis
(Domain I) In the past, The Joint Commission standards have focused on promoting the use of a
facility-approved abbreviation list to be used by hospital care providers. With the advent of The Joint
Commission's national patient safety goals, the focus has shifted to the:
- prohibited use of leading zeros
- use of prohibited or dangerous abbreviations
- use of abbreviations in the final diagnosis
- flagrant use of specialty-specific abbreviations - ANS use of prohibited or dangerous abbreviations
(Domain I) The primary focus of screen format design in an EHR should be to ensure that:
- the user is capturing essential data elements
- data fields can be randomly accessed
,- programmers develop standard screen formats for all facilities in a system
- paper forms are easily converted to computer screens - ANS the user is capturing essential data
elements
(Domain I) Which of the following key data items would you expect to find recorded on an ER record,
but you would be less likely to find in an acute care record?
- time and means of arrival
- instructions for follow-up care
- physical findings
- lab and diagnostic test results - ANS time and means of arrival
(Domain I) Which of the following components of the problem-oriented record serves to index
documentation throughout the record?
- problem list
- initial plan
- database
- SOAP notes - ANS problem list
(Domain I) A quantitative review of a health record reveals that the history and physical for a patient
admitted on September 26 was performed on September 30 and transcribed on October 1. Which of
the following statements regarding completion and charting of the history and physical is true in this
situation?
- compliance with Medicare regulations
- compliance with Joint Commission standards for non-surgical patients
- compliance with Joint Commission standards
- noncompliance with Joint Commission standards - ANS noncompliance with Joint Commission
standards
(Domain I) Good screen design, along with alerts, makes it easier to ensure that all essential data
items have been captured. One essential item to be captured on the physical exam is:
,- family history as related by the patient
- general appearance as assessed by the physician
- smoking and alcohol intake status
- review of systems - ANS general appearance as assessed by the physician
(Domain I) Which of the following would be the most efficient use of secondary data sources to
gather the health records of all juvenile patients treated for diabetes, and all juvenile patients
treated for diabetes who have had surgery, within the past 6 months?
- procedure index
- disease index
- disease and procedure indexes
- pediatric census sheet - ANS disease index
(Domain I) For continuity of care, ambulatory care providers are more likely than providers of acute
care services to rely on the documentation found in the:
- discharge summary
- problem list
- interdisciplinary patient care plan
- transfer record - ANS problem list
(Domain II) It has been decided that the coders will have access to all ePHI in the EHR but they will
not be able to add or edit data. This process is known as:
- limited data set
- workforce clearance procedure
- information system activity review
- incidental disclosure - ANS workforce clearance procedure
(Domain II) According to the HIPAA Privacy Rule, PHI includes:
, - only paper individually identifiable health information
- non-individually identifiable health information in any format stored by a health care provider
- individually identifiable health information in any format stored by a health care provider or
business associate
- only electronic individually identifiable health information - ANS individually identifiable health
information in any format stored by a health care provider or business associate
(Domain II) Before we can proceed with our organization's risk analysis, we need to determine what
systems/information need to be protected. This step is known as:
- vulnerability
- control analysis
- risk determination
- system characterization - ANS system characterization
(Domain II) Mike has asked you to explain the rights he has per the HIPAA Privacy Rule. Which of the
following would you tell Mike is an example of a HIPAA patient right?
- he can challenge his bill
- he can ask to be contacted at an alternative site
- he can ask a patient advocate to sit in on all appointments at the healthcare organization
- he can discuss financial arrangements with business office staff - ANS he can ask to be contacted at
an alternative site
(Domain II) A healthcare organization had a security breach. The breach was identified on October
10. The investigation was completed on October 15. Identify the deadline that the organization has
to notify its patients.
- 60 days from October 15
- 30 days from October 10
- 60 days from October 10
- 30 days from October 15 - ANS 60 days from October 10
