2025 LATEST REIMBURSEMENT RHIA
EXAM| COMPREHENSIVE EXAM WITH
OVER 700+ ACTUAL QUESTIONS WITH
THEIR CORRECT MARKING SCHEME
ANSWERS. A+ GRADED
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:
A. recovery room record
B. pathology report
C. operative report
D. discharge summary
B. pathology report
Although a gross description of tissue removed may be mentioned on the
operative note or discharge summary, only the pathology report will contain a
microscopic description.
,Patient data collection requirements vary according to health care setting. A data
element you would expect to be collected in the MDS, but NOT in the UHDDS
would be:
A. personal identification
B. cognitive patterns
C. procedures and dates
D. principal diagnosis
B. cognitive patterns
The other answer choices represent items collected on Medicare inpatients
according to UHDDS requirements. Only "cognitive patterns" represents a data
item collected more typically in long-term care settings and required in the MDS
In the past, 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 Commission's national patient safety goals, the focus has shifted to
the
A. prohibited use of any abbreviations
B. flagrant use of specialty-specific abbreviations
C. use of prohibited or "dangerous" abbreviations
D. use of abbreviations in the final diagnosis
C. use of prohibited or "dangerous abbreviations
The Joint Commission requires hospitals to prohibit abbreviations that have
caused confusion or problems in their handwritten form, such as "U" for unit,
,which can be mistaken for "O" or the number "4." Spelling out the unit is
preferred.
Engaging patients and their families in health care decisions is one of the core
objectives for
A. achieving meaningful use of EHRs
B. the Joint Commission's National Patient Safety goals
C. HIPAA 5010 regulations
D. establishing flexible clinical pathways
A. achieving meaningful use of EHRs
There are several core objectives for achieving meaningful use. Engaging patients
and their families is one of these objectives.
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
A. doctors' progress notes
B. integrated progress notes
C. incident report
D. nurses' notes
C. incident report
, Factual summaries investigating unexpected facility events should not be treated
as part of the patient's health information and therefore would not be recorded
in the health record.
For continuity of care, ambulatory care providers are more likely than providers of
acute care services to rely on the documentation found in the
A. interdisciplinary patient care plan
B. discharge summary
C. transfer record
D. problem list
B. discharge summary
Joint Commission does not approve of auto authentication of entries in a health
record. The primary objection to this practice is that
A. it is too easy to delegate use of computer passwords
B. evidence cannot be provided that the physician actually reviewed and
approved each report
C. electronic signatures are not acceptable in every state
D. tampering too often occurs with this method of authentication
B. evidence cannot be provided that the physician actually reviewed and
approved each report
EXAM| COMPREHENSIVE EXAM WITH
OVER 700+ ACTUAL QUESTIONS WITH
THEIR CORRECT MARKING SCHEME
ANSWERS. A+ GRADED
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:
A. recovery room record
B. pathology report
C. operative report
D. discharge summary
B. pathology report
Although a gross description of tissue removed may be mentioned on the
operative note or discharge summary, only the pathology report will contain a
microscopic description.
,Patient data collection requirements vary according to health care setting. A data
element you would expect to be collected in the MDS, but NOT in the UHDDS
would be:
A. personal identification
B. cognitive patterns
C. procedures and dates
D. principal diagnosis
B. cognitive patterns
The other answer choices represent items collected on Medicare inpatients
according to UHDDS requirements. Only "cognitive patterns" represents a data
item collected more typically in long-term care settings and required in the MDS
In the past, 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 Commission's national patient safety goals, the focus has shifted to
the
A. prohibited use of any abbreviations
B. flagrant use of specialty-specific abbreviations
C. use of prohibited or "dangerous" abbreviations
D. use of abbreviations in the final diagnosis
C. use of prohibited or "dangerous abbreviations
The Joint Commission requires hospitals to prohibit abbreviations that have
caused confusion or problems in their handwritten form, such as "U" for unit,
,which can be mistaken for "O" or the number "4." Spelling out the unit is
preferred.
Engaging patients and their families in health care decisions is one of the core
objectives for
A. achieving meaningful use of EHRs
B. the Joint Commission's National Patient Safety goals
C. HIPAA 5010 regulations
D. establishing flexible clinical pathways
A. achieving meaningful use of EHRs
There are several core objectives for achieving meaningful use. Engaging patients
and their families is one of these objectives.
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
A. doctors' progress notes
B. integrated progress notes
C. incident report
D. nurses' notes
C. incident report
, Factual summaries investigating unexpected facility events should not be treated
as part of the patient's health information and therefore would not be recorded
in the health record.
For continuity of care, ambulatory care providers are more likely than providers of
acute care services to rely on the documentation found in the
A. interdisciplinary patient care plan
B. discharge summary
C. transfer record
D. problem list
B. discharge summary
Joint Commission does not approve of auto authentication of entries in a health
record. The primary objection to this practice is that
A. it is too easy to delegate use of computer passwords
B. evidence cannot be provided that the physician actually reviewed and
approved each report
C. electronic signatures are not acceptable in every state
D. tampering too often occurs with this method of authentication
B. evidence cannot be provided that the physician actually reviewed and
approved each report
