RHIT EXAM PREP 2024 QUESTIONS AND CORRECT ANSWERS WITH DETAILED RATIONALES GRADED A+.

A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? - correct answer Identify data content requirements for all areas of the organization. Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: - correct answer Vocabulary standards At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: - correct answer Data consistency Identify the documentation that records the attending physician's assessment of the patient's current health status. - correct answer Physical examination Which of the following is a key characteristic of the problem-oriented health record? - correct answer Uses an itemized list of the patient's past and present health problems A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? - correct answer UHDDS A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? - correct answer Medication administration record and clinical laboratory reports Which of the following is considered the authoritative resource in locating a health record? - correct answer Master patient index A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations? - correct answer Consultation The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? - correct answer Laboratory What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? - correct answer Gap analysis To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours be notified. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare (Sayles 2020b, 72). Risk management analysis Qualitative analysis Gap analysis Document management analysis The gap analysis process compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis. Once complete, the HIM professional would analyze the data and develop a plan for correction (Rossiter 2017, 279). after admission. Which of the following would be the best way to ensure the completeness of the health record? - correct answer Review each patient's health record concurrently to ensure the history and physicals are present. The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? - correct answer Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices Creekside Care, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? - correct answer Medicare Conditions of Participation A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): - correct answer Delinquent record How do accreditation organizations such as the Joint Commission use the health record? - correct answer To determine whether standards of care are being met Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? - correct answer Outcomes and Assessment Information Set Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located. - correct answer Licensure The following descriptors about the data element ADMISSION_DATE are included in a data dictionary—definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: - correct answer The template was defined In designing an input screen for an EHR, which of the following would be best to capture structured data? - correct answer Drop-down menus A medical group practice has contracted with an HIM professional to help define the practice's designated record set. Which of the following should the HIM professional perform first to identify the components of the designated record set? - correct answer Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records. Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: - correct answer By the hospital Copies of personal health records (PHRs) are considered part of the designated record set when: - correct answer Used by the organization to provide treatment Which of the following is a true statement about the content of the legal health record? - correct answer The legal health record may contain metadata. The clinical forms committee is the entity within a healthcare facility that: - correct answer Provides oversight for the development, review, and control of forms and computer screens Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. She should educate the class against doing which of the following? - correct answer Obliterating or deleting errors Which of the following is a risk of copy and pasting documentation in the electronic health record? - correct answer Copying the note in the wrong patient's record Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family conditions? - correct answer Medical history How is the patient registration department assisted by the HIM department? - correct answer Assigns the health record number Which of the following is part of qualitative analysis review? - correct answer Checking that only approved abbreviations are used Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? - correct answer Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned. Which of the following statements is true regarding HIPAA security? - correct answer Institutions are allowed flexibility in the way they implement HIPAA standards. Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: - correct answer Legitimate need for access The release of information function requires the HIM professional to have knowledge of: - correct answer Federal and state confidentiality laws When data has been lost in an EHR, which action is taken to remedy this problem? - correct answer Data recovery A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): - correct answer Audit trail A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? - correct answer Review the subpoena and appear at the time and place supplied to give testimony. The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond? - correct answer Notice of privacy practices is required on the first provision of service A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond? - correct answer Provide the records in paper format only On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? - correct answer Determine what information was printed and why