Health Data Content and Standards Final Questions with
detailed answers guaranteed pass (RHIA/RHIT)
1. 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?
medical consultation
pharmacy consultation
emergency record
physical exam
2. The health care providers at your hospital do a very thorough job of periodic open record review to
ensure the completeness of record documentation. A qualitative review of surgical records would likely
include checking for documentation regarding
the quality of follow-up care.
whether a postoperative infection occurred and how it was treated.
whether the severity of illness and/or intensity of service warranted acute level care.
the presence or absence of such items as preoperative and postoperative diagnosis, description of
findings, and specimens removed.
3. For inpatients, the first data item collected of a clinical nature is usually
admitting diagnosis.
review of systems.
expected payer.
principal diagnosis.
4. You have been asked to identify every reportable case of cancer from the previous year. A key resource
will be the facility's
disease index.
, patient index.
physicians' index.
number control index.
5. Joint Commission does not approve auto authentication of entries in a health record. The primary
objection to this practice is that
evidence cannot be provided that the physician actually reviewed and approved each report.
it is too easy to delegate use of computer passwords.
tampering too often occurs with this method of authentication.
electronic signatures are not acceptable in every state.
6. As the chair of a Forms Review Committee, you need to track the field name of a particular data field
and the security levels applicable to that field. Your best source for this information would be the
glossary of health care terms.
UHDDS.
facility's data dictionary.
MDS.
7. 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
use of abbreviations in the final diagnosis.
use of prohibited or "dangerous" abbreviations.
flagrant use of specialty-specific abbreviations.
prohibited use of any abbreviations.
8. One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care
organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish
this, which of the following would NOT be considered part of a preoperative verification process?
, Confirm the patient's true identity.
Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
Mark the surgical site.
Review the medical records and/or imaging studies.
9. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk
notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this
clerk performing?
legal review
utilization review
quantitative review
qualitative review
10. A primary focus of screen format design in a health record computer application should be to ensure
that
data fields can be randomly accessed.
the user is capturing essential data elements.
programmers develop standard screen formats for all hospitals.
paper forms are easily converted to computer forms.
11. A key data item you would expect to find recorded on an ER record but would probably NOT see in an
acute care record is the
time and means of arrival.
lab and diagnostic test results.
instructions for follow-up care.
physical findings.
detailed answers guaranteed pass (RHIA/RHIT)
1. 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?
medical consultation
pharmacy consultation
emergency record
physical exam
2. The health care providers at your hospital do a very thorough job of periodic open record review to
ensure the completeness of record documentation. A qualitative review of surgical records would likely
include checking for documentation regarding
the quality of follow-up care.
whether a postoperative infection occurred and how it was treated.
whether the severity of illness and/or intensity of service warranted acute level care.
the presence or absence of such items as preoperative and postoperative diagnosis, description of
findings, and specimens removed.
3. For inpatients, the first data item collected of a clinical nature is usually
admitting diagnosis.
review of systems.
expected payer.
principal diagnosis.
4. You have been asked to identify every reportable case of cancer from the previous year. A key resource
will be the facility's
disease index.
, patient index.
physicians' index.
number control index.
5. Joint Commission does not approve auto authentication of entries in a health record. The primary
objection to this practice is that
evidence cannot be provided that the physician actually reviewed and approved each report.
it is too easy to delegate use of computer passwords.
tampering too often occurs with this method of authentication.
electronic signatures are not acceptable in every state.
6. As the chair of a Forms Review Committee, you need to track the field name of a particular data field
and the security levels applicable to that field. Your best source for this information would be the
glossary of health care terms.
UHDDS.
facility's data dictionary.
MDS.
7. 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
use of abbreviations in the final diagnosis.
use of prohibited or "dangerous" abbreviations.
flagrant use of specialty-specific abbreviations.
prohibited use of any abbreviations.
8. One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care
organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish
this, which of the following would NOT be considered part of a preoperative verification process?
, Confirm the patient's true identity.
Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
Mark the surgical site.
Review the medical records and/or imaging studies.
9. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk
notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this
clerk performing?
legal review
utilization review
quantitative review
qualitative review
10. A primary focus of screen format design in a health record computer application should be to ensure
that
data fields can be randomly accessed.
the user is capturing essential data elements.
programmers develop standard screen formats for all hospitals.
paper forms are easily converted to computer forms.
11. A key data item you would expect to find recorded on an ER record but would probably NOT see in an
acute care record is the
time and means of arrival.
lab and diagnostic test results.
instructions for follow-up care.
physical findings.
