RHIA CERTIFICATION EXAM– QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A health information management (HIM) director is reviewing hospital compliance
regarding the timely completion of medical records by attending physicians. According to
Joint Commission standards, within how many days following discharge must medical
records be fully completed?
A. 15 days
B. 30 days
C. 60 days
D. 90 days
ANSWER: B. 30 days
The Joint Commission standards require that hospital medical records be completed within 30
days following discharge. Options A, C, and D do not align with the standard timeframe
mandated by accrediting bodies for medical record finalization.
2. A privacy officer receives a formal request from a patient seeking an amendment to their
protected health information (PHI) within their electronic health record. The covered
entity believes the record is accurate and complete. What is the appropriate course of
action under HIPAA privacy regulations?
A. Immediately delete the disputed entries from the active medical record without
documentation.
B. Deny the request in writing, provide a timely explanation, and inform the patient of their right
to submit a written statement of disagreement to be included in the record.
C. Ignore the request because patients do not have the right to request amendments to clinical
documentation.
D. Alter the clinical notes to match the patient's exact phrasing without physician authorization.
ANSWER: B. Deny the request in writing, provide a timely explanation, and inform the
patient of their right to submit a written statement of disagreement to be included in the
record.
,Under the HIPAA Privacy Rule, if a covered entity denies a patient's amendment request, it
must provide a timely written denial containing specific elements and permit the patient to
submit a statement of disagreement. Option A violates record integrity laws, Option C violates
patient rights, and Option D compromises clinical documentation accuracy.
3. An HIM coding supervisor notices a sudden, significant upward shift in the case mix
index (CMI) for inpatient admissions without a corresponding change in facility service
lines or patient demographics. What is the most appropriate initial investigation step?
A. Immediately increase physician billing rates across all departments.
B. Conduct a focused internal audit of high-weight diagnosis-related group (DRG) assignments,
secondary diagnoses capture, and documentation specificity to verify coding integrity.
C. Assume all coding staff are committing deliberate fraud and terminate their employment.
D. Disregard the shift because a higher CMI always indicates improved clinical care quality.
ANSWER: B. Conduct a focused internal audit of high-weight diagnosis-related group
(DRG) assignments, secondary diagnoses capture, and documentation specificity to verify
coding integrity.
An unexplained CMI spike often signals changes in documentation patterns, coding practices,
or potential over-coding that require immediate internal auditing to ensure compliance.
Option A and D ignore compliance risks, while Option C is premature without evidentiary
investigation.
4. A hospital risk manager requests patient records for an impending malpractice lawsuit.
Before releasing the records to the legal counsel, what must the HIM professional verify
first?
A. That the attorney is wearing professional business attire.
B. The presence of a valid, HIPAA-compliant patient authorization or a valid court
order/subpoena accompanied by satisfactory assurances of patient notification or protective
orders.
C. That the patient's outstanding hospital balance is completely paid in full.
D. That the records are physically printed on blue paper.
ANSWER: B. The presence of a valid, HIPAA-compliant patient authorization or a valid
court order/subpoena accompanied by satisfactory assurances of patient notification or
protective orders.
,Releasing PHI for legal proceedings requires strict adherence to HIPAA and state laws,
necessitating either proper authorization or court documentation with satisfactory assurances.
Financial status and paper color have no legal bearing on release of information.
5. A data quality analyst is evaluating the master patient index (MPI) and discovers a high
rate of duplicate medical record numbers (MRNs) caused by registration staff entering
minor spelling variations of patient names. Which system control is most effective in
preventing this issue at the point of entry?
A. Requiring staff to memorize every patient's social security number.
B. Implementing probabilistic or deterministic duplicate check algorithms that flag potential
matches in real-time during patient search and registration.
C. Disabling the patient search function entirely.
D. Allowing registration staff to create a new MRN for every outpatient encounter.
ANSWER: B. Implementing probabilistic or deterministic duplicate check algorithms that
flag potential matches in real-time during patient search and registration.
Automated matching algorithms alert registration staff to potential duplicate records before a
new MRN is generated, effectively maintaining MPI integrity. Options A, C, and D introduce
operational barriers or exacerbate data degradation.
6. An HIM director is designing a retention schedule for diagnostic imaging films,
pathology slides, and fetal monitor strips in accordance with federal guidelines and state
laws. Generally, what is the standard minimum retention period for adult medical records
in the absence of more stringent state laws?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
ANSWER: C. 5 years
Under standard federal guidelines and many state statutes, adult medical records must be
retained for a minimum of 5 years. (Note: pediatric records are typically retained until the
patient reaches the age of majority plus the statute of limitations).
7. A healthcare organization is preparing for a transition from ICD-9-CM (historical
context) / ICD-10-CM to an advanced clinical documentation improvement (CDI) program
, focusing on specificity. Which documentation element has the most direct impact on
severity of illness (SOI) and risk of mortality (ROM) scoring within inpatient prospective
payment systems?
A. The patient's favorite color.
B. The explicit documentation of secondary diagnoses, comorbidities (CCs), and major
comorbidities (MCCs).
C. The brand name of the hospital bed used during the stay.
D. The name of the insurance payer.
ANSWER: B. The explicit documentation of secondary diagnoses, comorbidities (CCs), and
major comorbidities (MCCs).
CCs and MCCs directly influence MS-DRG assignment, reflecting higher resource
consumption, severity of illness, and risk of mortality. Payer, brand name, and color have no
clinical coding or reimbursement impact.
8. An HIM manager is reviewing the security controls of the electronic health record
(EHR) system. Under the HIPAA Security Rule, which safeguard category covers the
implementation of hardware, software, and procedural mechanisms that record and
examine activity in information systems that contain or use ePHI?
A. Administrative safeguards
B. Physical safeguards
C. Technical safeguards
D. Organizational safeguards
ANSWER: C. Technical safeguards
Audit controls, access controls, and transmission security fall under technical safeguards of
the HIPAA Security Rule. Administrative safeguards cover policies and procedures, while
physical safeguards cover facility access and workstation hardware.
9. A physician submits a late entry into an electronic health record. The system records the
date and time of the actual entry alongside the date and time the entry is attributed to (the
date of service). How should the HIM professional view this documentation practice?
A. It is illegal and constitutes immediate fraud.
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A health information management (HIM) director is reviewing hospital compliance
regarding the timely completion of medical records by attending physicians. According to
Joint Commission standards, within how many days following discharge must medical
records be fully completed?
A. 15 days
B. 30 days
C. 60 days
D. 90 days
ANSWER: B. 30 days
The Joint Commission standards require that hospital medical records be completed within 30
days following discharge. Options A, C, and D do not align with the standard timeframe
mandated by accrediting bodies for medical record finalization.
2. A privacy officer receives a formal request from a patient seeking an amendment to their
protected health information (PHI) within their electronic health record. The covered
entity believes the record is accurate and complete. What is the appropriate course of
action under HIPAA privacy regulations?
A. Immediately delete the disputed entries from the active medical record without
documentation.
B. Deny the request in writing, provide a timely explanation, and inform the patient of their right
to submit a written statement of disagreement to be included in the record.
C. Ignore the request because patients do not have the right to request amendments to clinical
documentation.
D. Alter the clinical notes to match the patient's exact phrasing without physician authorization.
ANSWER: B. Deny the request in writing, provide a timely explanation, and inform the
patient of their right to submit a written statement of disagreement to be included in the
record.
,Under the HIPAA Privacy Rule, if a covered entity denies a patient's amendment request, it
must provide a timely written denial containing specific elements and permit the patient to
submit a statement of disagreement. Option A violates record integrity laws, Option C violates
patient rights, and Option D compromises clinical documentation accuracy.
3. An HIM coding supervisor notices a sudden, significant upward shift in the case mix
index (CMI) for inpatient admissions without a corresponding change in facility service
lines or patient demographics. What is the most appropriate initial investigation step?
A. Immediately increase physician billing rates across all departments.
B. Conduct a focused internal audit of high-weight diagnosis-related group (DRG) assignments,
secondary diagnoses capture, and documentation specificity to verify coding integrity.
C. Assume all coding staff are committing deliberate fraud and terminate their employment.
D. Disregard the shift because a higher CMI always indicates improved clinical care quality.
ANSWER: B. Conduct a focused internal audit of high-weight diagnosis-related group
(DRG) assignments, secondary diagnoses capture, and documentation specificity to verify
coding integrity.
An unexplained CMI spike often signals changes in documentation patterns, coding practices,
or potential over-coding that require immediate internal auditing to ensure compliance.
Option A and D ignore compliance risks, while Option C is premature without evidentiary
investigation.
4. A hospital risk manager requests patient records for an impending malpractice lawsuit.
Before releasing the records to the legal counsel, what must the HIM professional verify
first?
A. That the attorney is wearing professional business attire.
B. The presence of a valid, HIPAA-compliant patient authorization or a valid court
order/subpoena accompanied by satisfactory assurances of patient notification or protective
orders.
C. That the patient's outstanding hospital balance is completely paid in full.
D. That the records are physically printed on blue paper.
ANSWER: B. The presence of a valid, HIPAA-compliant patient authorization or a valid
court order/subpoena accompanied by satisfactory assurances of patient notification or
protective orders.
,Releasing PHI for legal proceedings requires strict adherence to HIPAA and state laws,
necessitating either proper authorization or court documentation with satisfactory assurances.
Financial status and paper color have no legal bearing on release of information.
5. A data quality analyst is evaluating the master patient index (MPI) and discovers a high
rate of duplicate medical record numbers (MRNs) caused by registration staff entering
minor spelling variations of patient names. Which system control is most effective in
preventing this issue at the point of entry?
A. Requiring staff to memorize every patient's social security number.
B. Implementing probabilistic or deterministic duplicate check algorithms that flag potential
matches in real-time during patient search and registration.
C. Disabling the patient search function entirely.
D. Allowing registration staff to create a new MRN for every outpatient encounter.
ANSWER: B. Implementing probabilistic or deterministic duplicate check algorithms that
flag potential matches in real-time during patient search and registration.
Automated matching algorithms alert registration staff to potential duplicate records before a
new MRN is generated, effectively maintaining MPI integrity. Options A, C, and D introduce
operational barriers or exacerbate data degradation.
6. An HIM director is designing a retention schedule for diagnostic imaging films,
pathology slides, and fetal monitor strips in accordance with federal guidelines and state
laws. Generally, what is the standard minimum retention period for adult medical records
in the absence of more stringent state laws?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
ANSWER: C. 5 years
Under standard federal guidelines and many state statutes, adult medical records must be
retained for a minimum of 5 years. (Note: pediatric records are typically retained until the
patient reaches the age of majority plus the statute of limitations).
7. A healthcare organization is preparing for a transition from ICD-9-CM (historical
context) / ICD-10-CM to an advanced clinical documentation improvement (CDI) program
, focusing on specificity. Which documentation element has the most direct impact on
severity of illness (SOI) and risk of mortality (ROM) scoring within inpatient prospective
payment systems?
A. The patient's favorite color.
B. The explicit documentation of secondary diagnoses, comorbidities (CCs), and major
comorbidities (MCCs).
C. The brand name of the hospital bed used during the stay.
D. The name of the insurance payer.
ANSWER: B. The explicit documentation of secondary diagnoses, comorbidities (CCs), and
major comorbidities (MCCs).
CCs and MCCs directly influence MS-DRG assignment, reflecting higher resource
consumption, severity of illness, and risk of mortality. Payer, brand name, and color have no
clinical coding or reimbursement impact.
8. An HIM manager is reviewing the security controls of the electronic health record
(EHR) system. Under the HIPAA Security Rule, which safeguard category covers the
implementation of hardware, software, and procedural mechanisms that record and
examine activity in information systems that contain or use ePHI?
A. Administrative safeguards
B. Physical safeguards
C. Technical safeguards
D. Organizational safeguards
ANSWER: C. Technical safeguards
Audit controls, access controls, and transmission security fall under technical safeguards of
the HIPAA Security Rule. Administrative safeguards cover policies and procedures, while
physical safeguards cover facility access and workstation hardware.
9. A physician submits a late entry into an electronic health record. The system records the
date and time of the actual entry alongside the date and time the entry is attributed to (the
date of service). How should the HIM professional view this documentation practice?
A. It is illegal and constitutes immediate fraud.
