RHIT Practice Exam: Chapter 2: Health Data Management and Health Services Organization, Delivery and Reimbursement Methodologies

D: Honorary

Dr. Lewis is retired. Which medical staff membership might he be awarded?
A: Consulting
B: Courtesy
C: Tributary
D: Honorary

D: Chronic kidney dialysis for end stage renal disease

Medicare coverage applies to
A: Military dependents
B: No options are correct
C: The indigent
D: Chronic kidney dialysis for end stage renal disease
E: Children

134 / 3489
D: 0.0384

During the month of December, there were 3489 discharges with 134 incomplete records. What was the incomplete record rate for the month?
A: 0.384
B: 0.00384
C: 0.2603
D: 0.0384

D: Indefinitely

How long should the master patient index be maintained?
A: 10 years
B: 5 years
C: 20 years
D: Indefinitely

D: quantitative analysis.

A health record analyst is reviewing the medical record for authentication of all entries. This process is commonly termed:
A: point of care review.
B: closed record review.
C: qualitative analysis.
D: quantitative analysis.

B: enacted legislation funding the construction of hospitals and other health care facilities.

The Hill-Burton Act of 1946:
A: assured the provision of health care for the indigent.
B: enacted legislation funding the construction of hospitals and other health care facilities.
C: provided health care to Americans 65 years of age and older.
D: establ

B: The Joint Commission

As the director of health information of a newly established acute care facility, where would you expect to find directives concerning the minimum health record contents?
A: Benchmarks from area acute care facilities
B: The Joint Commission
C: Medical rec

D: Managed care

The arrangement that links health care financing and service delivery and allows payers to exercise significant economic control over how and what services are delivered is referred to as what?
A: Medicare
B: Fee for service
C: Medicaid
D: Managed care

B: speed at which individual sheets can be located.

A major advantage of the source-oriented medical record is the:
A: forms are designed to support numbering and tracking of problems.
B: speed at which individual sheets can be located.
C: ease with which health care providers can follow the course of one

D: 25

LTCHs are hospitals with an average length of stay of _____ days or more
A: 20
B: 60
C: 30
D: 25

D: Hospice

Ellen, a 78-year-old end-stage renal cancer patient, is in need of palliative care. Which facility would best meet her needs?
A: Rehabilitation facility
B: Home health care
C: Skilled nursing facility
D: Hospice

B: Includes protected health information

A legal health record
A: Includes ICD-10-CM diagnostic codes
B: Includes protected health information
C: Must be encrypted
D: Is disclosed upon request

A: Transcription

A physician dictates a report on a radiology exam. Which of the following clinical processes would come NEXT on the report workflow?
A: Transcription
B: Procedure
C: Billing
D: Coding

D: Immediately after surgery

A patient had an appendectomy due to appendicitis. This operative report must be completed when?
A: Within 15 days of discharge
B: Within 24 hours of surgery
C: Within 48 hours of surgery
D: Immediately after surgery

D: treatments and procedures to be performed by health care providers.

By signing a consent for treatment, the patient agrees to:
A: allow the hospital to release information to his/her insurance company.
B: take all medications prescribed and dispensed by health care providers.
C: allow hospital to dispose of property and v

B: 10

For how many years does AHIMA suggest the physician index be maintained?
A: Permanently
B: 10
C: 5
D: 8

B: Record tracking/location

Which application is best suited for bar coding?
A: Birth certificate registration
B: Record tracking/location
C: Misfiled records
D: Diagnostic and procedural coding

A: American Medical Association

Which of the following is an example of a government agency that has an interest in the standardization of records and data collection?
A: American Medical Association
B: American Health Information Management Association
C: The Joint Commission
D: Depart

B: Cardiac

Which of the following is not a major hospital classification?
A: General
B: Cardiac
C: Special
D: Psychiatric

C: Health information management department

Which of the following is considered a clinical support service?
A: Volunteer services
B: OB/GYN
C: Health information management department
D: Cardiology

B: Draw a single line through the error

Dr. Thomas made an error in recording the progress notes in a patient's medical record. What is the first thing he should do to correct the error?
A: Obliterate the error and enter correct entry
B: Draw a single line through the error
C: Tell the nursing

A: Dependents of totally disabled veterans

CHAMPVA is a healthcare program for military
A: Dependents of totally disabled veterans
B: Retirees and their families
C: Active duty and their dependents
D: Spouses and certain former spouses

A: 2014

ICD-10-CM and ICD-10-PCS implementation year is
A: 2014
B: 2017
C: 2016
D: 2015

B: There was no previous legislation

Prior to HIPAA, which of the following federal statutes generally protected the confidentiality of health information?
A: HITECH Act
B: There was no previous legislation
C: Privacy Act
D: Patient Protection and Affordable Care Act

C: Within 24 hours of surgery

A post-anesthesia note is required when?
A: Within 48 hours of surgery
B: Within 15 days of discharge
C: Within 24 hours of surgery
D: Immediately after surgery

A: Third party payer

An example of an institutional user of a health record is
A: Third party payer
B: Physician
C: Hospital employee
D: Patient

A: Requisition slip

Which of the following would be most beneficial in locating a charged-out medical record?
A: Requisition slip
B: Outguide
C: Master patient index
D: Transfer notice

A: Instructions for future care

Which of the following would the physician include in the discharge summary?
A: Instructions for future care
B: Blood pressure and pulse
C: Do not resuscitate order
D: Review of systems

A: Centers for Disease Control and Prevention

Which of the following agencies is concerned with communicable diseases, environmental health, and foreign quarantine activities?
A: Centers for Disease Control and Prevention
B: Centers for Medicare and Medicaid Services
C: Health Resources and Services

A: Permanently

AHIMA suggest the Master Patient Index be retained for how many years?
A: Permanently
B: 3
C: 2
D: 1

C: Case-mix index

The types or categories of patients treated by a hospital is termed
A: Diagnostic index
B: MS-DRG
C: Case-mix index
D: AP-DRG

A: Meaningful use

HIPAA does NOT contain
A: Meaningful use
B: Prevention of healthcare fraud
C: Privacy rule
D: Administrative simplification

C: ARRA

The HITECH Act is a part of which legislation?
A: HIPAA
B: Privacy Act
C: ARRA
D: Patient Protection and Affordable Care Act

A: OSHA

Which of the following organizations is responsible for developing standards and conducting investigations to determine compliance in matters related to occupational safety and health?
A: OSHA
B: DHHS
C: COBRA
D: CMS

B: Implement paper-based records

It is determined that the EMR/EHR is down. What should be done concerning documentation?
A: Dictate documentation
B: Implement paper-based records
C: Use scribes to record
D: Suspend documentation

D: Encryption

In an EHR, which of the following is the most important in regards to HIPAA compliance?
A: Media
B: Speed of delivery
C: Back-up frequency
D: Encryption

A: Operative report

The _______ provides documentation on the tissue removed during surgery.
A: Operative report
B: Discharge summary
C: Pathology report
D: Anesthesia report

A: government or non-government.

Hospital ownership is either:
A: government or non-government.
B: proprietary or government.
C: charitable or government.
D: stand alone or with clinics.

(517
1.8) / (36
7) = 3.69 (this has to be rounded up)
D: 4

Last month Houston Hospital discharged 517 patients. Each chart is approximately 1.8 inch thick. A shelving unit in the health information department has 7 shelves and each shelf is 36 inches. How many shelving units are needed to store one month of disch

C: accreditation

The process by which an organization or agency performs an external review and grants recognition to the program of study or institution that meets certain predetermined standards is called:
A: formalization
B: standardization
C: accreditation
D: registra

C: Omnibus Budget Reconciliation Act

When this act was passed, it helped to improve the quality of health care, reduce cost, and enhance the effectiveness of health care.
A: Occupational Safety and Health Act
B: Health Information Portability and Accountability Act
C: Omnibus Budget Reconcil

D: promote performance improvement.

According to TJC (formerly JCAHO) standards, a hospital is required to:
A: provide charitable care to the indigent.
B: review and update policies yearly.
C: employ an RHIA or RHIT.
D: promote performance improvement.

A: improve patient care.

Information in a tumor registry is collected to:
A: improve patient care.
B: bill for treatment rendered.
C: inform patients of their cancer status.
D: determine the appropriate cancer stage.

A: Selecting TJC standards to uphold

The governing board is responsible for setting the overall direction of the hospital. Other responsibilities include all except which of the following?
A: Selecting TJC standards to uphold
B: Monitoring the quality of care
C: Selecting qualified administr

D: quantitative analysis.

Reviewing the record to assure the presence of a discharge summary is referred to as:
A: legal analysis.
B: documentation analysis.
C: qualitative analysis.
D: quantitative analysis.

A: 0.67

Dr. Barbette is delinquent, with 10 of her 15 medical records needing to be completed. What is her delinquency rate?
A: 0.67
B: 0.05
C: 0.33
D: 0.1

A: Neoplasms

ICD-O-3 is used to code
A: Neoplasms
B: Durable medical equipment
C: OB/GYN
D: Outpatient

B: is not required for a stay of 48 hours or less.

A discharge summary:
A: may be completed in lieu of a clinical resume.
B: is not required for a stay of 48 hours or less.
C: is not required when death occurs within 48 hours or less.
D: must be dictated and typed for ease of readability.

C: Patient register

A health information technician wants to obtain a chronological list of all patients admitted to the facility during the third quarter with a diagnosis of appendicitis. Which database should the technician utilize?
A: Accession register
B: Master patient

B: CARF

Many rehabilitation facilities are accredited by
A: AAAHC
B: CARF
C: ACOG
D: HEDIS

C: Government

This hospital provides care to military personnel and their dependents. How is it classified?
A: Not for profit
B: Voluntary
C: Government
D: Proprietary

A: Hill-Burton Act of 1946.

At the close of World War II, the growth in the number of hospitals can be attributed to:
A: Hill-Burton Act of 1946.
B: AARP, founded in 1958.
C: HIPAA of 1996.
D: Clinton Health Security Act of 1993.

A: COBRA

Which act established the Patient Antidumping Law?
A: COBRA
B: HIPAA
C: OSHA
D: TEFRA

A: Advance directive

LaToya wants to put her health care decisions in writing in the event she has an incurable or irreversible condition and is unable to communicate her wishes. What should she institute?
A: Advance directive
B: Legal guardian
C: Executor of her estate
D: Tr

A: Home health care

Cecile, a 78-year-old female, needs intermittent skilled nursing care. Which facility would best meet her needs?
A: Home health care
B: Hospice
C: Skilled nursing facility
D: Rehabilitation facility

B: Encryption

Which of the following keeps PHI secure during the transcription transmission of a dictated report?
A: HIPAA training
B: Encryption
C: Tape dictation
D: Passwords

A: The patient left against medical advice.

Upon discharge analysis of a patient's record, the analyst does not see a discharge order written by the physician. What can the analyst assume?
A: The patient left against medical advice.
B: The patient will continue treatment on an outpatient basis.
C:

C: Final progress note

A patient is hospitalized for less than 48 hours. Which of the following is permissible in lieu of a discharge summary?
A: Final diagnosis
B: Discharge order
C: Final progress note
D: Discharge diagnosis

A: stores current and past health record locations.

The automated record tracking system is a database that:
A: stores current and past health record locations.
B: verifies the requested patient's name and health record number.
C: records dissatisfaction of record requesters with service.
D: locates mispla

B: Patient authorization

Which of the following is not required documentation for a progress note?
A: Clinician's note
B: Patient authorization
C: Date
D: Signature

B: ICD-9-CM code of 650 in the diagnostic index

Which of the following is a secondary record for J. Pratt?
A: Mental health record at Houston Honorary Adolescent Center
B: ICD-9-CM code of 650 in the diagnostic index
C: Emergency room record dated June 6
D: Admitted and discharged same day with ICD-9-C

D: Patient reviews record with provider for understanding of health status.

The health record may be used for personal and non-personal reasons. Which is an example of personal use of the health record?
A: Accrediting agency reviews record to assure quality health care.
B: Employer reviews health care data to evaluate job injurie

principal

The condition that is primarily responsible for the patient's admission to the hospital is the ____________ diagnosis.
A: primary
B: discharge
C: preliminary
D: principal

A: Unit numbering

Which system avoids assigning a new number for each patient encounter?
A: Unit numbering
B: Serial-unit numbering
C: Serial numbering
D: Straight numerical

A: Medical staff

Who is responsible for developing bylaws governing physicians' completion of medical records?
A: Medical staff
B: Chief executive officer
C: Governing board
D: Chief of medicine

...

Which of the following filing systems would be most affected in the event of a divorce?
a. Family
b. Unit
c. Serial
d. Serial-unit

...

Place the following in terminal digit order: 01-34-54, 01-35-55, 02-05-49, 02-66-48
a. 01-34-54, 01-35-55, 02-05-49, 02-66-48
b. 02-05-49, 01-34-54, 01-35-55, 02-66-48
c. 02-66-48, 02-05-49, 01-34-54, 01-35-55
d. 02-66-48, 02-05-49, 01-34-54, 01-35-55

...

Manuel receives surgery in 1 day and is discharged to home. Where was he treated.
a. Surgicenter
b. Satellite
c. Ancillary department
d. Observation unit

Appeal

The process by which a decision of a lower court is brought for review to a court of higher jurisdiction, typically known as a appellate court.

Court order;

A reading to me or direction ordered by court or judge

Cross examination:

Questioning Of a witnessed by opposing attorney

Defendant:

The party gifts from my complaint is brought.

Direct examination:

Initial question of a witness by the attorney has requested the witness to testify.

Jurisdiction:

The power of attorney which each court has to hear cases; a jurisdiction is the subject matter of the case, the person in the case, and by geographical areas

Plaintiff:

The party who brings a complaint against a Notherv