RHIA Exam Questions and Answers: Health Records, Data, and Database Management, Exams of Nursing

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Source-Oriented Health Record - Correct answer-Documents organized into sections according to the provider's and departments that provide treatment (lab together, rad. together, clinical notes together) Problem-Oriented Health Record - Correct answer-Divided into four parts: database, problem list, initial plan, progress notes (SOAP) SOAP what does S stand for? - Correct answer-Subjective (patient's point of view) SOAP what does O stand for? - Correct answer-Objective (what the practitioner finds) SOAP what does A stand for? - Correct answer-Assessment (combine subjective and objective to make a conclusion) SOAP what does P stand for? - Correct answer-Plan (approach to be taken to resolve patient's problem Integrated Health Records - Correct answer-Documentation from various sources organized in strict chronological or reverse chronological order Advantage of Integrated Health Record? - Correct answer-Easy to follow course of diagnosis and treatment Disadvantage of Integrated Health Record? - Correct answer-Difficult to compare similar information (ex. lab results or oncology information) When should H&P be documented in record? - Correct answer-Within 24

Quantitative Analysis - Correct answer-A review of health record to determine its completeness and accuracy Data Accuracy - Correct answer-Data are the correct values and are valid Data Accessibility - Correct answer-Data items are easily obtainable and legal to collect Data Comprehensiveness - Correct answer-All required data items included AND entire scope of data is collected and intentional limitations documented Data Consistency - Correct answer-Value of data is reliable and consistent across applications Data Currency - Correct answer-Data is up to date, if it is outdated it must have been up to date at the time it was presented Data Definition - Correct answer-Clear definitions provided so users know what data means, each data element should have clear meaning and accepted values Data Granularity - Correct answer-The attributes and values of data should be defined at the correct level of detail Data Precision - Correct answer-Data values should be just large enough to support the application or process and acceptable values or ranges must be defined Data Relevance - Correct answer-The data are meaningful to the performance of the process or application for which they are collected Data Timeliness - Correct answer-Determined by how the data are being used and their context Minimum Data Set (MDS) purpose? - Correct answer-Promote comparability and compatibility of data by using standard data items with uniform definitions Uniform Hospital Discharge Data Set (UHDDS) - Correct answer-Uniform collection of data on inpatients Uniform Ambulatory Core Data Set (UACDS) - Correct answer-Improve ability to compare data in ambulatory care settings

Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI) - Correct answer-Comprehensive functional assessment of long- term care patients

What are fields in a database table? - Correct answer-Columns What are records in a database table? - Correct answer-Rows

Relational Model Database - Correct answer-Database management system in which data are organized and managed as a collection of tables Object Oriented Database Model - Correct answer-Uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways Hierarchical Database Model - Correct answer-Data is organized in tree's according to relationships (one to many) Network Database Model - Correct answer-Data is organized in tree's according to relationships (many to many) Open System Architecture - Correct answer-Hardware, software, transmission, media, and database industry standards allow different computer vendor systems to communicate to each other Closed System Architecture - Correct answer-Communication is possible only on one vendor's system Hardware - Correct answer-Physical equipment that makes up computers and computer systems What are the 3 types of computers? - Correct answer-Mainframes, minicomputers, microcomputers Software - Correct answer-Operating systems software and application software Local Area Network (LAN) - Correct answer-Multiple devices connected via communications media and located in a small geographical area Wide Area Network (WAN) - Correct answer-A computer network that connects separate institutions across a large geographical area Intranet - Correct answer-Private network that has its servers located inside a firewall Alphabetic Health Record Identification - Correct answer-A patient's name identifies the patient record Numeric Identification - Correct answer-A number identifies the patient record Serial Numbering - Correct answer-A new number is assigned to the patient for

Serial-Unit Numbering - Correct answer-A new number is assigned to the patient for each new encounter at the facility, but the former records are brought forward and filed under the new number Centralized Filing - Correct answer-Records filed in one location Decentralized Filing - Correct answer-Records filed in multiple locations Alphabetic Filing - Correct answer-Starts with last names and then includes first name and middle initial Straight Numeric Filing - Correct answer-Filing charts in sequential order; the records start with the chart with the lowest number value and end with the chart with the highest number value Terminal Digit Filing - Correct answer-Numeric filing is divided into three parts and is read from right to left instead of left to right What does AHA recommend for record retention? - Correct answer-Minimum of 10 years When does AHA recommend record retention for a minor? - Correct answer- years past the age of majority Index - Correct answer-Listing or arrangement of data in a designated order; contains special types of information, and purpose is to assist in location of desired information Master Patient Index (MPI) - Correct answer-Identifies all patients admitted to a health care facility for treatment, along with their identifying information Number Index - Correct answer-Chronological list of patient's identification numbers issued to patients Physician Index - Correct answer-Provides every physician with a list of identifying medical cases Disease Index - Correct answer-List of diseases and conditions according to the classification system used in the facility Procedure or Operation Index - Correct answer-List of surgical and procedural codes

Registry - Correct answer-Created to monitor various diseases and health problems with different goals and objectives

Client - Correct answer-Individual who is receiving professional services

Hill Burton Act - Correct answer-Legislation enacted in 1946 that provided funding for the construction of hospitals and other health care facilities Secondary Patient Record - Correct answer-A record used for selected data elements to aid in research conducted by clinical and non-clinical people American Medical Association (AMA) was established to...? - Correct answer- Assure the quality of American medical education American Hospital Association (AHA) was established to...? - Correct answer- Promote public welfare by providing better health care in hospitals What did the Flexner Report of 1910 do? - Correct answer-Identify serious problems and inconsistencies in medical education American College of Surgeons (ACS) was established to...? - Correct answer- Develop a system of hospital standardization to improve patient care and recognize hospitals that had the highest ideals What is the Department of Health and Human Services (DHHS) responsible for? - Correct answer-Health issues, including health care and cost, welfare of various populations, occupational safety, and income security plans What did the Tax Equity and Fiscal Responsibilities Act (TEFRA) do? - Correct answer- Established a mechanism for controlling the cost of the Medicare program and set limits on reimbursement and required the development of the prospective payment system What did the Consolidated Omnibus Budget Reconciliation Act (COBRA) establish?

• Correct answer-Anti-dumping statue, established criteria for the transfer and discharge of Medicare and Medicaid patients What did the Patient Self-Determination Act of 1990 establish? - Correct answer- Gave patients the right to set advance directives Hierarchical Organizational Chart - Correct answer-Individuals at the top have authority and it passes downward through a chain of command Vertical Organizational Chart - Correct answer-Governing Board has ultimate authority, followed by the CEO, Medical Staff, Department Directors, Supervisors, and Numerous Subordinates Matrix Organizational Chart - Correct answer-Supports general managers who

Product Line Management - Correct answer-Hospitals organized around product line categories (obstetrics, rehabilitation, cardiology) Health Maintenance Organizations (HMO's) - Correct answer-Managed health care that integrates health care delivery with insurance for healthcare Nursing Long-Term Care - Correct answer-Nursing care and related services for residents who need medical, nursing, or rehabilitative care provided on a 24 hour basis Domiciliary - Correct answer-Supervision, room, and board provided for those unable to live independently Mobile Diagnostic Services - Correct answer-Health care services are transported to the patients, especially diagnostic procedures Fee for Service - Correct answer-Third party payers and/ or patients issue payments to health care providers based on charges assigned to each service performed for each patient Traditional Fee-For-Service - Correct answer-Third party payers and/ or patients pay health care providers after services have been rendered Managed Fee-For-Service - Correct answer-Costs are controlled by the managed- care plan's management of members' uses of services; providers are reimbursed by fee schedules Episode of Care - Correct answer-Health care plan compensates providers with a lump- sum payment to compensate them for all services delivered to a patient for a specific illness and over a specific period of time Resource-Based Relative Value Scale (RBRVS) - Correct answer-for reimbursement of physician services of beneficiaries covered under Medicare Part B Clinical Practice Guidelines - Correct answer-Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances Clinical Protocols - Correct answer-Treatment recommendations often based on guidelines, step-by-step description of an accepted procedure Critical Paths - Correct answer-Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals

with optimal efficiency Clinical Pathways - Correct answer-Structured plans of care

What are the three elements of privileged communication? - Correct answer-1. Relationship between patient and provider

2. Information must have been acquired through such a relationship

3. Information must have some connection with the provider's task of treating the patient Durable Power of Attorney - Correct answer-Legal document in which patients name someone close to them to make decisions about their health care in the event they become incapacitated Subpoena - Correct answer-Court order requiring someone to appear in court to give testimony What can happen if you disregard a subpoena? - Correct answer-You can be held in contempt of court Subpoena Duces Tecum - Correct answer-A written order commanding a person to appear, give testimony, and bring all documents(records) described in the subpoena to court Subpoena Ad Testificandum - Correct answer-Court order that requires a person to appear in court to testify Drug Abuse and Treatment Act (1972) - Correct answer-Requires drug and alcohol abuse patient records to be kept confidential and not subject to disclosure except as provided by law Heath Care Quality Improvement Act (1986) - Correct answer-Established the NPDB Patient Self Determination Act (1990) - Correct answer-Requires that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their health record Privacy Act (1974) - Correct answer-Gives individuals some control over the information collected about them by the federal government Omnibus Budget Reconciliation Act (1987) - Correct answer-Created the Nursing Home Reform Act, which ensures residents of nursing homes receive quality care, requires provision of certain services, and establishes a residents' bill of rights Tax Equity and Fiscal Responsibility Act (1936) TEFRA - Correct answer-Introduced the Peer Review Organization (PRO) program as a component of Medicare law to ensure the quality of care rendered to patients Uniform Business Records as Evidence Act (1936) - Correct answer-Stipulates that records can be admitted as evidence in a court of law if they were kept in the