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This document offers a valuable resource for students and professionals preparing for the rhia exam. it presents a wide range of questions and answers covering key topics in health information management, including medical record organization, coding, data analysis, and legal and ethical considerations. The questions are designed to test knowledge and understanding of core concepts, making it an excellent study tool for those seeking to enhance their expertise in this field.
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This committee makes recommendations to the governing board for appoints to the medical staff - Correct answer-executive physicians who deliver most of the medical care in hospitals and who site on committees are - Correct answer-active staff accreditation organization which accredits health information educational programs is - Correct answer-CAHIIM which component, group has ultimate authority and is responsible for providing quality care to patients? - Correct answer-governing board which organization was the first to require a medical record on each patient and developed standards for its content? - Correct answer-American college of surgeons what documents specify the principles and policies by which both medical staff and governing board agree to abide by - Correct answer-bylaws which hospital department is responsible for arranging a transfer to a nursing home? - Correct answer-social service which professional association organized to resolve inconsistencies and
ASTM developed a standard to provide guidance for collection of data for the purpose of.. - Correct answer-computerizing the patient record primary purpose of quantitative analysis - Correct answer-to have a complete medical record what resource provides standard definitions for inpatient data commonly collected in acute care hospitals? - Correct answer-UHDDS What is aggregate data? - Correct answer-data combined from several measurements ex: data the media uses to report on health info of epidemiological interest to the public when records are analyzed for deficiencies on the unit while the patient is still in house, this is called? - Correct answer-concurrent analysis confirmation of the diagnosis and treatment options from another physician within the same specialty is called? - Correct answer-a second opinion cancer registries can be accredited by? - Correct answer-ACS case files of cancer patients are abstracted when - Correct answer-patient is diagnoses and/or treated a graph most frequently used to present continuous data? - Correct answer- histogram the filing system used in an electronic environment? - Correct answer-straight numeric assessment of nursing productivity is usually based on - Correct answer- inpatient service days full time responsibility for the operation of a hospital is delegated by the governing board to the - Correct answer-CEO the system of numbering in which a patient receives a number on his first admission to the hospital and retains that number on all subsequent admissions to the hospital is - Correct answer-unit
what is the function of CAHIIM - Correct answer-accrediting college educational programs quantitative analysis purpose - Correct answer-complete medical record qualitative analysis purpose - Correct answer-consistent medical record
NCQA - Correct answer-National committee for quality assurance non profit organization dedicated to improving healthcare quality physician query - Correct answer-requesting clarification for inconsistent, ambiguous, or incomplete documentation for coding nomenclature - Correct answer-naming system controlled by rules
clinical interface technology - Correct answer-systematic collection of health care related phrases that can be converted to structured data elements recognized between computer programs UMLS - Correct answer-unified medical language system converts terms from one vocabulary to another to enable information exchange between databases and systems how length of stay can affect the hospital's finances under PPS - Correct answer- the longer the patient stays, the more money the hospital loses. if the patient's stay is less than average LOS the hospital will not make as much money as they expect encoder - Correct answer-converts information from one code to another and keeps standardization groupers - Correct answer-computer programs that assign patients to case-mix groups and have an algorithm that determines the patient groups RAC - Correct answer-recovery audit contractor they ensure correct payments are made to providers and facilities by Medicare part A&B claims COLA - Correct answer-cost of living adjustment DSH - Correct answer-disproportionate share hospital GAF - Correct answer-geographical adjustment factor AHRQ - Correct answer-agency for healthcare research and quality a US government agency that functions as a part of the dept of Health & Human Services to support research to help improve the quality of healthcare When defining the LHR in a healthcare entity, it is best practice to establish a policy statement of the LHR along with? - Correct answer-health record matrix the insured party's member identification number is an example of what kind of data - Correct answer-financial data
in a LTC setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items - Correct answer-resident assessment protocols (RAPs) decision making and authority over data-related matters is known as: - Correct answer- data governance abbreviations in the health record... - Correct answer-should have only one meaning In ICD 10, what value is used if there is a character that doesn't apply to a given code? - Correct answer-Z primary responsibility of a coder - Correct answer-ensure quality of coded data what is the data model most widely used to illustrate a relational database structure? - Correct answer-entity-relationship diagram name the proper ways to destroy paper records - Correct answer-pulverize, shred, burn, pulp examples of metadata - Correct answer-name of element definition application in which the data element is found locator key ownership entity relationships what are LOINC codes used for? - Correct answer-identifying test results the inpatient data set incorporated into federal law and required for Medicare reporting is the - Correct answer-UHDDS What is the desired outcome of analyzing data for a specific purpose? - Correct answer- information root operation - extirpation - Correct answer-taking or cutting out solid matter from a body part penalties for HIPAA violations can be: - Correct answer-civil and criminal how long does the hospital have to respond to request for information? -
Correct answer-30 days when ownership of a physician practice changes.. - Correct answer-the health records of the practice may be transferred as assets
Rank the next-of-kin in the following order for medical decision making purposes - Correct answer- Spouse adult child parent adult sibling
Per HITECH, breach notification requirements, what is the threshold for the immediate notification of each individual? - Correct answer-500 individuals affected Per HITECH, an accounting of disclosures must include disclosures made during the previous: - Correct answer-3 years What does not have to be included in a CE's NPP - Correct answer-patient's signature and email let the master answer - Correct answer-respondeat superior employees in the hospital business office may have legitimate access to patient health info without patient authorization based on what HIPAA principle - Correct answer- minimum necessary CEs must retain documentation of their security policies for at least: - Correct answer-6 years from the date when last in effect regarding an individual's right of access per HIPAA, a CE... - Correct answer- may require individuals to make their requests in writing Administrative Simplification portion of Title II of HIPAA addresses which of the following? - Correct answer-uniform standards for transactions and code sets An original goal of HIPAA administrative simplification was to standardize: - Correct answer-the electronic transmission of health data technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: - Correct answer-technical safeguards name a "public interest and benefit" exception to the authorization requirement - Correct answer-PHI regarding victims of domestic violence most common method for implementing entity authentication - Correct answer- password systems what is a two factor authentication system - Correct answer-something you know, have, are
a subpoena duces tecum compels the recipient to - Correct answer-bring records to a legal proceeding Business record exception - Correct answer-the rule under which a record is determined to not be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge if a breach occurs, which of the following must be provided to the individual whose PHI has been breached? - Correct answer-the types of unsecured PHI that were involved e-discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended which legislation? - Correct answer-Federal Rules of Civil Procedure a valid subpoena duces tecum seeking health records does not have to - Correct answer-be signed by the plaintiff and defendant which landmark legal case established the responsibility of the hospital for the quality of care given by its physician? - Correct answer-Darling vs Charleston Community Memorial Hospital what type of safeguards compromise over half of all of the safeguards included in the Security Rule? - Correct answer-administrative safeguards within context of data security, protecting data privacy means defending or safeguarding: - Correct answer-access to information what is the most constant threat to health information integrity? - Correct answer- humans res ipsa loquitur - Correct answer-the thing speaks for itself Safe Medical Devises Act requires the reporting of injuries due to medical devices to whom? - Correct answer-FDA components of a late entry - Correct answer-should be documented as late entry should include date/time entry was made should be documented ASAP which doctrine do courts apply indicating that they are unwilling to revisit
issues of previously settled cases? - Correct answer-res judicata