RHIA TESTS COMPILATION BUNDLE

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 i...

Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the: a.) Admitt...

A discharge summary must be completed within____days after discharge for most patients but within ___for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ___ correct answer: 30 days/24 hours/48 hours systematic...

A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: correct answer: Charting by exception The discharge summary must be completed within _________ after discharge for most patients but within ___...

Data capture: correct answer: the process of recording healthcare-related data in a health record system or clinical database Data cleansing correct answer: The process of detecting, diagnosing, and editing faulty data DEEDS correct answer: Data Elements for Emergency Department Systems: a ...

Data Set correct answer: A group of data items or elements and their definitions. Each element can have its own defined value. Clinical or Medical Vocabulary correct answer: A formally-recognized list of preferred medical terms and their corresponding definitions. They assist in standardizing t...

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Fragmentation d. Release correct answer: b. Extirpation...

Information Governance correct answer: Refers to the overall management of the availability, usability, integrity, and security of company data Data Governance correct answer: Establishes the processes and responsibilities that ensure the quality and security of the data used across a business ...

Primary responsibility of coder correct answer: Ensure quality of coded data Responsible for quality and completion of discharge summary correct answer: Attending Physician Data set for px that does not require an overnight stay correct answer: Uniform Ambulatory Care Data Set Records no...

quantitative analysis correct answer: HIM professionals analyze medical records for any missing reports, forms, or required signatures and deletions. Which of the following is not usually a component of acute care patient records? medical history nurse assessment problem list progress not...

__________ are implemented prior to an activity to stop an error from occurring. correct answer: Preventative controls ________are designed to find errors that have already been made. correct answer: Detective controls _______- are designed to fix problems that have been discovered (LaTour, ...

Legal Health Record correct answer: Formal business record to be utilized during legal procedings If privacy issues emerge... correct answer: Determine source of problem and issue HIPAA training If patient is unable to sign... correct answer: Implied Consent Psychiatric patients may view...

An HIM professional who releases health information that he or she knows will result in genetic discrimination is violating the ethical principle of: A. nonmaleficence B. Autonomy C. Beneficence D. Justice correct answer: A Define nonmaleficence correct answer: There is an obligation not ...

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 li...

Request for proposal (RFP) correct answer: A type of business correspondence asking for very specific product and contract information that is often sent to a narrow list of vendors that have been preselected after a review of requests for information during the design phase of the systems developm...

Record retention program correct answer: conducting an inventory of the facility's records, Determining the format and location of record storage, Assigning each record a retention period, Destroying records no longer needed root operation: resection (T) correct answer: What operation does:...